EKG. Figure 1. Chromoblastomycosis and Depression. Muhammad H. Majeed M.D.*, Asad Javaid M.D., Khawar Nazir M.D., Branden A. Youngman D.O.*.
Chromoblastomycosis and Depression Muhammad H. Majeed M.D.*, Asad Javaid M.D., Khawar Nazir M.D., Branden A. Youngman D.O.* *Department of Psychiatry DUCOM.
Abstract
Discussion
Depression can coexist with many chronic medical illnesses. Untreated depression can cause medication non-compliance and complicate the clinical course. In this case report we found that treatment of depression helped to improve the patient’s compliance with his treatment for his fungal infection.
• Definition: Chromoblastomycosis is a chronic fungal infection of the skin and the subcutaneous tissue caused by traumatic inoculation through the skin. MDD is diagnosed when 5 or more of these symptoms are present for more than 2 weeks: depressed mood, anhedonia, sleep changes, PMA/PMR, LOC, suicidal thoughts, weight changes, fatigue and guilt .
Case Description
• Epidemiology: Chromoblastomycosis occurs golbally in rural areas caused by an infection of Fonsecaea pedrosoi. HLA-A29 correlation suggests a genetic linkage. Incidence of MDD alone is 6.7 % but cooccurrence with chronic medical conditions (i.e. angina, asthma, arthritis and HIV) it is significantly higher at 9-23%.
Treatment of underlying depression, in a 19 year old male with a case of recurrent Chromoblastomycosis, improves medication compliance •
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HPI and PMH: At the age of seven patient experienced a wood pencil injury to his left cheek. Three days following the injury, he developed a small bump on his left cheek and a fever. Two to three months later he developed another bump at same site which then spread progressively over the next 4-5 months and involved both cheeks, as well as his nose, and caused intense itching. A biopsy of the lesions confirmed the diagnosis of Chromoblastomycosis.
Course of Disease: After almost 4 years of Anti fungal treatment, patient's active lesions were healed and he underwent a skin graft. Then after only 1 week the lesion reappeared in the graft. For the Next 7 years, because of poor compliance, patient had multiple Inpatient hospitalizations and was treated with systemic antifungals, cryotherapy and thermotherapy. Pt reports a depressed mood over the last four years. However, It was not until 3 months ago he was referred to a psychiatrist because of a increase in suicidal thoughts. The psychiatrist diagnosied him with MDD, recurrent, severe without psychotic features.
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Associated Problems: Recently, he developed renal insufficiency, cervical lymphadenopathy (fig. 1) and biopsy showed Cryptococcus infection. He also developed sensorineuronal hearing loss. He also reported decreased self esteem, poor self image, worthlessness, poor self care and suicidal gestures related to the disfiguring nature of the disease, being on his face, as well as the many health complications.
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Psycho Social issues: He had frequent crying spells due to the poor self esteem and depression brought on by his chronic lesions. He remained depressed, hopeless, complained of anhedonia, difficulty sleeping, weight loss and suicidal ideation with a plan to shoot himself with a gun. He also complained of a lot of anxiety and nervousness related to his disease. He is very sensitive about his looks and for a long time he confined himself to his room without a mirror. He refused to engage in any social interaction out of fear of rejection. He feared that people would find his face “ugly and disgusting.” He could not stand having other people look at his face . After being referred to a psychiatrist 3 months ago he was started on antidepressants and now receives weekly CBT sessions.
• Pathophysiology:. In Chromoblastomycosis the agents often gain entry into the human body by contact with wood splinters or thorns after injury. The lesions develop slowly at the site of implantation, producing a warty nodule, which tends to be limited to the skin and the subcutaneous tissue. In depression, along with neurotransmitter imbalance the psychological and social aspects of one’s life also play a role in the etiology. Co-occurance of any chronic medical condition increases the likelihood of Depression .
Figure 1. Facial lesions can cause significant emotional turmoil. Early Psychosocial interventions can improve compliance and help to improve prognosis.
• Diagnosis: KOH scrapings are commonly used to examine fungal infections. The pathognomonic finding is observing Medlar bodies, sclerotic cells. On histology, Chromoblastomycosis manifests as pigmented yeasts resembling "copper pennies." Different rating scales are used to measure depression i.e : BDI, HAM-D . He scored 41 on BDI on initial Psychiatric evaluation. (with the range of 29-63 being severe depression).
Environment
Future Figure
2. EKG Beck’s triad of depression
• Clinical Manifestations: Lesions of chromoblastomycosis are most often found on exposed parts of the body and it is extremely rare on face. Because of the rare occurrence of the face early psychological and psychosocial interventions were missed and that later lead to treatment non-compliance and treatment failure .
Self
• Complications: The most common complications of Chromoblastomycosis are ulceration; secondary infection; and lymphedema. Rare cases of malignant transformation (Squamous cell carcinoma) have been reported. Along with increased suicide risk, poor quality of life other complications of MDD are poor compliance with treatment; which can in turn make the medical conditions worse. • Prognosis: With consistent antifungal treatment prognosis of Chromoblastomycosis is good, but it rarely self remits. With bio-psychosocial intervention depression usually has a good prognosis. • Management: • Azole antifungal, given orally, with or without Flucytosine (5-FC). • Alternatively, cryosurgery with liquid nitrogen or heat therapy has also been shown to be effective. • To treat depression biological and psychotherapeutic interventions are used. • Discussion : The patient was started on Posaconzole 200 mg TID for the Chromoblastomycosis infection. The patient was also started on Citalopram 40 mg daily for depression along with weekly CBT sessions. He confirms improvement in his mood and a decrease in his anxiety. He has started again spending time with his family and friends again and started seeing an ENT specialist for hearing loss. Extensive lesions on the face can cause invisible scarring in the patient’s mind. To manage these patients it is important to get a multi-disciplinary team involvement including a mental health specialist. An early psychosocial intervention can improve patient compliance to help treat the lesions but also prevent the long term psychological consequences of these problems. Had the patient been diagnosed with and started treatment for depression earlier there could have been a less complicated clinical course of the infection. All patients getting treatment for a disease that can cause disfigurement of the body or especially the face should be evaluated for depression and necessary psychosocial intervention should be started early. In evaluation of noncompliance, for any treatment clinicians must consider the subjective aspects of the patient’s perception of self and world. Starting treatment for depression earlier can increase compliance and produce a better clinical outcome.
