Subcutaneous Phaeohyphomycosis in a Patient with Metabolic Comorbidities: A Rare Diagnostic Alert in a Low-Resource Setting
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Abstract
Phaeohyphomycosis is a rare subcutaneous fungal infection caused by melanized (dematiaceous) fungi, usually linked to trauma and, in some cases, to immunosuppression. We report the case of a farm worker living in a remote area of Maranhão, Brazil, with limited access to specialized health services. The patient had systemic arterial hypertension and insulin-dependent type 2 diabetes mellitus, metabolic comorbidities that may increase susceptibility and influence the course of infection. He developed multiple subcutaneous nodules and long-standing fistulized, draining masses on the right upper limb. The diagnostic pathway was prolonged, reflecting challenges in areas with limited health infrastructure, where general practitioners often have little training in endemic fungal diseases because they are perceived as uncommon in routine practice. An initial biopsy led to an incorrect diagnosis of chromoblastomycosis. The definitive diagnosis was established after referral to a specialized hospital, with magnetic resonance imaging (MRI) showing multiple nodular subcutaneous lesions, direct microscopy revealing septate dematiaceous hyphae, and fungal culture isolating Exophiala spp. Treatment with itraconazole at 400 mg/day led to progressive clinical improvement and a marked reduction in lesion size. This case highlights the importance of early clinical suspicion of subcutaneous phaeohyphomycosis, even in patients without classic immunosuppression, particularly when metabolic comorbidities are present.
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References
Hoffmann CC. Infecções causadas por fungos demáceos e suas correlações anátomo-clínicas. An Bras Dermatol. 2011;86(1):138-141.
Lourenço NLP, et al. Feohifomicose sistêmica em cão: relato de caso. Trabalho de Conclusão de Curso. Belo Horizonte: Universidade Federal de Minas Gerais; 2024.
Maquiné GA, et al. Subcutaneous phaeohyphomycosis due to Cladophialophora bantiana: first case report in an immuno-competent patient in Latin America and literature review. Rev Soc Bras Med Trop. 2019;52:e20180480.
Jarrah SA, et al. Cladosporium cladosporioides isolado de gato com carcinoma de células escamosas. Arq Bras Med Vet Zootec. 2017;69(2):377-380.
Ministério da Saúde (BR). Feohifomicose: protocolo clínico e diretrizes terapêuticas. Brasília: Ministério da Saúde; 2022.
Castro LR, et al. Feo-hifomicose subcutânea causada por Exophiala jeanselmei em paciente imunocompetente. Rev Cient IAMSPE. 2024;13(1).
Filho MAA, et al. Epidemiologia das micoses subcutâneas em um serviço público de referência dermatológica em Fortaleza, Ceará, Brasil. Rev Soc Bras Med Trop. 2020;52.
Pereira GB, et al. Ocorrência das infecções fúngicas subcutâneas em pacientes atendidos no laboratório de micologia médica do Centro de Pesquisa em Medicina Tropical. Braz J Dev. 2021;7(12):121016-121029.
Bay C, et al. Feohifomicosis nasal por Curvularia spicifera en un paciente pediátrico con neutropenia y leucemia mieloide aguda. Rev Chil Infectol. 2017;34(3):280-286.
Telles VMS, et al. Feohifomicose cutânea em paciente imunocompetente: relato de caso. Braz J Infect Dis. 2023;27:103287.
Sadigursky D, Ferreira LN, Corrêa LMO. Infecção por feohifomicose em joelho. Rev Bras Ortop. 2016;51:231-234.
Rossetto AL, et al. Feo-hifomicose subcutânea por Exophiala jeanselmei localizada na bolsa escrotal: relato de caso. An Bras Dermatol. 2010;85:517-520.
Salles EF. Feo-hifomicose no Rio Grande do Sul: apresentação de série de casos e comentários sobre o tema em nosso meio. Dissertação (Mestrado). Porto Alegre: Universidade Federal do Rio Grande do Sul; 2010.
Coelho RA, et al. New possibilities for chromoblastomycosis and phaeohyphomycosis treatment: identification of two compounds from the MMV Pathogen Box® that present synergism with itraconazole. Mem Inst Oswaldo Cruz. 2022;117:e220089.
Lima ACC, et al. Therapeutic management of subcutaneous phaeohyphomycosis and chromoblastomycosis in kidney transplant recipients: a retrospective study of 82 cases in a single center. Int J Dermatol. 2022;61(3):346-351.
Oliveira JC, et al. Doença renal crônica e infecções fúngicas: revisão da literatura. Trabalho de Conclusão de Curso. Floria-nópolis: Universidade Federal de Santa Catarina; 2021.
Silva M, et al. Subcutaneous phaeohyphomycosis by Exophiala jeanselmei in a cardiac transplant recipient. Rev Inst Med Trop Sao Paulo. 2005;47(1):55-57.
Fernandes NC, et al. Feohifomicose subcutânea causada por Cladophialophora sp.: relato de caso. Rev Inst Med Trop Sao Paulo. 2007;49(2):109-112.
Menezes CP, De Lima Perez ALA, Oliveira EL. Cladosporium spp.: morfologia, infecções e espécies patogênicas. Acta Bras. 2017;1(1):23-27.
Casqueiro J, Casqueiro J, Alves C. Infections in patients with diabetes mellitus: review of pathogenesis. Indian J Endocrinol Metab. 2012;16(Suppl 1):S27-S36. doi:10.4103/2230-8210.94253.
Filho RR, et al. Feo-hifomicose causada por Veronaea bothryosa: relato de dois casos. An Bras Dermatol. 2005;80:53-56.
Guarner J, Brandt ME. Histopathologic diagnosis of fungal infections in the 21st century. Clin Microbiol Rev. 2011;24(2):247-280. doi:10.1128/CMR.00053-10.
Revankar SG, Sutton DA. Melanized fungi in human disease. Clin Microbiol Rev. 2010;23(4):884-928. doi:10.1128/CMR.00019-10.
Pagnussat V, et al. Suscetibilidade antifúngica in vitro de agentes de feohifomicoses superficiais. Rev Soc Port Dermatol Venereol. 2020;78(2):145-152.