Lymphocutaneous Sporotrichosis Research Articles

Sporotrichosis, Plain of Jars, Lao People's Democratic Republic

To the Editor: In May 2003, a previously healthy, 42-year-old rice farmer and miller, living on the Plain of Jars (Xieng Khuang Province) in northeast Lao People's Democratic Republic (PDR) (Laos), dehusked and polished glutinous rice in her hand-operated rice mill. While milling, her hand slipped, removing the skin covering the interpharyngeal joint of her right index finger, on a dusty, wooden part of the machine. She did not recall the implantation of a wood splinter. During the following 4 weeks, multiple firm, erythematous lesions developed, which were not tender, fluctuant, or itchy, at the site of the injury and on the medial and anterior aspects of the lower and upper arm (Figure). The lesions spread proximally from the site of injury, but they remained confined to her right arm. She had no fever, and no lymphadenopathy developed. Her household had no domestic animals, including cats. No systemic disease developed, and she showed no evidence of immunosuppression, diabetes, or alcoholism. While waiting for a diagnosis, she persuaded a surgeon to excise all the lesions, but they soon recurred. She believed that the only solution would be to have her arm amputated. Initial biopsy specimens demonstrated no organisms and showed no growth on Sabouraud dextrose agar. Without facilities for further fungal diagnostic work in Lao PDR, but with a probable clinical diagnosis of sporotrichosis, we sent one of the excised lesions to Taiwan for molecular analysis by previously described methods (1,2). Polymerase chain reaction (PCR) was negative for mycobacteria but positive for Sporothrix schenckii, the cause of sporotrichosis, and the diagnosis was confirmed by sequencing the 18S rRNA gene, which showed 100% identity to that of S. schenckii (1,2). The lesions resolved with 6 months of oral itraconazole therapy (100 mg every 12 h). Figure Lesions on the right arm of the patient. S. schenckii is a dimorphic fungus found in soil, hay, decaying vegetation, and moss. Persons exposed to these environmental foci, such as farmers and gardeners, are especially at risk. Percutaneous inoculation is presumably the main method of infection, although inhalation and insect and mammal bites and scratches, especially from armadillos and cats, have been implicated (3,4). Our patient presumably contracted the fungus from the wood frame of the milling machine. In the 1940s, contamination from untreated wood was responsible for an epidemic that affected ≈3,000 gold miners in South Africa (from timbers in the mine). Lymphocutaneous sporotrichosis is the most frequent presentation, and the traditional treatments are oral saturated potassium iodide solution and local hyperthermia, but oral itraconazole for 3 to 6 months is now recommended (3,4). Sporotrichosis has been described from North and South America, Europe, and Japan. In Asia and Australasia, it has been described from India (5), Taiwan (1), Australia (6), and Thailand (7), but apparently not from Laos, Cambodia, and Burma (Myanmar). Serologic evidence for human sporotrichosis infection is found in highland areas of southwest Vietnam (8). At least in part, the relative paucity of reports probably reflects the lack of sophisticated fungal diagnostic techniques in much of Southeast Asia. Some evidence suggests that sporotrichosis is more prevalent in tropical environments with relatively cool temperatures and high humidity such the Peruvian Andes (9), northwest India (5), southwestern Vietnam (8), and in Laos in the Plain of Jars. If this environmental association is correct, sporotrichosis may occur more extensively in the cooler humid areas of Asia, such as the highlands of China, Laos, Vietnam, and Burma. Sporotrichosis can disseminate in HIV-infected patients, and this syndrome may increase as the prevalence of HIV infection rises in these areas. With 73% of the Lao population living on <US$2/day (10) and one accessible microbiologic culture laboratory in Laos, PCR is not an available local routine diagnostic technique. We were fortunate to have access to an overseas diagnostic facility, which allowed confirmation of the clinical diagnosis before the patient received a prolonged course of a drug with adverse effects and drug interactions. Diagnosis by histopathologic examination and culture may be difficult, and identifying laboratories in different regions of the subtropics and tropics with an interest in diagnosis of sporotrichoid lesions and the capability to perform culture and PCR would facilitate the diagnosis and awareness of this disease. Itraconazole, which has become the drug of choice for lymphocutaneous sporotrichosis, is expensive. Saturated solution of potassium iodide is an inexpensive alternative and appears to be effective, although adverse effects occur frequently (3,4).

Multifocal sporotrichosis with meningeal involvement in a patient with AIDS

This report describes a 29-year-old man with AIDS and disseminated lymphocutaneous sporotrichosis diagnosis presenting a poor therapeutic adhesion to itraconazole therapy that later evolved to neurological impairment and death. Necropsy showed granulomatous reaction and yeast-like forms similar to Sporothrix schenckii in meninges, lymph nodes, marrow bone, skin, testicles, epididymides and pancreas. Meningeal sporotrichosis cases associated to AIDS are reviewed in brief.

Clinical microbiological case: infection imitating lymphocutaneous sporotrichosis during pregnancy in a healthy woman from the south-eastern USA

Clinical microbiological case: infection imitating lymphocutaneous sporotrichosis during pregnancy in a healthy woman from the south-eastern USA

Clinical microbiological case: infection imitating lymphocutaneous sporotrichosis during pregnancy in a healthy woman from the south-eastern USA

A painless red nodule developed on the proximal lower leg in a 34-year-old Caucasian woman during the late second trimester of pregnancy. After she gave birth to a full-term healthy child, additional nodules appeared in crops over the more distal aspect of the tibia (Figure 1). She had no complaints, and physical examination was otherwise normal. The results of laboratory studies were as follows: white blood cell count, 5000/mL, hemoglobin, 12 g/dL, platelets, 278 000/mL, and erythrocyte sedimentation rate, 5mm/h. Serum creatinine, aminotransferases, alkaline phosphatase, albumin and globulin, as well as chest radiograph, were normal. Skin biopsy showed large necrotizing granulomaswithin thedeep dermis. Prominent destruction of the subcutaneous fat and dimorphic inflammation including neutrophils and lymphocytes were found in the dermis and subcutis. No microorganisms were identified. A three-phase radionuclide (25.0mCi technetium) bone scan and magnetic resonance images of the lower extremities showed normal subcutaneous tissue and bone.

Population-based surveillance and a case-control study of risk factors for endemic lymphocutaneous sporotrichosis in Peru.

Population-based surveillance and a case-control study were conducted in Abancay, Peru, to estimate the burden of disease and to determine risk factors for sporadic lymphocutaneous sporotrichosis (LS). Laboratory records from local hospitals were reviewed for the years of 1997 and 1998, and prospective surveillance was conducted for the period of September 1998 through September 1999. A case-control study was conducted with 2 matched control subjects per case patient. The mean annual incidence was 98 cases per 100,000 persons. Children had an incidence 3 times higher than that for adults and were more likely to have LS lesions on the face and neck. Identified risk factors included owning a cat, playing in crop fields, having a dirt floor in the house, working mainly outdoors, and having a ceiling made of raw wood or conditions associated with a lower socioeconomic status. Decreased environmental exposure, such wearing protective clothing during construction activities for adults or limiting contact with cats and soil for children, and improvements in living spaces may decrease the incidence of LS.

Potassium iodide in dermatology: A 19th century drug for the 21st century—uses, pharmacology, adverse effects, and contraindications

Potassium iodide (KI) is a useful drug in the dermatologic armamentarium. It is successfully used for inflammatory dermatoses, most notably erythema nodosum, subacute nodular migratory panniculitis, nodular vasculitis, erythema multiforme, and Sweet's syndrome. KI is also successfully used for cutaneous and lymphocutaneous sporotrichosis. The precise mechanism by which KI acts is unknown. Although many minor side effects are common with this drug, major side effects can occur in pregnant patients and those with a history of kidney or thyroid disease. This article reviews the pharmacology, mechanism of action, indications, contraindications, and adverse effects of KI as a therapeutic agent. (J Am Acad Dermatol 2000;43:691-7.)

Terbinafine: broad new spectrum of indications in several subcutaneous and systemic and parasitic diseases.

Immunocompromised patients are at risk of contracting serious fungal infections. The emergence of acquired resistance to azole treatment by opportunistic fungal organisms is increasing and poses a major therapeutic challenge. Treatment of some deep cutaneous and subcutaneous mycoses remains unresolved, relapses are frequent, lack of tolerability of the antifungal drugs becomes an obstacle, and, unfortunately, surgery is, in some cases, the last option. The development of allylamine antifungals, of which terbinafine is the most effective to date, may help to resolve this situation. In vitro, terbinafine is highly active against a broad spectrum of pathogenic fungi. Clinical studies have shown that terbinafine is effective in the treatment of both cutaneous and lymphocutaneous sporotrichosis, and in several patterns of disseminated and refractory aspergillosis. Patients with chromoblastomycosis, and other mycoses (phaeohyphomycosis, maduromycosis, and mucormycosis) have also been successfully treated with terbinafine. Old World cutaneous leishmaniasis, a parasitic disease, has also been treated with terbinafine. These results suggest that the therapeutic potential of terbinafine extends well beyond its currently licensed applications to include a range of serious and life-threatening subcutaneous and systemic mycoses.

Endemic mycoses: a treatment update.

Endemic mycoses remain a major public health problem in several countries and they are becoming increasingly frequent with the spread of HIV infection. Amphotericin B remains the drug of choice during the acute stage of life-threatening endemic mycoses occurring in both immunocompetent and immunocompromised hosts. Ketoconazole is effective in non-AIDS patients with non-life-threatening histoplasmosis, blastomycosis, or paracoccidioidomycosis. Itraconazole is the treatment of choice for non-life-threatening Histoplasma capsulatum or Blastomyces dermatitidis infections occurring in immunocompetent individuals and is the most efficient secondary prophylaxis of histoplasmosis in AIDS patients. Itraconazole is also effective in lymphocutaneous and visceral sporotrichosis, in paracoccidioidomycosis, for Penicillum marneffei infection, and is an alternative to amphotericin B for Histoplasma duboisii infection. Coccidioidomycosis may be effectively treated with prolonged and sometimes life-long itraconazole or fluconazole therapy. Fluconazole has relatively poor efficacy against histoplasmosis, blastomycosis and sporotrichosis. New antifungal agents have been tested in vitro or in animal models and may soon be evaluated in clinical trials.

Fine‐needle aspiration cytologic diagnosis of lymphocutaneous sporotrichosis: A case report

Fine‐needle aspiration cytologic diagnosis of lymphocutaneous sporotrichosis: A case report

Outbreak of sporotrichosis among tree nursery workers.

In spring 1994, an outbreak of sporotrichosis occurred at a tree nursery in Florida; 9 (14%) of 65 workers involved in production of sphagnum moss topiaries developed lymphocutaneous sporotrichosis. A cohort study of all 65 employees was conducted to identify risk factors for sporotrichosis, and an environmental investigation was done. The risk of sporotrichosis increased significantly with the duration of working with sphagnum moss (P < .05), in particular with filling topiaries (P < .05), and with having less gardening experience (P < .05). Wearing gloves was protective (P < .005). Sporothrix schenckii was cultured from patients and sphagnum moss used in topiary production. Use of restriction fragment length polymorphism revealed an identical pattern for patient isolates that was different from the patterns of environmental isolates. Physicians should be aware of sporotrichosis in patients with ulcerative skin lesions who have a history of occupational or recreational exposure to sphagnum moss.

Successful treatment of cutaneous sporotrichosis with terbinafine

Three cases of lymphocutaneous sporotrichosis were successfully treated with oral terbinafine at a dose of 125 mg once daily rather than 250 mg twice daily as reported previously. The clinical response was rapid in two patients. The duration of treatment was 8, 10 and 29 weeks, respectively, for the three patients treated. No major side-effects were noted. There was no relapse on subsequent follow-up. Terbinafine at a dose of 125 mg once daily thus proved to be effective and safe in the treatment of lymphocutaneous sporotrichosis.

Old and New Therapies for Sporotrichosis

The old therapies for sporotrichosis--saturated solution of potassium iodide (SSKI) and amphotericin B--have largely been supplanted by itraconazole treatment. Although SSKI is effective for the treatment of lymphocutaneous sporotrichosis, it is difficult to administer and is frequently associated with side effects; response rates of >90% are associated with itraconazole therapy for lymphocutaneous sporotrichosis. Patients with osteoarticular sporotrichosis rarely have systemic symptoms and can be effectively treated with a prolonged course of itraconazole, thus obviating the need for intravenous amphotericin B therapy with its associated toxic effects. Pulmonary sporotrichosis in patients infected with human immunodeficiency virus continue to be difficult therapeutic problems, but itraconazole appears to be at least as effective as amphotericin B as treatment for these forms of sporotrichosis.

Itraconazole in the Treatment of Sporotrichosis: A Korean Experience

We describe three cases of sporotrichosis which were successfully treated with itraconazole 100mg daily. Itraconazole was effective and well tolerated in one patient with lymphocutaneous sporotrichosis who discontinued potassium iodide therapy because of side-effects and in two patients with fixed cutaneous sporotrichosis.

Newer Developments in Therapy for Endemic Mycoses

In the 1960s and 1970s, amphotericin B was the only effective therapy for serious systemic endemic fungal infections due to Histoplasma capsulatum, Blastomyces dermatitidis, and Sporothrix schenckii. In the 1980s, ketoconazole was introduced as therapy for endemic mycoses; after this antifungal agent was introduced, some of these infections could be treated orally in an outpatient setting rather than intravenously in an inpatient setting. The 1990s have become the triazole era. It is now standard practice to treat nonmeningeal, non-life-threatening histoplasmosis and blastomycosis orally on an outpatient basis; the drug of choice for this treatment is itraconazole. Itraconazole also has proved useful as treatment for histoplasmosis in patients infected with human immunodeficiency virus. Although itraconazole has not yet been approved for the treatment of sporotrichosis, in preliminary studies it has been shown to be effective therapy not only for cutaneous and lymphocutaneous sporotrichosis but also for disseminated infection with S. schenckii.

Systemic Sporotrichosis Treated with Itraconazole

Amphotericin B is recommended for the treatment of systemic infection caused by Sporothrix schenckii. However, this agent is toxic, its use is frequently followed by relapse, and some isolates of S. schenckii are resistant. Recent studies suggest that newer azole compounds, such as itraconazole, are effective in cutaneous and lymphocutaneous sporotrichosis, but data on their efficacy in systemic infections are scarce. We used itraconazole in the sequential treatment of six patients with systemic sporotrichosis: three with bone and joint disease and three with disseminated infection manifested by subcutaneous nodules. In all six cases, symptoms and signs of infection improved, with resolution of subcutaneous nodules, normalization of imaging studies, cessation of wound drainage, and return of joint mobility and function. No toxicity was noted. One patient with disseminated infection had a relapse while receiving 100 mg of itraconazole daily. The average duration of follow-up was 18 months. Thus itraconazole appears promising for the treatment of systemic sporotrichosis. A dose of at least 200 mg/d appears to be needed to prevent relapse.

Sporotrichosis following a rodent bite

A ten year old boy developed lymphocutaneous sporotrichosis following a wild rodent bite. The infection was successfully treated with potassium iodide. Sporotrichosis in humans has followed bites, pecks and stings inflicted by a variety of animals, birds and insects. Many species of animals are susceptible to infection by Sporothrix schenkii, but transmission from infected animals to man is uncommon.

Mother‐and‐Child Cases of Infection

We report the appearance of lymphocutaneous sporotrichosis on the left arm of a 28-year-old farmer's wife, followed two months later by the same type of lesion on the right upper eyelid of this patient's three-year-old child. According to the mother, the child was accustomed to sleeping with the right side of her face applied to the lesion on the mother's arm, and so it was presumed that the infection had been transmitted by direct contact from mother to child. Cases of person-to-person contagion of this disorder are thought to be extremely rare, but where there has been close contact on a daily basis, such contagion is likely to occur.

Sporotrichosis in a father and son

A 41-year-old man developed classic lymphocutaneous sporotrichosis on the left arm; his 2-year-old son developed a single lesion of the “fixed“ type on the right leg. Both patients responded rapidly to therapy with oral potassium iodide. Seven previous reports of familial sporotrichosis are listed, and therapy is reviewed briefly.

Immunologic profile of a patient with lymphocutaneous sporotrichosis

Sporotrichosis is characterized by a wide range of clinical manifestations from mild fixed cutaneous forms to systemic dissemination of the disease, despite an apparent regular pattern of virulence of the etiological agent, S. schenckii. These facts suggest that immunological mechanisms of the host could play an important role on the pathogenesis of the mycosis. On this basis, an immunologic survey was carried out in patients with lymphocutaneous sporotrichosis. Cell-mediated immunity was evaluated by means of lymphocyte transformation stimulated with phytohaemagglutinin and the response to several intradermal reaction antigens. Lymphocyte blastic transformation was normal as compared with a control group. All patients were positive at least against one of the antigens tested. These results indicate that this group of patients did not show any cell-mediated immunity deficiency. Serum immunoglobulins (IgG, IgM, IgA), and C3 measured to evaluate humoral immunity, were also within normality. Since many cases of sporotrichosis cure with the administration of potassium iodine, whose mechanisms of therapeutic activity are unknown, a possible impairment in the management of iodine was investigated, with the premise that iodine enhances the host defenses rather than acting against the fungus. Thyroid function tests performed in all patients to support this hypothesis, gave normal results. These data permit to conclude that susceptibility to sporotrichosis in the affected patients does not depend on gross abnormal humoral and/or cell-mediated immunity, and their response to potassium iodine is not related to deficient thyroid function.

Sporotrichosis in Sudan

Two cases of lymphocutaneous sporotrichosis are reported from Sudan in a boy aged four and a half years and a girl aged 16 years respectively. Diagnosis was based mainly on the clinical findings and the dramatic response to treatment with oral potassium iodine, as well as the histological finding of yeasts compatible with the yeast phase Sporothrix schenkii.