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Conidiobolomycosis in a Young Malaysian Woman Showing Chronic Localized Fibrosing Leukocytoclastic Vasculitis: A Case Report and Meta-analysis Focusing on Clinicopathologic and Therapeutic Correlations With Outcome

Choon, Siew-Eng AM, MBBS, MRCP(UK), FRCP(UK)*; Kang, Justine BS, MBA; Neafie, Ronald C. MS; Ragsdale, Bruce MD§; Klassen-Fischer, Mary MD; Carlson, J. Andrew MD, FRCP(C)

The American Journal of Dermatopathology: July 2012 - Volume 34 - Issue 5 - p 511–522
doi: 10.1097/DAD.0b013e31823db5c1
Critical Review

Background: Conidiobolomycosis (also known as rhinoentomophthoramycosis) is a rare cutaneous/mucosal fungal infection seen mainly in the tropical rain forest regions of the world that can be associated with disfiguring facial elephantiasis, and rarely, death.

Objective: To present an exemplary case report and perform a systematic review of the world's literature to more accurately describe the natural history and the effect of therapy on outcome in conidiobolomycosis.

Methods: Case report and meta-analysis of published case reports and series of conidiobolomycosis to determine which clinical, pathologic, mycologic, and treatment factors impact on prognosis.

Results: We document delay in diagnosis of conidiobolomycosis in a young Malaysian woman, whose biopsy showed pathognomonic features—massive tissue eosinophilia and Splendore–Hoeppli phenomenon surrounding broad hyphae. These findings coexisted with granuloma faciale–like changes (fibrosing leukocytoclastic vasculitis) and lymphedema. Treatment with multiple antifungals was followed by complete resolution. For the meta-analysis, pooled data from 199 cases (162 with full outcome data) from 120 reports revealed a similar course for most cases: a disease affecting healthy young adults who present with progressive nasal symptoms (eg, nasal obstruction) and central facial swelling and show improvement or cure after surgical excision and/or treatment with one or more antifungal agents in 83%. Persistent–progressive facial disease occurred in 11%, and 6% died rapidly of fungal infection. Presentation with facial elephantiasis correlated with persistent–progressive rhinoentomophthoramycosis and a longer duration of disease before diagnosis (P = 0.02). Lethal infections were significantly associated with nonstereotypical presentation (eg, orbital cellulitis), visceral infection, absence of the Splendore–Hoeppli phenomenon, presence of comorbidities (eg, immunosuppression, hematolymphoid malignancy), infection with Conidiobolus incongruus or Conidiobolus lamprauges (not Conidiobolus coronatus), lack of response to amphotericin B, and female sex (all P ≤ 0.002). The few sensitivity studies performed demonstrated in vitro multidrug resistance of Conidiobolus species to most available antifungal agents.

Limitations: Publication bias, reporting heterogeneity, and data deficits may affect results.

Conclusions: Conidiobolomycosis should be included in the differential diagnosis of patients who present with nasal symptoms and painless centrofacial swelling. Massive tissue eosinophilia and Splendore–Hoeppli material coating thin-walled hyphae confirms the clinical diagnosis. The granuloma faciale–like histology found in this case can explain the onset of facial lymphedema by fibroinflammatory destruction of lymphatic vessels; the duration of disease and severity of inflammation likely predicts whether the lymphedema is reversible or not. Although rhinoentomophthoramycosis ostensibly responds in vivo to most available antifungal agents, routine culture and susceptibility testing is recommended to better define the efficacy of these therapeutic agents.

Supplemental Digital Content is Available in the Text.

*Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru, Malaysia

Divisions of Dermatopathology and Dermatology, Department of Pathology, Albany Medical College, Albany, NY

Armed Forces Institute of Pathology

§Western Dermatopathology, San Luis Obispo, CA

INOVA Health Systems, Falls Church, VA.

The authors declare no conflicts of interest.

Presented at the 61st Annual Meeting of the Pacific Dermatologic Association, August 2009, Portland, OR, and as an unknown in the Self Assessment Course at the 14th Joint Meeting of International Society of Dermatopathology, New Orleans, LA, February 2011.

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Reprints: J. Andrew Carlson, MD, FRCP(C), Albany Medical College MC-81, 47 New Scotland Avenue, Albany, NY 12208 (e-mail:

© 2012 Lippincott Williams & Wilkins, Inc.