Postsplinter injury chromoblastomycosis

Chromoblastomycosis is a chronic, localized fungal infection of the skin and subcutaneous tissues, most commonly caused by dematiaceous (pigmented) fungi. This condition typically occurs following traumatic implantation of the fungus into the skin, often in individuals exposed to soil or organic matter, making it more prevalent among rural workers involved in outdoor occupations such as agriculture, forestry, and welding. The disease presents as slow-growing, verrucous plaques or nodules and is most seen on the extremities [1]. Diagnosis is often delayed due to its resemblance to other dermatological conditions such as verruca vulgaris or tuberculosis verrucosa cutis. Histopathological examination revealing characteristic fungal sclerotic bodies, also known as Medlar bodies, is crucial for confirming the diagnosis. Here, we present a case of a 29-year-old male who developed chromoblastomycosis following a metal splinter injury, which was successfully managed with surgical excision and antifungal therapy. A 29-year-old male presented with 9-month history of slow-growing lesion over his left arm. The lesion was initially papular, which gradually progressed to warty plaque (Fig. 1). It was not associated with any pain or discharge. The lesion had occurred at a site of metal splinter injury that had taken place while the patient was involved in a welding job 6 months prior to the onset of the lesion. Dermoscopic examination revealed thick scales with few follicular plugs and areas of vascularity comprising dotted and globular vessels (Fig. 2). A differential diagnosis of verruca vulgaris, chromoblastomycosis, and tuberculosis verrucosa cutis was considered. The histopathological examination revealed the presence of pigmented fungal sclerotic bodies, also known as Medlar bodies or copper bodies (Fig. 3), along with dense mixed inflammatory infiltrate forming granuloma (Fig. 4). Hence, the diagnosis of chromoblastomycosis was confirmed and the patient was managed with surgical excision followed by a course of Itraconazole 100 mg twice a day for 3 months to which he responded well. There has been no recurrence in the last 1 year.Figure 1: A 2×2 cm nontender warty plaque present on the lateral aspect of left arm.Figure 2: Dermoscopic examination revealed thick scales with few follicular plugs and areas of vascularity comprising dotted and globular vessels (DL IV).Figure 3: Histopathological examination revealed the presence of pigmented fungal sclerotic bodies, also known as Medlar bodies or copper bodies (hematoxylin and eosin).Figure 4: Histopathological examination revealed the formation of granuloma with mixed inflammatory infiltrate along with some giant cells around central caseation necrosis.Chromoblastomycosis is an uncommon fungal infection, primarily affecting individuals exposed to soil or organic matter following minor trauma. In the present case, the patient, a welder, developed the lesion at the site of a metal splinter injury, consistent with the known pathogenesis of traumatic inoculation. The lesion initially presented as a papule that progressed into a warty plaque, a classic presentation of chromoblastomycosis. Given the slow-growing nature of the lesion and its verrucous appearance, differential diagnoses included verruca vulgaris, tuberculosis verrucosa cutis, and chromoblastomycosis. Dermoscopic findings in chromoblastomycosis, such as vascular structures and thick scaling, can assist in the differential diagnosis, but histopathological examination is definitive [2,3]. The presence of pigmented fungal sclerotic bodies (Medlar bodies) in tissue sections is pathognomonic for chromoblastomycosis, as observed in this case. Granulomatous inflammation, which was also noted, is a common feature of the disease and reflects the chronicity of the infection [4]. Treatment typically involves long-term antifungal therapy, with Itraconazole being a preferred option due to its efficacy and safety profile. In this case, a combination of surgical excision and a 3-month course of Itraconazole resulted in complete resolution of the lesion, with no recurrence observed after 1 year. Early diagnosis and appropriate treatment are crucial to prevent complications such as fibrosis, ulceration, or dissemination of the infection. Chromoblastomycosis, though rare, should be considered in any patient presenting with chronic verrucous lesions, particularly in those with a history of trauma involving organic material. Acknowledgements Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.