Cutaneous phaeohyphomycosis caused by an Itraconazole and Amphoterecin B resistant strain of Veronaeae 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.