Cutaneous phaeohyphomycosis caused by an Itraconazole and Amphoterecin B resistant strain ofVeronaeae botryosa

BACKGROUND: Although the dematiaceous fungus Veronaea botryosa is rarely encountered clinically, it can be pathogenic. METHODS: A patient with a history of diabetes mellitus, coronary artery disease, and Cushing's syndrome had recurrent multifocal, crusted, brownish-red noduloplaques on the right forearm, left upper limb, and right knee. A skin biopsy was obtained for histopathology and fungal cultures. RESULTS: The histopathology showed brownish hyphae and yeast-like cells scattered in granulomatous infiltrates. Slide cultures revealed erect and straight conidiophores with two-celled cylindrical conidia, which have round tops and truncated bases. The fungus was identified as Veronaea botryosa. The disease slowly progressed despite a 6-month itraconazole regimen (200 mg daily). Subsequent use of Amphoterecin B produced only mild clinical improvements. Susceptibility tests showed resistance to both agents. CONCLUSIONS: Cutaneous phaeohyphomycosis caused by V. botryosa is extremely rare. Antifungal susceptibility tests are important for choosing the appropriate drug and predicting the clinical outcome.