The use of glucan as immunostimulant in the treatment of a severe case of chromoblastomycosis Conceic ¸a ˜ o de Maria Pedrozo e Silva Azevedo, 1 Sirley Garcia Marques, 1 Maria Aparecida Resende, 2 Azizedite Guedes Gonc ¸alves, 1 Daniel Vagner de Castro Lima Santos, 1 Raimunda Ribeiro da Silva, 1 Maria da Glo ´ ria Teixeira de Sousa 3 and Sandro Rogerio de Almeida 3 1 Departamento de Patologia, Universidade Federal do Maranha ˜o, Maranha ˜o, Brazil, 2 Departamento de Microbiologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil and 3 Departamento de Ana ´lises Clı´nicas e Toxicolo ´gicas, Faculdade de Cie ˆncias Farmace ˆuticas, Universidade de Sa ˜o Paulo, Sa ˜o Paulo, Brazil Summary We report the case of an alternative treatment for a patient with a severe form of chromoblastomycosis that responded poorly to the traditional antifungal therapy. We hereby show, in this study, the improvement of lesions after treatment with itraconazole associated with an intramuscular administration of glucan. We observed that the regression of lesions was associated with an improvement of the cellular immune response. This favourable response that we observed suggests that the therapeutic regimen we used might be an option for the treatment of patients with a severe form of chromoblastomycosis. Introduction Chromoblastomycosis is a chronic and progressive mycosis that usually occurs in tropical and subtropical regions of the world. Fonsecaea pedrosoi is considered its most frequent etiologic agent. The disease is character- ised by dry, crusted, warty, violaceous lesions that spread locally, but are usually limited to the skin and subcutaneous tissues (Brandt ME et al., J Chemother 2003; 15(Suppl. 2): 36–47; Londero AT et al., Am J Trop Med Hyg 1976; 25: 132–35). However, in some cases, the lesions may disseminate to neighbouring tissues leading to a cutaneous diffuse chromoblatomy- cosis (Salgado CG et al., Lancet Infect Dis 2005; 5: 528). Chromoblastomycosis usually affects male agricul- tural workers who are not adequately protected while handling soil, vegetables and decomposing organic matter, which are natural habitats of the fungus (Rippon JW. Chromoblastomycosis. In: Medical mycol- ogy. WB Sunders, 1988, pp. 276–98). Infection is initiated by the traumatic implantation of mycelium fragments or conidial cells into the skin by thorns or wood splinters (Zeppenfeldt G et al., Rev Iberoam Micol 1994; 11: 61–63; Salgado CG et al., Rev Inst Med Trop Sao Paulo 2004; 46: 33–36). Different therapeutic approaches have been used throughout the years, with varying results; however an effective treat- ment for chromoblastomycosis has not yet been estab- lished (Queiroz Telles FF et al., Int J Dermatol 1992; 31: 805–12). Case report A 50-year-old white male, resident in the state of Maranha ˜o, Brazil, presented a 27-year history of a nodular lesion on the right side of his torso which progressed to infiltrative plaques on all torsos. Gradu- ally, the lesion increased in size and, after 1 year, similar lesions developed on his nose with progression to malar regions which took the form of butterfly wings. He was first examined by us in 1997, and presented a disseminated lesion on his torso and face (Fig. 1). Chromoblastomycosis was diagnosed and F. pedrosoi was isolated from the lesion (Fig. 2). Treatment was initiated with itraconazole (200 mg day )1 ) for 24 months but no improvement was noted. In 1999, due to the poor response to the treatment the dose was increased to 400 mg day )1 , and after 12 months, the Correspondence: Sandro Roge ´ rio de Almeida, Departamento de Ana ´ lises Clı´nicas e Toxicolo ´ gicas, Faculdade de Cie ˆ ncias Farmace ˆ uticas, Universidade de Sa ˜ o Paulo, Avenida Prof. Lineu Prestes, 580, Bloco 17, Sa ˜ o Paulo 05508- 900, Brazil. Tel.: +55 11 3091 3633. Fax: +55 11 3813 2197. E-mail: sandroal@usp.br Accepted for publication 11 December 2007 Letter to the editor Ó 2008 The Authors Journal compilation Ó 2008 Blackwell Publishing Ltd • Mycoses 51, 341–344 doi:10.1111/j.1439-0507.2007.01485.x