ANSWER TO THE PHOTO QUIZ
Anthony Amoroso, Section Editor
A 43-Year-Old Brazilian Man With a Chronic Ulcerated Lesion
(See page 264 for the Photo Quiz.)
Figure 2. Skin biopsy section. Short chains of lemon-shaped fungal
cells connected by thin, tubelike bridges (arrow). A, Periodic acidSchiff stain. B, Gomori-Grocott methenamine silver stain (×1000
magnification).
Figure 1. Skin biopsy: round or oval yeast-like organisms from 6 to 12
μm in diameter, isolated or in chains with a bi-refringent membrane; direct
microscopic examination (×1000 magnification).
Diagnosis: lacaziosis, or lobomycosis [1].
The diagnosis was confirmed by direct examination of the
skin biopsy, highlighting the presence of round or oval yeastlike organisms 6–12 µm in diameter, either isolated or in
chains, with a birefringent membrane (Figure 1). The periodic
acid-Schiff–stained and the Gomori-Grocott methenamine silver–stained sections of the sample revealed short chains of
lemon-shaped fungal cells connected by thin, tubelike bridges
(Figure 2). Morphology was consistent with the appearance of
Lacazia loboi.
There was a minor improvement of the lesion after pentamidine treatment, whereas the Leishmania research by microscopic examination, culture, and molecular biology was
negative. However, these exams were done after treatment initiation, so an initial coinfection cannot be ruled out.
Mycological cultures on Sabouraud-gentamicin-cycloheximide
with and without actidionewere performed and were negative after
2 months. The patient is currently under treatment with terbinafine (250 mg twice daily), awaiting surgical excision of the lesion.
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ANSWER TO THE PHOTO QUIZ
Lacaziosis, or lobomycosis [1], is a chronic infectious disease
that was first described in 1930 in Brazil by the dermatologist
Jorge Lobo [2]. Since then, >500 human cases have been reported [3], mainly in Central and South America.
The etiological agent, Lacazia loboi (formerly known as
Loboa loboi), an Onygenales dimorphic fungus [4], seems to
be saprophytic in vegetation, soil, and water. It gains access to
the skin following cutaneous traumatism, or animal bites [5].
After the initial lesion, there is a slow local dissemination period
leading to pleomorphic lesions. The typical clinical aspect is
generally multiple keloidal lesions, with a smooth, shiny aspect,
but can also appear as papules, nodules, ulcers, sclerodermiform, or verrucous plaques [6]. These lesions are painless and
hypo- or hyperchromic.
Clinical diagnosis is generally difficult because of pathology
scarcity and frequently atypical cases. For example, infiltrated
plaque-type lesions can be mistaken for cutaneous leishmaniasis;
lesions with a keloidal aspect can be mistaken for lepromatous
leprosy [7]; and lesions with a verrucous, vegetating, or nodular
aspect can be mistaken for sporotrichosis, chromoblastomycosis, paracoccidioidomycosis, keloids, or neoplastic processes [6].
The diagnosis is based on macroscopic examination of the lesions
and on direct microscopic examination of biopsy or curettage.
The diagnostic feature of Lacazia loboi is the chain of samesized buds, unlike Paracoccidioides, whose buds are smaller
than the mother cell.
The most effective treatment consists in surgical excision of
the lesions, whereas an adjuvant antifungal therapy may be used
to prevent frequent recurrences [6].
Note
Potential conflicts of interest. All authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Marie Cheuret,1,a Charline Miossec,1,a Sarah Milley,2 Pierre Couppie,2,3
Denis Blanchet,1 and Christine Aznar1,3
1
Laboratoire hospitalier et universitaire de Parasitologie et Mycologie Médicale and
Service de Dermatologie, Centre Hospitalier de Cayenne “Andrée Rosemon”; and
3
Faculté de Médecine H. Bastaraud–UAG, Cayenne, French Guiana
2
References
1. Taborda PR, Taborda VA, McGinnis MR. Lacazia loboi gen. nov, comb.
nov, the etiologic agent of lobomycosis. J Clin Microbiol 1999; 37:2031–3.
2. Lobo JO. Nova especie de blastomicose [in Portuguese]. Brasil Med 1930;
44:1227.
3. Fuchs J, Milbradt R, Pecher SA. Lobomycosis (keloidal blastomycosis):
case reports and overview. Cutis 1990; 46:227–34.
4. Herr RA, Tarcha EJ, Taborda PR, Taylor JW, Ajello L, Mendoza L.
Phylogenetic analysis of Lacazia loboi places this previously uncharacterized pathogen within the dimorphic Onygenales. J Clin Microbiol 2001;
39:309–14.
5. Rodriguez-Toro G. Lobomycosis. Int J Derm 1993; 35:324–32.
6. Paniz-Mondolfi A, Talhari C, Sander Hoffmann L, et al. Lobomycosis: an
emerging disease in humans and Delphinidae. Mycoses 2012;
55:298–309.
7. Tubilla LHM, Schettini APM, Da Costa Eiras J, et al. Lacaziosis
mimicking borderline tuberculoid leprosy. An Bras Dermatol 2008;
83:261–3.
a
M. C. and C. M. contributed equally to this work.
Correspondence: Charline Miossec, PharmD, Laboratoire Hospitalier Universitaire de Parasitologie Mycologie, Centre hospitalier Andrée Rosemon, Avenue des flamboyants BP 6006, 97306
Cayenne Cedex ([email protected]).
Clinical Infectious Diseases 2014;59(2):314–5
© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases
Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@
oup.com.
DOI: 10.1093/cid/ciu379
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