Lobomycosis Clinical Presentation: History, Physical Examination, Causes

Sections

Lobomycosis

Presentation

History

Skin lesions develop slowly.^[58]For example, the incubation time in the patient who acquired the disease from an affected dolphin was 3 months,^[32]and the incubation period in the American who had traveled to Venezuela was 2.5 years.^[26]

When a volunteer was inoculated with the etiologic agent, the lesion was 1 X 2 mm in the first month, and then it waxed and waned. At 5 months, the lesion was a 2- to 3-mm, red papule. At 15 months, it measured 1 cm, with a small telangiectasis. At 25 months, the lesion was 15 X 10 mm, and at 4 years, it measured 33 mm in diameter, and a 4-mm satellite lesion developed.^[39]

Because of this slow growth, patients do not present for many years, or they may present only after the lesions become large. The lesions often begin as small papules or pustules, and they may occur at sites of minor trauma.^[39] The lesions may be mildly pruritic, or they may burn.^[55] Single lesions occasionally regress and form scars. However, the disease never disappears, and organisms are identifiable in the scar tissue.^[59] Aside from occasional lymphadenopathy, patients lack other systemic symptoms.^[56]However, a recent case report describes a squamous cell carcinoma arising in old lobomycosis lesion scars.^[60]

Physical Examination

The disease predominately affects exposed areas and extremities. Examples include the ears, buttocks, lumbosacral area, scapular area, elbows, and lower limbs.^[61]The scalp and mucosae are spared.

Lesions, papules, or plaques are most often described as keloidal, but the adjectives gummatous, verrucous, or ulcerative have also been applied.^[13]

Lesions have well-defined lobulated margins and are not attached to deeper structures.^[62]

The epidermis may be shiny, atrophic, and discolored.^[13]

The disease may spread proximally from the extremities and fungal cells have been found in the lymph nodes, indicating lymphatic spread.^{[47, 63]} Lymph nodes that drain the affected regions may be enlarged and infected with the organism in 0-25% of patients.^[13]

See the images below.

Keloidal nodule on the leg. Courtesy of Dr Roberto Baruzzi, Sao Paulo, Brazil.

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Lobomycosis in this patient appears as a flat plaque lesion. Courtesy of Dr Roberto Baruzzi, Sao Paulo, Brazil.

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Separate keloidal lesions in a localized area. Courtesy of Dr Roberto Baruzzi, Sao Paulo, Brazil.

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Causes

Other than geography and possible implantation of organisms through skin trauma,^[64]no predisposing factors have been identified.

Important data regarding the interplay among genetic, cultural, and geographic factors have been derived from studies of the Caiabi Indians of Brazil. After they relocated to a geographic area similar to their former one, no new cases have been reported. Furthermore, their original neighbors did not have similar prevalence rates.^[65]

Immunodeficiencies appear to occur in patients with lobomycosis. These immunodeficiencies include a delayed skin allograft rejection, a failure to sensitize to dinitrochlorobenzene, and an anergy to Candida species.^[66] Whether the immunodeficiencies are primary and predispose patients to infection or secondary and the result of infection is not known. Based on the large number of fungal cells in the infected tissue and the disorganized cell arrangement in the granuloma, it has been hypothesized that patients with lobomycosis have immunoregulatory disturbances, which are likely to be specific and perhaps responsible for the lack of containment of the pathogen.^[67] One patient infected with the HIV has been reported to have lobomycosis.^[68]

Complications

General complications may include the following:

Disfigurement
Ulceration
Superinfection of ulcerated lesions
Potential loss of function of affected areas in advanced cases

Two cases of squamous cell carcinoma have been reported in long-standing lesions.^[57]

Differential Diagnoses

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Media Gallery

Keloidal nodule on the leg. Courtesy of Dr Roberto Baruzzi, Sao Paulo, Brazil.
Lobomycosis in this patient appears as a flat plaque lesion. Courtesy of Dr Roberto Baruzzi, Sao Paulo, Brazil.
Separate keloidal lesions in a localized area. Courtesy of Dr Roberto Baruzzi, Sao Paulo, Brazil.
Characteristic histologic appearance of the organism. Courtesy of Dr Roberto Baruzzi, Sao Paulo, Brazil.

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Author

Manuel Valdebran, MD Junior Specialist Physician, Visiting Scholar in Dermatology/Dermatopathology, Department of Dermatology, University of California, Irvine, School of Medicine

Manuel Valdebran, MD is a member of the following medical societies: International Dermoscopy Society, Medical Dermatology Society, Society for Pediatric Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for MOHS Surgery, Association of Military Dermatologists, Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey P Callen, MD Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American College of Rheumatology

Disclosure: Received honoraria from UpToDate for author/editor; Received royalty from Elsevier for book author/editor; Received dividends from trust accounts, but I do not control these accounts, and have directed our managers to divest pharmaceutical stocks as is fiscally prudent from Stock holdings in various trust accounts include some pharmaceutical companies and device makers for i inherited these trust accounts; I serve on a safety monitoring committee for Principia Biopharma for: Allergen; Pfizer; 3M; Johnson and Johnson; Merck; Abbott Laboratories; AbbVie; Procter and Gamble; Amgen.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Gregory J Raugi, MD, PhD Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle School of Medicine; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle

Gregory J Raugi, MD, PhD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Kyle L Horner, MD, MS Physician, Grace Dermatology and Micrographic Surgery, Lebanon, OR

Kyle L Horner, MD, MS is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Dr. Kord Honda, MD, to the development and writing of this article.

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