Chromomycosis is a chronic fungal infection that is caused by a large number of fungal genera that share a similar clinical and gross mycologic appearance. Included among these are Fonsecaea and, more recently, Exophiala. The causative organisms are among the most common fungi found in soil and decaying organic matter. Cutaneous injury to the lower extremities is the principle mode of entry but any traumatized skin may become infected. The initial injury is often of minor extent and may be forgotten long before clinical presentation. The majority of cases are agriculture related (2,15).

The fungus produces a slowly progressive infectious process that may first be noted as a papule or nodule and progresses to a warty lesion that may eventually appear as exuberant "cauliflower" lesions. Fistulae are uncommon as is bony invasion or visceral disease (1,2,15).

The diagnosis is suspected on the basis of clinical appearance and epidemiology. Pathology yields a pyogranuloma as seen with some endemic fungi. Characteristic "sclerotic bodies" with characteristic hyphal elements may be identified on microscopy. Appropriate material for fungal culture may yield characteristic pigmented colonies with oval hyphae. An experienced mycologist can speciate the organism by its microscopic appearance. Differential diagnosis includes mycobacterial disease, endemic fungi, tertiary syphilis, yaws, leishmaniases, and carcinoma (2,15).

Treatment varies with the extent of the disease. Early disease may be treated successfully with surgery or liquid nitrogen. A variety of anti-fungals have been used. Therapy with ketoconazole, itraconazole with or without 5-flurocytosine have received significant attention. Thermal therapy may be useful, particularly as an adjunct. Newer azoles or echinocandins may prove to have efficacy (2,12,15).

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