A 20-year-old male, truck driver, presented with a primary complaint of genital swelling developed over the last six months. He also had concomitant bizarre and protean skin lesions over lower abdomen, face, neck and thighs along with discharging lesion over right axilla. He gave a history of lesions over face appearing first and other lesions presenting slowly over two years, all with centrifugal expansion. The genital swelling was associated with recent onset pain and itching. The patient had a history of multiple sexual exposures. There was no history of discharge per urethra, genital ulcer or trauma. He also had history of antituberculous and antifilarial treatment with no alleviation of symptoms.
Examination revealed pallor and generalized lymphadenpathy. The patient had grotesque swelling over scrotum and penis [Figure 1a]. There were multiple, well defined large plaques with warty surface over lower abdomen, encircling the upper medial and posterior thighs, superimposed with crusting and discharge [Figure 1a]. Similar warty papules were seen over forehead and neck with satellite lesions peripherally and a discharging sinus over left axillary region [Figure 2a].
The differential diagnosis of cutaneous tuberculosis, bacterial STI with complications, filariasis and immunosuppression associated symptoms were kept. Hematological investigations, FNAC, chest X-ray, and USG abdomen were done- all of which were normal. Serum HIV, VDRL with titre were non reactive. The case was reanalyzed and subjected to surgical biopsy to evaluate for less considered diagnosis of chromoblastomycosis in case of genital elephantiasis. Biopsy was suggestive of foreign body granuloma showing muriform body; pseudo epitheliomatous hyperplasias of the epidermis and on staining, fungal hyphae were seen favoring the diagnosis of chromoblastomycosis. Fungal culture was not feasible.
The patient was then put on oral fluconazole 200mg twice a day and cycles of injection amikacin 750mg/day with three weeks on and two weeks off dosing pattern for three months along with cryotherapy, to which he responded well and the lesions healed with mild scarring over a period of one month [Figures 1b, 2b]. The scrotal swelling did not resolve much. He was then advised surgery for reduction of secondary lymphedema induced genital elephantiasis.