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.