Endemic Chromoblastomycosis Caused Predominantly by Fonsecaea nubica , Madagascar1

C hromoblastomycosis is a chronic, implantation, fungal disease caused by melanized fungi from a variety of genera of the order Chaetothyriales.This disease is included in a group of melanized infections and easily identifiable by verrucous lesions that eventually lead to cauliflower-like eruptions on the skin.Infection is acquired traumatically by implantation of infected plant material from thorns or wood splinters or by soil contamination of an existing wound (1,2).The causative agents are mainly Fonsecaea spp., Cladophialophora spp., and Rhinocladiella spp.However, rare cases caused by other genera, such as Phialophora spp. or Exophiala spp., have been reported (1,3).As is the case for other implantation mycoses, chromoblastomycosis lesions are located mainly on the lower limbs, particularly on the dorsal face of the feet, ankles, and legs (1,4-6).Infection is caused by a lack of protective clothing or shoes for persons working in rural areas in which spiny plants are common.Chromoblastomycosis is linked to poverty and is highly prevalent in low-income resource countries.It was the first fungal infection to be recognized as a neglected tropical disease (along with mycetoma, which is not exclusively of fungal origin) (7).The clinical manifestation of chromoblastomycosis is polymorphous but is dominated by verrucous and tumoral lesions resembling cauliflower.No clinical particularity associated with the fungal species or genera has been described (1,4,5,7).Infection begins with development of muriform cells in the skin, provoking a granulomatous immune response.Muriform cells are specific to chromoblastomycosis and described as large brown, thickwalled, compartmented cells.They are also found in the infected plants assumed to be the source of human contamination.Albeit belonging to the same order, the species found in these plants and the soil are different from the pathogenic ones (4,5,7,8).Infection involves >1 nodules that develop into verrucous, hyperkeratotic, or papillomatous lesions or plaques.