27910 A sporotrichoid rash in a landscaper and fish owner

Abstract

A 63-year-old male presented with nonhealing tender nodules in lymphocutaneous pattern to the right hand and forearm for two months. Patient had significant risk factors for both Sporotrichosis and Mycobacterium marinum: he works as a landscaper with recent thorn injury to his right second finger, and raises freshwater fish. Patient was initially evaluated in the emergency department, where itraconazole was started for presumed sporotrichosis. He reported no improvement on itraconazole, with development of new nodules ascending his right arm despite five weeks of therapy. He then presented to dermatology for further evaluation. Exam showed erythematous papulonodules to the right forearm and distal upper arm in a lymphocutaneous pattern. Histopathology revealed suppurative granulomatous inflammation with pseudoepitheliomatous hyperplasia, and mixed lymphohistiocytic infiltrate. PAS-F, GMS, and Warthin-Starry stains were negative, and no organisms were identified. Itraconazole therapy was discontinued and patient was started on saturated solution of potassium iodide (SSKI) drops. Clinical improvement was noted after four weeks of SSKI therapy. Wound cultures grew no fungi, possibly due to itraconazole use prior to obtaining cultures. After 8 weeks of incubation, cultures were positive for Mycobacterium marinum. SSKI was discontinued, and patient was transitioned to azithromycin and rifampin. He continues to improve on these antibiotics. Both Sporothrix schenckii and Mycobacterium marinum infections can present in a sporotrichoid pattern. In cases refractory to itraconazole therapy, SSKI has been an effective treatment for sporotrichosis. Treatment of M marinum typically includes a combination of antibiotics. This case highlights a possible coinfection with two distinct organisms.