Discussion
Chromoblastomycosis is a tropical skin infection caused by various
dematiaceous fungi, such as Fonsecaea spp . andCladophialophora spp . Clinically, it manifests as slow-growing,
warty plaques and nodules that can ulcerate2,3. As a
neglected tropical disease, chromoblastomycosis can lead to serious
complications, including secondary bacterial infections, chronic
lymphedema, deep tissue fibrosis, and squamous cell
carcinoma4. In our case, Streptococcus agalactiae was
identified as a superinfection, marking the first reported association
between these two infectious agents. Diagnosing chromoblastomycosis is
challenging due to its ability to mimic various infectious and
inflammatory disorders3,4. The fungus induces a
granulomatous response in the dermis, with pseudoepitheliomatous
hyperplasia of the epidermis. The fungal elements, often visible as
sclerotic or muriform bodies, are brown and extruded transepidermally,
appearing as black dots on the lesion’s surface, which is characteristic
of chromoblastomycosis3. Potassium hydroxide
examination of these black dots, revealing muriform bodies, provides a
simpler, less invasive diagnostic method, especially when these bodies
are not seen on histology4. The antifungal drugs of
choice are itraconazole or terbinafine, administered alone or together
for a year or more. Other treatment options include oral potassium
iodide solution, cryotherapy, posaconazole, voriconazole, photodynamic
therapy, and excision of solitary lesions. In our case, terbinafine and
itraconazole monotherapies were ineffective, and other treatment
modalities, such as voriconazole or photodynamic therapy, were
unavailable. The patient showed significant improvement with a
combination of cryotherapy, topical 5-Fluorouracil (5-FU), and oral
itraconazole2–4. To our knowledge, this is the first
case of chromoblastomycosis reported in Lebanon1,
highlighting a novel therapeutic approach for treatment-resistant cases
where broader-acting antifungals like voriconazole and posaconazole are
not available.