Micoses Subcutâneas

Deep Fungal Infections
  • Deep = deeper than the epidermis
  • Includes subcutaneous and systemic

Micoses subcutâneas

  • Na verdade, a maioria está na derme
  • Geralmente transmissão por inoculação direta dérmica (têm um comum haver um orifício na pele por onde entraram)
  • Work-up for suspected deep fungal infection
    • Skin biopsy for tissue culture
      • “Touch prep”
    • Skin biopsy for histopathology

Chronoblastomycosis

  • Etiologia
    • Saprophytic organism found in soil, decaying vegetation, wood
    • “Bucket term” para fungos Dematiaceae, que inclui 4:
      • Fonsecaea pedrosoi (mais frequente)
        • F. compacta, cladosporium carrionii, phialophora verrucosa, rhinocladeilla aquaspersa, exophiala jeanselmei
        • “Pedro’s Compact Car gets Very Wet” (mnemónica)
      • Cladophialophora carrionii
      • Phialophora verrucosa
      • Rhinocladiella aquaspersa
    • These black fungi can change their hyphal in vitro morphology to spherical cells with internal septa (sclerotic bodies) in vivo
  • Anatomia patológica
    • Microabcessos epidérmicos
    • Resposta granulomatosa do tecido
    • “Copper pennies” (corpos escleróticos, corpos medlar, chromobodies)
  • Epidemiologia
    • Tropics & subtropics
  • Transmissão
    • Traumatic injury in agricultural workers to foot, leg (occasionally chest, shoulders)
  • Apresentação clínica
    • Cauliflower-like tumores
    • May coalesce
    • Irregular verrucous plaques & nodules
    • Annular with a central clearing and transepidermal elimination
  • Complication
    • Secondary infection
    • Lymphedema
    • Elephantiasis
    • Squamous cell carcinoma
  • Diagnosis
    • Dermoscopy - role?
    • Direct microscopy - muriform cells (sclerotic bodies)
    • Histopathology- pseudo-epitheliomatous hyperplasia, neutrophil/FBG cell clusters, transepidermal elimination
    • Culture - NB different Fonecaeae morphologies
    • PCR
  • Tratamento
    • Notoriamente resistente à terapia
    • Excisão cirúrgica das pequenas lesões
    • 5-fluorocytosina com ou sem anfotericina B
    • Itraconazole: 200-600mg/dia durante pelo menos 1 ano
    • Cetoconazol 400-800 pode ser eficaz
    • Flucytosina (100-200 mg/kg/dia) em combinação com itraconazole
    • Fluconazole (100-400 mg/dia) não é suficiente
    • Terbinafina (500mg/dia durante 6-12 meses) com resultados encorajadores
    • EADV Copenhaga:
      • Chemotherpay: tervinafine 250mg id, itraconazol 200-400mg id, amphotericin B or above plus flucytosine
      • Other methods: heat (lancheira térmica com água quente 2h/dia durante 6 semanas), surgery, cryotherapy

Mycetoma / Madura foot / maduromycosis

Lobomycosis / Doença de Lobo / Blastomicose queloidiana

  • Etiologia
    • Chronic skin infection cause by Loboa loboi (has not been successfully isolated in culture)
  • Apresentação clínica
    • Characterized by slowly growing tumors of the dermis that present smooth, verrucoid or ulcerated surfaces
  • Epidemiologia
    • Reported in relatively few countries: Brazil, Surinam, French Guiana, other Central and South American countries and Europe (only one case)
    • Man and dolphin the only victims of the disease
  • Diagnóstico laboratorial
    • All attempts to culture Loboa loboi have been so far unsuccessful
    • Direct examination of the fungus in curettage, surgical excision or biopsy materials is the only means of laboratory identification
    • koh of macerated material revals: globose to lemon-shaped cells (9microm) singly or in short chains
    • Multiple budding can be confused with paracoccidioides brasiliensis, however, the mother cells and the multiple daughters share the same diameter in L. loboi
  • Tratamento
    • Único tratamento eficaz é excisão cirúrgica
    • Recorrência é frequente
    • Em casos avançados, a excisão extensa das lesões não é necessário, particularmente porque a doença não impões uma ameaça à saúde em geral
    • Cetoconazol é ineficaz

Sporotrichosis

  • Etiologia
    • Causado por Sporothrix schenckii (s. mexicana, S brasiliensis, S globosa)
    • Dimorphic
    • Found in soil, leaf mould, moss, roses etc
    • Natural infections of animals (cats) and humans - cutaneous and systemic
    • Hypo, meso and epidemic
    • Occupational infection eg. flower workers, packers
  • Mecanismo
    • Progride por via linfática
  • Apresentação clínica
    • Mais comum na mão
    • Pensar em chifres de rosas
    • Considerar infeções por mycobacterium marinum
    • Epifenómenos imunológicos com S. bransiliensis
      • Eritema multiforme like lesions
  • Diagnosis
    • Direct microscopy non specific
    • Histopathology: asteroid bodies (also in sarcoidosis), few organisms, round to pleomorphic yeasts
    • Culture - dimorphic. Variable melanisation
    • PCR
    • Serology
  • Tratamento
    • Itraconazole 200mg id
    • Terbinafine 250mg id
    • Iodeto de potássio. Saturated solution (tastes bad). Start with 1mL tds and build the dose up very gradually to 4-6ml id.
José Carlos: Caso de micose subcutânea de alternaria da Dra. Mane