10.5826/dpc.1202a51
text/xml
2160-9381
1837
en
Nadia  Shirazi
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dermoscopy
Dermoscopy of Rhinofacial Entomophthoromycosis in Skin of Color
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2022-05-02
2021-06-11
2022-05-02
2022-05-24
e2022051
Dermatol Pract Concept
Nadia  Shirazi
2022/05/02
10.5826/dpc.1202a51
e2022051
Department of Pathology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand
2160-9381
dermoscopy
en
e2022051
Dermoscopy of Rhinofacial Entomophthoromycosis in Skin of Color
https://dpcj.org/index.php/dpc/article/download/1837/1588
                    Dermatology Practical & Conceptual


 Dermoscopy of Rhinofacial Entomophthoromycosis
          in Skin of Color: First Report
                                  Payal Chauhan1, Rashmi Jindal2, Nadia Shirazi3


1 Department of Dermatology, All India Institute of Medical Sciences (AIIMS), Himachal Pradesh, India
2 Department of Dermatology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand
3 Department of Pathology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand



Key words: Dermoscopy, subcutaneous mycoses, deep mycosis, rhinofacial entomophthoromycosis
Citation: Chauhan P, Jindal R, Shirazi N. Dermoscopy of rhinofacial entomophthoromycosis in skin of colour: first report.
Dermatol Pract Concept. 2022;12(2):e2022051. DOI: https://doi.org/10.5826/dpc.1202a51
Accepted: August 11, 2021; Published: April 2022
Copyright: ©2022 Chauhan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication
Corresponding author: Payal Chauhan, Assistant Professor, Department of Dermatology, All India Institute of Medical Sciences (AIIMS),
Himachal Pradesh, India E-mail: chauhanpayal89@gmail.com




Introduction                                                            progressing to involve the upper half of the face including
                                                                        nose, cheeks, and forehead with significant facial disfigure-
Rhinofacial entomophthoromycosis or zygomycosis is a rare               ment for 8 months. There were no other symptoms associ-
infection, caused by Conidiobolus corononatus involving the             ated with the swelling. The patient had taken multiple short
nasal cavity, paranasal sinuses, and soft tissues of the face. It       courses of antibiotics and antifungals without improvement.
initially starts as a painless swelling of the rhinofacial region       General physical and systemic examination of the patient was
which is locally invasive and can lead to facial disfigurement          normal. Upon mucocutaneous examination, diffuse skin-col-
over time [1]. The disease tends to involve immunocompe-                ored to erythematous, slight scaly, woody hard, lobulated sub-
tent males, usually involved in agriculture between the age of          cutaneous swelling was present over the nose extending to
20-50 years. The diagnosis is established through histopatho-           involve the center of forehead, upper part of both the cheeks,
logical and mycological examination. Special stains like pe-            inner canthus of the eye, and infraorbital area restricting the
riodic acid schiff and silver methanamine can help in the               patient’ vision (Figure 1A). Laboratory examination including
visualization of fungal hyphae and confirmation of diagnosis.           blood count and blood chemistry were within normal limits.
Herein, we present a case of rhinofacial entomophthoromyco-             ELISA assays for detection of Human immunodeficiency vi-
sis and describe the dermoscopic findings seen in the patient.          rus and hepatitis B surface antigen were negative. Computed
                                                                        tomography scan revealed heterogeneously enhancing soft tis-
                                                                        sue mass in the left nasal cavity arising from inferior turbinate
Case Presentation
                                                                        extending into the soft tissue of nasal septum. Dermoscopic
A 19-year-old male, a farmer by occupation from the Hi-                 examination (x10, polarized non-contact mode) was done
malayan region of north India, presented with diffuse fa-               which revealed focal yellowish-orange structureless area, dot-
cial swelling which initially started as nasal mass, gradually          ted and linear vessels over a background of diffuse erythema



Research Letter | Dermatol Pract Concept. 2022;12(2):e2022051                                                                           1
    Figure 1. (A) Diffuse skin colored to erythematous, slight scaly, subcutaneous swelling involving nose, forehead, inner canthus of eye,
    upper part of both cheeks. (B) Dermoscopy of the swelling over infraorbital area (represented by blue star in clinical image) displays fo-
    cal yellowish-orange structureless area (black star), multiple dotted vessels (black circle) over a background of diffuse erythema. Yellow
    dots (blue circle) and scattered yellow-brown scales also appreciated. (C) Focal yellowish-orange structureless area (black star), white
    areas (blue star), linear (black arrow) and dotted vessels seen from dermoscopy of the swelling over nose (represented by black star in
    clinical image).


(Figure 1, B and C). Few white areas, scaling, and yellow fol-            differential diagnosis of the present case include cutaneous
licular plugs seen as yellow dots were also appreciated.                  tuberculosis, other deep mycosis like cutaneous sporo-
     Histopathological examination was done from the skin                 trichosis, though clinical appearance can help distinguish
and underlying nasal mass. Skin biopsy revealed epidermal                 rhinofacial entomophthoromycosis from the latter. Timely
acanthosis, follicular plugs, and multiple epithelioid granu-             diagnosis of this rare disorder is important to initiate early
lomas in the dermis with eosinophilic infiltrate (Figure 2, A             intervention and thus reduce patient morbidity. Application
and B). The nasal biopsy displayed amorphous eosinophilic                 of dermoscopy has lately expanded to the diagnosis of deep
material around fungal hyphae along with acute inflamma-                  fungal infections, though available literature is still limited
tory infiltrate (Figure 2C). Gomori methanamine silver stain              [2]. To the best of our knowledge, dermoscopy of rhinofacial
performed on the nasal biopsy sample demonstrated broad,                  entomorphthoromycosis has not been previously described.
aseptate fungal hyphae, a few branching at the right angle                Generalized erythema, yellowish structureless area, presence
(Figure 2, D and E). No organism could be grown on tissue                 of vessels, and white scar-like areas have been seen to be
culture. A final diagnosis of rhinofacial entomophthoromy-                common dermoscopic features of deep mycosis [2]. The yel-
cosis was made. The patient was started on itraconazole 200               low follicular plugs appreciated in the dermoscopy of the
mg twice a day and potassium iodide five drops 3 times a day.             present case are akin to yellow tears described in cutaneous
                                                                          leishmaniasis and cutaneous sporotrichosis The presence of

Discussion                                                                yellowish-orange areas on dermoscopy reflect the underlying
                                                                          granulomas, yellow dots correspond to dilated infundibulum
The clinical appearance of rhinofacial entomorphthoro-                    present on histopathology, whereas white areas represent
mycosis can mimic neoplasms like subcutaneous malig-                      dermal fibrosis, with generalized erythema and vessels sec-
nant, lymphatic oedema, tuberculosis. Dermoscopy-based                    ondary to the dermal inflammation and neoangiogenesis.



2                                                                              Research Letter | Dermatol Pract Concept. 2022;12(2):e2022051
       Figure 2. (A) Histopathology of the skin over infraorbital area showing follicular plugs, epidermal acanthosis, multiple gran-
       ulomas in the dermis (H&E, original magnification x4). (B) Dermal granuloma formed of epithelioid cells, lymphocytes,
       plasma, and acute inflammatory infiltrate (H&E, original magnification x40). (C) Histopathology of nasal mass demonstrat-
       ing amorphous eosinophilic infiltrate surrounding fungal hyphae with dense acute inflammatory infiltrate (H&E, original
       magnification x20). (D) Gomori methanamine silver stain showing multiple scattered broad, aseptate fungal hyphae (original
       magnification x 200). (E) Another section showing broad, aseptate fungal hyphae with branching at right angle seen in silver
       methanamine stain (original magnification x 400).




Conclusions                                                             References
Dermoscopic findings of rhinofacial entomophthoromycosi in-              1. Bhalla S, Srivastava VK, Gupta RK. Rhinofacial entomophthora-
                                                                            mycosis: A rare fungal infection in an adolescent boy. Indian J
clude yellowish-ornage structureless areas, erythematous back-
                                                                            Pathol Microbiol. 2015;58(3):402-403. DOI: 10.4103/0377-
ground, white areas, follicular plus, scaling, linear and dotted
                                                                            4929.162933. PMID: 26275280.
vessels. Dermoscopy can act as a useful tool in the diagnosis of         2. Dabas G, Kaur H, Vinay K, et al. Dermoscopy in disseminated spo-
this rare disfiguring deep mycosis and further work is needed               rotrichosis. J Eur Acad Dermatol Venereol. 2019;33(1):e33-e35.
in this field to corroborate findings seen in the present case.             DOI: 10.1111/jdv.15152. Epub 2018 Jul 18. PMID: 29953691.




Research Letter | Dermatol Pract Concept. 2022;12(2):e2022051                                                                             3
