What is your diagnosis?
Case for diagnosis. Pruritic erythematosquamous lesion in the auricle
Elaine Dias Meloa,
, Patrícia Motta de Moraisb, Débora Cristina de Lima Fernandesc, Paula Frassinetti Bessa Rebellod
Corresponding author
a Teaching and Research Department, Fundação de Dermatologia Tropical e Venereologia Alfredo da Matta, Manaus, AM, Brazil
b Department of Histopathology, Fundação de Dermatologia Tropical e Venereologia Alfredo da Matta, Manaus, AM, Brazil
c Laboratory of Mycology, Fundação de Dermatologia Tropical e Venereologia Alfredo da Matta, Manaus, AM, Brazil
d Department of Tropical Dermatology, Fundação de Dermatologia Tropical e Venereologia Alfredo da Matta, Manaus, AM, Brazil
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Lesão eritematoescamosa pruriginosa no pavilhão auricular" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "521" "paginaFinal" => "523" ] ] "contieneResumen" => array:1 [ "pt" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 542 "Ancho" => 755 "Tamanyo" => 142397 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">(A e B)</span> lesão eritematoescamosa, infiltrativa, na orelha esquerda. 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Pruritic erythematosquamous lesion in the auricle" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "521" "paginaFinal" => "523" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Elaine Dias Melo, Patrícia Motta de Morais, Débora Cristina de Lima Fernandes, Paula Frassinetti Bessa Rebello" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Elaine Dias" "apellidos" => "Melo" "email" => array:1 [ 0 => "e.dmelo@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Patrícia Motta de" "apellidos" => "Morais" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Débora Cristina de Lima" "apellidos" => "Fernandes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Paula Frassinetti Bessa" "apellidos" => "Rebello" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Teaching and Research Department, Fundação de Dermatologia Tropical e Venereologia Alfredo da Matta, Manaus, AM, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Histopathology, Fundação de Dermatologia Tropical e Venereologia Alfredo da Matta, Manaus, AM, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Laboratory of Mycology, Fundação de Dermatologia Tropical e Venereologia Alfredo da Matta, Manaus, AM, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Tropical Dermatology, Fundação de Dermatologia Tropical e Venereologia Alfredo da Matta, Manaus, AM, Brazil" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 573 "Ancho" => 755 "Tamanyo" => 113761 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A and B) After 25 days of treatment, and at the end of ten weeks.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 57-year-old male farmer presented a pruritic lesion on the left auricle, with 20 years of evolution. He did not recall local trauma at the onset of the condition. Upon examination, an infiltrated, erythematosquamous lesion was observed on the left ear. The histopathological examination presented a granulomatous inflammatory infiltrate with suppurative foci (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">What is your diagnosis?<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0015" class="elsevierStylePara elsevierViewall">Jorge Lobo's disease</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0020" class="elsevierStylePara elsevierViewall">Sarcoidosis</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0025" class="elsevierStylePara elsevierViewall">Paracoccidioidomycosis</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0030" class="elsevierStylePara elsevierViewall">Chromoblastomycosis</p></li></ul></p><p id="par0035" class="elsevierStylePara elsevierViewall">The review of the sections for histopathological examination evidenced the presence of fumagoid bodies, compatible with chromoblastomycosis.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the direct examination of biopsy fragments in 20% KOH, septate demaceous hyphae and isolated yeast cells in pairs were observed, as well as some gemmule structures. In culture, on Mycosel agar (DIFCO®) and Sabouraud dextrose agar (DIFCO®) with chloramphenicol (0.05<span class="elsevierStyleHsp" style=""></span>g/L), a blackened colony growth was observed; in microculture, phenotypic findings compatible with <span class="elsevierStyleItalic">Rhinocladiella</span><span class="elsevierStyleItalic">sp.</span> were observed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> A and B).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">R. aquaspersa</span> was confirmed through amplification and sequencing of the intergenic spacer (ITS) region of the ribosomal DNA (rDNA) using the polymerase chain reaction (PCR) technique.</p><p id="par0050" class="elsevierStylePara elsevierViewall">After confirmation of the diagnosis of chromoblastomycosis, itraconazole (300<span class="elsevierStyleHsp" style=""></span>mg/day) was initiated; the patient presented significant improvement after 25 days and almost complete remission in ten weeks (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> A and B). The patient remains under outpatient follow-up.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Chromoblastomycosis is a subcutaneous mycosis caused by demaceous fungi of the order Chaetothyriales, family Herpotrichiellaceae, found in decomposing soil, vegetables, plants, and wood.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> The main etiological agents are from the genera <span class="elsevierStyleItalic">Fonsecaea</span>, <span class="elsevierStyleItalic">Cladophialophora</span>, <span class="elsevierStyleItalic">Phialophora</span>, <span class="elsevierStyleItalic">Rhinocladiella,</span> and <span class="elsevierStyleItalic">Exophiala</span>. Inoculation occurs after trauma with contaminated material.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3,4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The condition most frequently affects men between 40 and 50 years of age, being considered a cosmopolitan disease, with greater prevalence in tropical and subtropical regions.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> In Brazil, it occurs in most states, with a predominance in the Amazon region, particularly in the state of Pará.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The disease mainly affects the lower limbs. In cases with long evolution, association with lymphedema is common.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,4,6</span></a> In Japan, the most common locations involved are the upper limbs, face, and cervical region.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Reports of manifestations exclusively on the auricle are rare.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3,6–10</span></a> Among the cases reported in this topography, <span class="elsevierStyleItalic">Fonsecaea</span><span class="elsevierStyleItalic">pedrosoi</span><a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3,10</span></a> and <span class="elsevierStyleItalic">Phialophora</span><span class="elsevierStyleItalic">verrucosa</span><a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> were the most commonly identified agents, followed by <span class="elsevierStyleItalic">Fonsecaea</span><span class="elsevierStyleItalic">nubica</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> and <span class="elsevierStyleItalic">Rhinocladiella aquaspersa</span>.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">According to the literature consulted, this is the second case with isolated involvement of the auricle caused by <span class="elsevierStyleItalic">R. aquaspersa</span>.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the Amazon region, the differential diagnosis must include Jorge Lobo's disease, leprosy, anergic leishmaniasis, cutaneous tuberculosis, and paracoccidioidomycosis. Histopathological and mycological exams are essential for diagnosis.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Several treatments are indicated for chromoblastomycosis. For localized lesions, surgical excision, cryotherapy, or thermotherapy are recommended; for more extensive cases, systemic and immunoadjuvant antifungals are recommended.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,4</span></a> Among systemic antifungals, itraconazole, posaconazole, voriconazole, and isavuconazole are used.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The literature reports two cases of chromoblastomycosis in auricular locations, which presented complete regression after treatment with flucytosine<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> and itraconazole<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> for 12 and 10 weeks, respectively.</p><p id="par0085" class="elsevierStylePara elsevierViewall">There are reports of a good therapeutic response with the association of systemic antifungals and topical immunoadjuvants, such as imiquimod.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0110" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Authors’ contributions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Elaine Dias Melo: Conception and planning of the study; elaboration and writing of the manuscript; obtaining, analyzing, and interpreting the data; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical review of the literature.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Patrícia Motta de Morais: Approval of the final version of the manuscript; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Débora Cristina de Lima Fernandes: Elaboration and writing of the manuscript; critical review of the literature.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Paula Frassinetti Bessa Rebello: Approval of the final version of the manuscript; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1370015" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1259087" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 4 => array:2 [ "identificador" => "sec0020" "titulo" => "Financial support" ] 5 => array:2 [ "identificador" => "sec0015" "titulo" => "Authors’ contributions" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 7 => array:2 [ "identificador" => "xack475737" "titulo" => "Acknowledgements" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-10-04" "fechaAceptado" => "2019-11-24" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1259087" "palabras" => array:4 [ 0 => "Auricle" 1 => "Chromoblastomycosis" 2 => "Ear, external" 3 => "Mycosis" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chromoblastomycosis is a subcutaneous mycosis with chronic evolution that mainly affects the lower limbs and, less frequently, the auricles. Clinically, it presents with papillary verrucous, nodular, and/or tumoral lesions, whether isolated or infiltrated, forming plaques and, sometimes, atrophic in some areas. Histopathologically, it is characterized by a dermal granulomatous inflammatory infiltrate, and the diagnosis can be confirmed by the presence of fumagoid bodies in anatomopathological or direct mycological exams. The treatment to be indicated will depend on the extent and location of the lesions, using systemic antifungals, surgical removal, cryotherapy, thermotherapy, and immunoadjuvants. The present study reports an atypical presentation of chromoblastomycosis on the auricle.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Melo ED, Morais PM, Fernandes DCL, Rebello PFB. Case for diagnosis. Pruritic erythematosquamous lesion in the ear. An Bras Dermatol. 2020;95:521–3.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Fundação de Dermatologia Tropical e Venereologia Alfredo da Matta, Manaus, AM, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 542 "Ancho" => 755 "Tamanyo" => 142397 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A and B) Erythematous, infiltrative lesion in the left ear. Histopathological examination: granulomatous inflammatory infiltrate with suppurative foci (Hematoxylin & eosin, ×400).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1038 "Ancho" => 755 "Tamanyo" => 104028 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A and B) Direct examination: fumagoid bodies. Microculture: septate demaceous hyphae and elliptical conidia in the upper portion of simple or slightly branched conidiophores – phenotypic characteristics compatible with <span class="elsevierStyleItalic">Rhinocladiella</span> spp. (KOH-20%, ×400; blue, lactophenol, ×400).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 573 "Ancho" => 755 "Tamanyo" => 113761 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A and B) After 25 days of treatment, and at the end of ten weeks.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chromomycosis: report of a case with unusual topography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "V.F.M. 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"idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009500000004/v3_202008041755/S036505962030129X/v3_202008041755/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S036505962030129X?idApp=UINPBA00008Z" ]
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