In vivo reflectance confocal microscopy, dermoscopy, high-frequency ultrasonography, and histopathology features in a case of chromoblastomycosis

Pleaseconfirmthatallheadinglevelsarerepresentedcorrectly: of caseA 60-year-old male patient presented to our outpatient clinic complaining of a 12-month history of a progressively enlarging painful ulcer on his right calf.For the past 6 months, with no previous confirmed diagnosis, he had been on varying doses of systemic and topical antibiotics that resulted unsuccessfully.On examination, a well-defined moderate severity violaceous verrucous plaque with raised edges [1], measuring 4.5 × 3.0 cm with ulceration in the periphery and multiple black dots, was seen on the right calf (Fig 1).Dermoscopy of the inferior portion of the lesion (DermLite IV DL4; 3Gen; polarized mode, ×10 magnification) showed white scales, black dots, hemorrhagic spots, and yellow crusts at the periphery.The center of the lesion had a distinct shiny white blotches and strands and polymorphic vessels surrounding the yellowish-orange ovoid areas (Fig 2).On in vivo reflectance confocal microscopy examination (Vivascope 1500; LucidAU : PerPLOSstyle; , Henrietta, NY, USA), the presence of small rounded hyperreflective bodies, 0.4 μm in size, in the epidermis suggested the transepidermal elimination of fungal cells (Fig 3).Ultrasonography was performed on the same area with a linear transducer using a 22-MHz frequency (My Lab Touch, Esaote, Italy).There was epidermal thickening, and 2 well-defined hyperechogenic round structures were seen in the epidermis and in the superficial dermis.Color Doppler sonography detected an irregular increase in echogenicity and vascularization giving the dermis a disorganized appearance (Fig 4).Histopathology of a 5-mm punch biopsy from the same area showed a flattened epidermis and a granulomatous infiltrate in the dermis, with giant cells surrounding pigmented spherical fungal structures, besides an increased number of dermal capillaries and dermal fibrosis (Fig 5).Direct mycological examination of specimens treated with KOH 20% + DMSO exhibited septate brownish muriform cells, and Fonsecaea sp. was isolated from tissue culture, consequently confirming the diagnosis of chromoblastomycosis.