Here in we report a case of chronic cutaneous Chromoblastomycosis in a middle aged woman from north eastern part of India, who was initially misdiagnosed as Tuberculosis verrucosa cutis. In histopathology characteristic brown colored spores of the fungus (also known as copper pennies) were seen within dermal abscess. The organism isolated from culture of the biopsy material was Fonsecaea pedrosoi thus confirming our diagnosis of cutaneous chromoblastomycosis. The patient responded well to oral Itraconazole.

The dermatologists and pathologists should be aware of this condition especially when dealing with verrucous lesion of the skin. The pathologists should search for fungal spores in cutaneous lesion with pseudoepitheliomatous hyperplasia and dermal abscess.

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Figure 1: Hyperpigmented verrucous lesion in the arm.

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Figure 2: Scanner view of the histopathology section showing pseudoepitheliomatous hyperplasia, dermal abscess formation, collection of multinucleated giant cells (arrow) and barely visible fungal profiles (encircled) in this magnification (H&E stain, x40) Inset: Brown-colored spores of Chromoblastomycosis (copper pennies) (H&E stain, x400).

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Figure 3: Higher magnification showing brown-colored spores of Chromoblastomycosis (copper pennies) within dermal microabscess (H&E stain, x400x).

Chromoblastomycosis is an indolent cutaneous infection, which can present as nodular, plaque like, verrucous, or cicatrical lesions⁶. The disease is cosmopolitan in distribution but most cases are encountered in tropical or sub-tropical regions. Mode of transmission is inoculation of soil or vegetable matter contaminated by the pigmented fungi though minor trauma⁸. Our patient being an agricultural worker, may have encountered a similar trivial injury which she could not recollect.

Primary lesions develop at the site of injury and remain localized for many years⁸. New lesions develop by autoinoculation or through propagation by lymphatic vessels causing elephantiasis; hematogenous spread can also occur rarely. Development of squamous cell carcinoma had also been reported in the long standing cases⁹. The HP of cutaneous Chromoblastomycosis reveals pseudoepitheliomatous hyperplasia, dermal abscess formation, chronic granulomatous inflammation with multinucleated giant cells and diagnostic ‘copper penny’ bodies^1,2,10. In this case though well defined granuloma was not observed, histiocytes and foreign body giant cells were noted. As the spores are naturally pigmented with melanin, diagnosis can be made on morphology alone; no special stains are required to demonstrate the fungi¹⁰. The brown colored sclerotic bodies are best demonstrated in H&E sections and easily identified in colorless background of unstained or de stained sections¹⁰. Thus examination of unstained or de stained sections for spores after their detection in H&E section provides confirmation of diagnosis without the use of unnecessary special stains¹⁰. Causative agents of chromoblastomycosis can be distinguished in culture but their tissue forms are identical. Culture of the organism show slow growing green to black colonies, and microscopic appearance of the conidia formation identifies the species^1,4.

Clinically the condition may simulate tuberculosis verrucosa cutis, squamous cell carcinoma, plamoplantar psoriasis and sporotrichosis^1,2,3. This case was misdiagnosed as tuberculosis verrucosa cutis clinically and undergone treatment for the same, with no response. Pradeepkumar et al.¹ and De et al.³ also reported cases of Chromoblastomycosis mimicking cutaneous tuberculosis.

Treatment of Chromoblastomycosis is not well established³. Previously radical, often mutilating surgery was considered as the optimal approach⁴. Recently itraconazole (200-400mg/ day) has been effectively used with 80-90% success rate³. This patient also responded well to itraconazole, with resolution of lesion within 6 months.

In conclusion, physicians, dermatologists and pathologists should consider chromoblastomycosis as one of the differentials during work up of verrucous lesions of the skin. The pathologists should purposefully search for the fungal profiles and ‘copper pennies’ in verrucous cutaneous lesions with pseudoepitheliomatous hyperplasia and dermal abscess.

ACKNO WLEDGEMENTS
We wish to thank Prof. Mamata Guha Mallik, Professor, Department of Pathology, North Bengal Medical College for her help and support.

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3) De A, Gharami RC, Datta PK. Verrucous plaque on the face: What is your diagnosis? Dermato Online J. 2010;16:6.

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6) Carrión AL. Chromoblastomycosis and related infections: New concepts, differential diagnosis, and nomenclatorial implications. Int J Dermatol. 1975;14:27-32.

7) Sharma NL, Sharma RC, Grover PS, Gupta ML, Sharma AK, Mahajan VK. Chromoblastomycosis in India. Int J Dermatol. 1999;38:846-51.

8) Tschen JA, Knox JM, McGavran MH, Duncan WC. Chromomycosis. The association of fungal elements and wood splinters. Arch Dermatol. 1984;120:107-8.

9) Caplan RM. Epidermoid carcinoma arising in extensive chromoblastomycosis. Arch Dermatol. 1968;97:38-41.

10) Chavan SS, Kulkarni MH, Makannavar JH. ‘Unstained’ and ‘de stained’ sections in the diagnosis of chromoblastomycosis: A clinico-pathological study. Indian J Pathol Microbiol. 2010;53:666-71.