Abstract
BackgroundChromoblastomycosis (CBM) is a difficult-to-treat chronic subcutaneous mycosis. In Brazil, the main agent of this disease is Fonsecaea pedrosoi, which is phenotypically very similar to other Fonsecaea species, differing only genetically. The correct species identification is relevant since different species may differ in their epidemiologic aspects, clinical presentation, and treatment response.Methodology/Principal findingsPartial sequencing of the internal transcribed spacer (ITS) was used to identify twenty clinical isolates of Fonsecaea spp. Their in vitro antifungal susceptibility was determined using the broth microdilution method, according to the M38-A2 protocol. Amphotericin B (AMB), flucytosine (5FC), terbinafine (TRB), fluconazole (FLC), itraconazole (ITC), ketoconazole (KTC), posaconazole (POS), voriconazole (VRC), ravuconazole (RVC), caspofungin (CAS), and micafungin (MFG) were tested. The association between ITC/TRB, AMB/5FC, and ITC/CAS was studied by the checkerboard method to check synergism. The available patients’ data were correlated with the obtained laboratory results. Fonsecaea monophora (n = 10), F. pedrosoi (n = 5), and F. nubica (n = 5) were identified as CBM’ agents in the study. TRB and VRC were the drugs with the best in vitro activity with minimal inhibitory concentrations (MIC) lower than 0.25 mg/L. On the other hand, FLC, 5FC, AMB, and MFG showed high MICs. The AMB/5FC combination was synergistic for three F. monophora strains while the others were indifferent. Patients had moderate or severe CBM, and ITC therapy was not sufficient for complete cure in most of the cases, requiring adjuvant surgical approaches.Conclusions/SignificanceF. monophora, the second most frequent Fonsecaea species in South America, predominated in patients raised and born in Rio de Janeiro, Brazil, without cerebral involvement in these cases. TRB, VRC, and the AMB/5FC combination should be further investigated as a treatment option for CBM.
Highlights
Chromoblastomycosis (CBM) is a chronic fungal infection of cutaneous and subcutaneous tissues caused by traumatic implantation of several species of dematiaceous fungi [1]
Chromoblastomycosis is a disfiguring disease usually occurring in rural workers from poor and remote communities
In Brazil, the most frequent agents of this neglected disease are the species belonging to the genus Fonsecaea
Summary
Chromoblastomycosis (CBM) is a chronic fungal infection of cutaneous and subcutaneous tissues caused by traumatic implantation of several species of dematiaceous fungi [1]. New species of the genus Fonsecaea have been described, based on molecular criteria: Fonsecaea monophora [4], Fonsecaea nubica [5], Fonsecaea multimorphosa [6], and Fonsecaea pugnacius [7]. These species can be found in nature, trace amounts in plant debris, thorns, and wood cortex, which provide microhabitats for these fungi [8]. The correct species identification is relevant since different species may differ in their epidemiologic aspects, clinical presentation, and treatment response.
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