Introduction (General View)
Subcutaneous fungal infections are sporadic and uncommon infections mainly seen in the tropics and subtropics. They are often referred to as mycoses of implantation as the usual portal of entry is through a penetrating injury often unnoticed into the deep dermis or sub cutis. Patients with subcutaneous mycoses are generally well although these diseases may be more severe in those with underlying immunodeficiency states such as HIV infection. Causative agent are found as saprobes, exist in soil, plants, decomposing vegetation and wood.
Subcutaneous Mycoses in Global View
- Sporotrichosis : most countries, rare in Europe.
- Mycetoma : dry tropic countries.
- Chromoblastomycosis : humid tropic countries.
- Subcutaneous phaeohypomycosis : anywhere.
- Subcutaneous zygomycosis : Africa, Latin America, Far East.
- Lobomycosis : South America. (Hay Roderick, Qt Flavio: 2000)
Sporotrichosis
Sporotrichosis is found in the tropics and subtropics, more rarely in temperate countries. Sporothrix schenckii is the organism, a dimorphic fungus found in soil and on vegetation. Inoculation after injury and lesion may separate into 5 types of infection: lymphocutaneous, fixed cutaneous, mucocutaneous, disseminated, pulmonary. In HIV patients, extensive skin lesions can occur; there is also a systemic form of sporotrichosis. Sporotrichosis responds to KI and also to itraconazole and terbinafine. (Hugo Degreef, Piet De Doncker, 2000)
Mycetoma
Mycetoma is a chronic infection caused by either fungi (eumycetomas) or filamentous bacteria or actinomycetes (actinomycetomas). Organisms include Madurella mycetomatis and Fusarium spp. (eumycetomas), Nocardia brasiliensis, Streptomyces somaliensis. Infection follows a penetrating injury usually by a thorn. The characteristics are local tissue swelling, osteomyelitis, formation of draining sinuses on the skin surface. Grains are discharged onto the skin surface through sinuses. The treatment is antibiotics, such as cotrimoxazole or rifampicin. Treatment is often unsuccessful, although ketoconazole is effective in a proportion of M. mycetomatis infection. Itraconazole may slow progression but is seldom effective on its own. (Piet de Doncker, 2000)
Chromoblastomycosis
Chromoblastomycosis is a tropical infection, which presents with warty or plaque-like lesions on exposed sites. The organisms are black mould fungi, such as Phialocladosporium carrioni and Fonsecaea pedrosoi. Present in the dermis and can be seen on biopsy or skin scrapings. Itraconazole is effective in localised lesions, although the relapse rate is high in widespread disease. Other treatment include flucytosine, terbinafine and amphotericin B. (Piet de Doncker, 2000)
Phaeohypomycosis
Phaeohypomycosis is a rare, generally localized subcutaneous or intramuscular infection, usually as cysts or abscesses, although systemic forms also exist. The pathogen probably originates by implantation from exogenous source. The pathogens are Exophiala jeanselmi, E. dermatides, Bipolaris spp., Alternaria spp. and other brown pigmented fungi. The diagnosis confirmed by biopsy, fungi on the inflammatory lining of the wall. Identification of causative agent can be performed by culture, but as many different species may be involved together with the failure of some primary isolates to sporulate, the help of a specialist laboratory may be required. The usual treatment is surgical excision.
Subcutaneous Zygomycosis
Subcutaneous zygomycosis is less common or rare infections. It caused by Conidiobolus or Basidiobolus. The treatment is slow and difficult.
Lobomycosis
Lobomycosis is caused by Loboa loboi. There is no effective medical therapy. And, where possible surgical excisions are performed.
Subcutaneous Mycosis in Indonesia
Several cases had been reported since 1996 in Indonesia, revealed of chromoblastomycosis, sporotrichosis, zygomycosis, mycetoma and lobomycosis. The data were collected from 10 referral hospital and medical education center of Medan, Jakarta, Bandung, Semarang, Solo, Padang, Surabaya, Malang, Denpasar and Jogyakarta.
Summary
- Subcutaneous mycoses are still rare fungal infections in Indonesia.
- There were only 45 (various) cases reported from 10 medical education centers in Sumatra, Java and Bali from 1996 - 2002.
- Laboratory findings with the help of an expert are required in identification of subcutaneous mycoses.
Adapted From Lecture Note on Subcutaneous Mycoses in Indonesia by dr. H.M. Goedadi Hadiloekito, Sp.KK.
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