Cutaneous phaeohyphomycosis presenting as a progressive disf
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A 45-year-old female, farmer by occupation presented with a painful, ulcerative, and disfiguring lesion over the right side of the face for 20 years. The lesion started as a pea-sized nodule and gradually progressed with advancing ulceration eroding the right half of the face. The patient gave history of difficulty in phonation and chewing food because of the lesion destroying the right part of her upper and lower lips. She was also severely depressed as she had to face social ostracization because of the disfiguring lesion. There was no antecedent history of trauma or any other comorbidities.

Patient had been managed with multiple medications including, antibiotics and antitubercular therapy with little relief. Examination at presentation revealed an ulcerated plaque with unhealthy granulation tissue and crusts discharging foul smelling pus, destroying the right upper and lower lips, ala of right nose, and the right lower eyelid. An ulcerated plaque measuring 5 cm × 3 cm was present in the right supraclavicular region.

Haematoxylin and eosin-stained sections from biopsy tissue revealed dense mononuclear inflammatory infiltrate with numerous foreign body giant cells in dermis. Numerous septate branching brown colored organisms were seen both extracellularly and inside giant cells suggesting dematiaceous fungi. Grocott's methenamine silver stains for fungus revealed brownish black hyphae. Fine-needle aspiration cytology was done from enlarged submental lymph node which revealed epithelioid cell granulomas and giant cells with yeast and hyphal forms of fungus among inflammatory cells suggesting the spread of fungus to lymph node.

The patient was diagnosed as a case of cutaneous phaeohyphomycosis on the basis of dematiaceous fungi seen on histopathology as septate brown-colored organisms. MRI of the face was done to evaluate the extent of lesion which revealed the lesion impinging on the inferior orbital wall superiorly, extending to and eroding the ramus of the mandible inferiorly, crossing the midline of nose medially and laterally extending to the right preauricular region. Mucosal disease was noted in right maxillary sinus. Multiple enlarged cervical and preauricular lymph nodes were noted.

Patient was managed with oral itraconazole 200 mg twice a day and showed good response to therapy with healing of lesions and no further extension. The treatment was continued for a year and there has been no relapse on follow up. The patient was offered reconstructive surgery but she was unwilling for it.