A Rare Case of Bilateral Facial Chromoblastomycosis Caused by Exophiala jeanselmei in an Immunocompetent Host: A Case Report

Abstract

Introduction: Chromoblastomycosis is a chronic fungal infection of the subcutaneous tissue caused by various melanized dematiaceous fungal species. It predominantly affects trauma-prone areas of the lower extremities. Facial involvement is exceedingly rare and may mimic various granulomatous dermatoses, leading to a diagnostic delay. We report a rare case of bilateral facial chromoblastomycosis with a remarkably long 20-year history. Case Presentation: A 57-year-old man from central Maharashtra, India, presented with slowly progressive, discolored, raised facial lesions of 20 years’ duration. Despite having no history of trauma, he had previously received multiple immunosuppressive therapies, including systemic corticosteroids, methotrexate, hydroxychloroquine, and dapsone, without improvement. Dermatologic examination revealed multiple well-defined, hyperpigmented-to-erythematous, indurated plaques with crusting on both cheeks, extending to the chin, angles of the mouth, and the lower lip margin. Histopathologic examination demonstrated pseudoepitheliomatous hyperplasia, granulomatous inflammation, and characteristic thick-walled muriform (sclerotic/copper-penny) bodies. Periodic acid-Schiff (PAS) staining was positive, whereas Ziehl-Neelsen staining was negative. A 10% potassium hydroxide (KOH) mount demonstrated numerous muriform (sclerotic/copper-penny) bodies. Fungal culture yielded black, velvety colonies identified as Exophiala jeanselmei. Plain magnetic resonance imaging of the face revealed diffuse cutaneous thickening without deep tissue invasion. Oral itraconazole, 200 mg twice daily, was prescribed for 1 year, with adjunctive cryotherapy administered to a single plaque on the right side of the face. This treatment resulted in near-complete resolution, with mild residual scarring and no relapse. Conclusions: Facial chromoblastomycosis is an uncommon presentation that may mimic several granulomatous dermatoses, resulting in a diagnostic delay. Early biopsy and mycologic evaluation are essential for establishing the diagnosis. Prolonged antifungal therapy combined with adjunctive procedures, such as cryotherapy, can achieve favorable outcomes, even in long-standing disease.