Sporotrichosis caused by Sporothrix brasiliensis in Argentina: Case report, molecular identification and in vitro susceptibility pattern to antifungal drugs.

Sporotrichosis is considered a neglected disease of humans and animals in many regions of the world and is the most frequent implantation mycosis in Latin America. OBJECTIVES: To illustrate the zoonotic importance of the disease, describing a case involving a veterinarian and an infant that acquired the disease from a domestic cat and to describe, genotype and characterize these new isolates. METHODS: Direct examination of tissue samples from the two patients and feline lesions revealed the presence of Sporothrix yeast-like organisms. Fungal cultures and molecular identification of the strains were performed. Since antifungal susceptibility data of animal-borne isolates are scarce, the in vitro susceptibility testing by a microdilution reference method was determined against azoles, amphotericin B and terbinafine. RESULTS: Fungal culture and sequence analysis of the ITS region of rDNA and calmodulin and ß-tubulin genes confirmed the diagnosis and the causative agent as Sporothrix brasiliensis. In all cases, terbinafine was the most active drug, followed by posaconazole, itraconazole and voriconazole; the least active drugs were amphotericine B and fluconazole. Lack of clinical response in the veterinarian and in the infant to itraconazole and potassium iodide, respectively was observed. CONCLUSIONS: This study contributed to the molecular epidemiology of Sporothrix species in Argentina and the characterization of the in vitro susceptibility pattern of S. brasiliensis isolates recovered from a cat and two humans involved in this case of zoonotic sporotrichosis. Bearing in mind the "One Health" concept, the experience described in the present study highlights the need for future strategies for sporotrichosis treatment, control and prevention.

Esporotricosis linfocutánea. A propósito de un caso pediátrico / Lymphatic-cutaneous sporotrichosis. A pediatric case

La esporotricosis es la micosis subcutánea más frecuente en Uruguay. Es producida por hongos del complejo Sporothrix. Su reservorio son los restos vegetales y madera en descomposición. En su hábitat natural las condiciones climáticas, temperatura y humedad son variables, pero es inviable a 40°C. Afecta al hombre y animales. Es una enfermedad ocupacional y recreativa, poco frecuente en la edad pediátrica. En nuestro país el modo habitual de adquirirla es a través de arañazos de armadillos (mulitas). La forma clínica clásica y más frecuente de la esporotricosis se caracteriza por un chancro cutáneo de inoculación acompañado de una linfangitis de carácter nodular y troncular. Su evolución tiene un desarrollo subagudo y crónico. A pesar de su signología típica es muchas veces confundida con otras afecciones dermatológicas lo que retarda el diagnóstico. La presentación visceral u osteoarticular es excepcional. El diagnóstico definitivo requiere el aislamiento del hongo en cultivos a partir del sitio de infección. La resolución espontánea es poco común. El tratamiento recomendado es itraconazol administrado durante 3 a 6 meses. También puede utilizarse de manera alternativa yoduro de potasio y la terbinafina. La termoterapia local preconizada por la escuela micológica uruguaya significa muchas veces una valiosa alternativa terapéutica. El objetivo de esta comunicación es la presentación del caso clínico de un niño que cursó una esporotricosis cutáneo-linfática. La misma fue confirmada por estudio micológico y recibió tratamiento con itraconazol y termoterapia local, con buena respuesta.

Sporotrichosis is the most frequent subcutaneous mycosis in Uruguay. It is caused by fungi from the Sporothrix complex. This fungus lives in decaying plant matter, including wood. Climate, temperature and humidity vary in their natural habitat, although they cannot survive when it is hotter than 40°C. It affects both men and animals. Sporotrichosis is an occupational and recreational disease, rather unusual in children. In our country it is usually acquired through armadillo scratches. The classical and most frequent clinical presentation is characterized by a chancre following inoculation, accompanied by nodular and troncular lymphangitis. Evolution of the condition has a subacute and chronic development. In spite of its typical signs, it is often confused with other skin diseases, what delays diagnosis. Visceral or osteoarticular presentation is exceptional. Final diagnosis requires the fungus to be isolated in cultures from the site of the infection. Spontaneous resolution is rather unusual. Itraconazole during 3 to 6 months is the recommended treatment. Alternatively, potassium iodide and terbinafine may be used. Local thermotherapy, recommended by the Uruguayan mycological school often constitutes a valuable therapeutic alternative. This study aims to present the clinical case of a boy with a lymphatic-cutaneous sporotrichosis. The condition was confirmed by mycological studies and he was treated with itraconazole and local thermotherapy, the response being good.

Two cases of sporotrichosis of the right upper extremity in right-handed patients with diabetes mellitus / Dos casos de esporotricosis de la extremidad superior derecha en pacientes diestros con diabetes mellitus

Background. Sporothrix species have proved to show high degrees of endemicity. Sporothrix globosa is the only pathogenic Sporothrix species that has till date been reported from China, where it is endemic in the northeastern provinces. Aims. We report two cases of lymphocutaneous sporotrichosis with diabetes mellitus as underlying disease in patients from the non-endemic area of China. Methods. A 59-year-old farmer and a 60-year-old gardener were admitted in February and June 2014, respectively. Both patients were right-handed men and presented with progressive plaques and nodules, which they had for several years, involving the right upper extremity. Skin biopsy from the granuloma was taken and cultured on Sabouraud medium, and molecular identification based on the calmodulin region was performed. Antifungal susceptibility testing was also performed with the microdilution method. Results. Biopsy of the lesions showed the presence of infectious granuloma. The fungal cultures were identified as Sporothrix globosa by conventional methods, and confirmed by molecular identification. A subsequent course of oral antifungal therapy with low dosage of itraconazole was well tolerated and resolved the infection. Conclusions. Identification of fungal species and antifungal susceptibility testing are mandatory for epidemiological and therapeutic reasons. Early diagnosis of sporotrichosis is essential to prevent those sequelae when the disease progresses and provides highly effective methods for treating this emerging disease. Avoiding the exposure to plant material potentially contaminated with fungal spores should be recommended, especially in immunocompromised patients (AU)

Antecedentes. Las especies de Sporothrix han demostrado un alto nivel de endemicidad. Sporothrix globosa es la única especie patógena descrita hasta la fecha en China, donde es endémica en las provincias del nordeste. Objetivos. Se describen dos casos de esporotricosis linfocutánea con diabetes mellitus como enfermedad de base, en pacientes procedentes de un área no endémica de China. Métodos. Un campesino de 59 años y un jardinero de 60 años de edad fueron atendidos en febrero y junio de 2014, respectivamente. Ambos eran varones, diestros y se presentaron con placas y nódulos de varios años de evolución, que afectaban a la zona superior del brazo derecho. Se tomaron biopsias de los granulomas de la piel, que fueron cultivados en medio de Sabouraud, y se realizó una identificación molecular basada en la región de la calmodulina. Se evaluó la sensibilidad a los antifúngicos mediante el método de microdilución. Resultados. La biopsia de las lesiones mostró la presencia de un granuloma infeccioso. Los hongos aislados en los cultivos fueron identificados como Sporothrix globosa por métodos convencionales, y confirmados mediante identificación molecular. La subsecuente administración de terapia antifúngica oral con bajas dosis de itraconazol fue bien tolerada y resolvió la infección. Conclusiones. La identificación de las especies fúngicas y el análisis de la sensibilidad a los antifúngicos son necesarios por razones epidemiológicas y terapéuticas. El diagnóstico temprano de la esporotricosis es esencial para prevenir las secuelas que genera el progreso de la enfermedad y para ofrecer métodos altamente efectivos para el tratamiento de esta enfermedad emergente. Debe recomendarse evitar la exposición a material vegetal potencialmente contaminado con esporas fúngicas, especialmente en pacientes inmunocomprometidos (AU)

Treatment of cutaneous sporotrichosis with itraconazole--study of 645 patients.

BACKGROUND: Itraconazole has become the first choice for treatment of cutaneous sporotrichosis. However, this recommendation is based on case reports and small series. The safety and efficacy of itraconazole were evaluated in 645 patients who received a diagnosis on the basis of isolation of Sporothrix schenckii in Rio de Janeiro, Brazil. METHODS: A standard regimen of itraconazole (100 mg/day orally) was used. Clinical and laboratory adverse events were assessed a grades 1-4. A multivariate Cox model was used to analyze the response to treatment. RESULTS: The median age was 43 years. Lymphocutaneous form occurred in 68.1% and fixed form in 23.1%. Six hundred ten patients (94.6%) were cured with itraconazole (50-400 mg/day): 547 with 100 mg/day, 59 with 200-400 mg/day, and 4 children with 50 mg/day. Three patients switched to potassium iodide, 2 to terbinafine, and 4 to thermotherapy. Twenty-six were lost to follow-up. Clinical adverse events occurred in 18.1% of patients using 100 mg/day and 21.9% of those using 200-400 mg/day. The most frequent clinical adverse events were nausea and epigastric pain. Laboratory adverse events occurred in 24.1%; the most common was hypercholesterolemia, followed by hypertriglyceridemia. Four hundred sixty-two patients (71.6%) completed clinical follow-up, and all remained cured. Only 2 variables were significant in explaining the cure: patients with erythema nodosum healed faster, and lymphocutaneous form took longer to cure. CONCLUSIONS: In the current series, the therapeutic response was excellent with the minimum dose of itraconazole, and there was a low incidence of adverse events and treatment failure.

Sporotrichosis: an update.

Sporotrichosis is the most frequent and worldwide distributed subcutaneous mycoses. The aim of this article is to review the most recent aspects of sporotrichosis about its epidemiology, etiologic agents, mycologic characteristics, clinical features, diagnosis and treatment. The causative agents of sporotrichosis belong to five well defined species of dimorphic fungi of the called Sporothrix schenckii complex. Sporotrichosis and its etiologic agents have specific endemic areas, but it is possible to find epidemics of the disease in practically every continent, the entrance via is cutaneous due to the inoculation of the fungi into the skin after a traumatism and less frequent due to respiratory way. Clinical manifestations are widely variable, with important involvement of the skin and the superficial lymphatic system, but also with affection of the mucosa and some organs like lungs, bones and joints. Nowadays sporotrichosis is considered a true zoonosis with important changes related to the endemic areas and the ecologic features of the causative pathogens. The therapy of choice is the potassium iodide (KI), but other alternatives are itraconazole, terbinafine, thermotherapy and in severe cases amphotericin B. The importance of the recognition of the clinical manifestations of the disease in some non-endemic areas helps to challenge the diagnosis and give an accurate therapy.

[Sporotrichosis and dematiaceous fungal skin infections].

Sporotrichosis is a chronic infectious granuloma of skin. The detection of fungal elements in pathological examination and the isolation of Sporothrix schenckii from the lesion are requisite for diagnosis. The sporotrichin test is useful as an auxiliary examination, but a false-negative reaction might occur in some cases. Oral potassium iodide is first choice of treatment, because of its modest cost and usefulness, although gastrointestinal disorder is a frequent side effect. Itraconazole should be the second selection, and then terbinafine. Local thermotherapy is also effective as an additional therapy. Dematiaceous fungal skin infections are divided into two groups by their parasitic form, chromoblastomycosis and phaeohyphomycosis. Chromoblastomycosis is also called chromomycosis in Japan. It is most important for clinical diagnosis to detect dark brown spores in the scale of chromoblastomycosis and dark brown hyphae in the pus of phaeohyphomycosis by microscopic examination. Both morphological and molecular biological approaches are recommended for identification of fungi. In treatment, the drug appropriate in each case should be selected, and the combination of surgical excision, local thermotherapy, laser therapy or cryotherapy must be considered.

Fixed sporotrichosis as a cause of a chronic ulcer on the knee.

Chronic wounds are a major health care problem worldwide. Wound healing is a holistic endeavour that requires an accurate identification of the specific entities interfering with wound healing in a particular patient. We present a case of fixed sporotrichosis as the cause of a chronic ulcer in the knee. Although a culture of Sporothrix schenckii could not be obtained, a positive response to the sporotrichin skin test, a skin biopsy showed a suppurative granuloma and an adequate response to oral administration of potassium iodide confirmed the diagnosis. The identification and correction of the underlying aetiology of any chronic wound is the first and most important step to restore wound healing.

Sporotrichosis in childhood: clinical and therapeutic experience in 25 patients.

Sporotrichosis in an uncommon mycoses in childhood and is generally associated with injuries received as a consequence of farm work. We undertook a retrospective study of sporotrichosis in children and adolescents seen over a 10-year period, focusing on their clinical, epidemiologic, and mycologic features as well as treatment. We included 25 children with a mean age of 9.3 years. Most of those affected were schoolchildren (84%) from rural areas. The main clinical variety of sporotrichosis seen was the lymphocutaneous form (64%), followed by the fixed cutaneous form (36%), and one instance of the disseminated cutaneous form. Most lesions were located on the upper limbs (40%) and the face (36%). Sporothrix schenckii was isolated in all patients and 24 of 25 had a positive sporotrichin skin test. Nineteen patients were treated and cured clinically and mycologically with potassium iodide, three were cured with itraconazole and one with heat therapy.

A case of lymphangitic sporotrichosis occurring on both forearms with a published work review of cases of bilateral sporotrichosis in Japan.

The patient, 56-year-old man who was working as a clerk and a farmer, presented with nodules that had appeared on the dorsa of both his hands 3 months earlier. At the first examination, there were multiple dark-red nodules scattered on the fingers, dorsa and wrists of both hands. The nodules were up to 3 cm in diameter and had crusts in the incenters. The patient was suspected to suffer from prurigo and was subsequently treated with topical steroid, but the nodules did not respond. Therefore, a skin biopsy and fungal culture were performed, and the patient was finally diagnosed as having bilateral multiple sporotrichosis. He was then successfully treated with local thermotherapy and oral potassium iodide. Bilaterally-distributed lymphangitic sporotrichosis is very rare and often difficult to diagnose. Careful attention is required to avoid misdiagnosis.

Esporotricosis: a proposito de un caso linfocutaneo / Sporotrichosis: a lymphocutaneus case

Se presenta un caso de esporotricosis linfocutánea de las extremidades tipo clásico. El diagnósdtico de certeza se hizo a través del cultivo; se logró la curación luego de 6 meses de tratamiento con toduro de potasio por vía bucal y termoterapia local con secuelas cicatrizales en el miembro afectado(AU)

Esporotricosis: a proposito de un caso linfocutaneo / Sporotrichosis: a lymphocutaneus case

Se presenta un caso de esporotricosis linfocutánea de las extremidades tipo clásico. El diagnósdtico de certeza se hizo a través del cultivo; se logró la curación luego de 6 meses de tratamiento con toduro de potasio por vía bucal y termoterapia local con secuelas cicatrizales en el miembro afectado

Comunicación de tres casos de esporotricosis en San Luis: una micosis de diagnóstico infrecuente en esta zona geográfica / Sporotrichosis in the province of San Luis: three cases presentation of an infrequent mycosis in our area

Presentamos a tres pacientes afectados de esporotricosis linfangítico-nodular, con las características comunes en lo concerniente a la clínica y el laboratorio. Lo distintivo estaría que nuestra área geográfica es naturalmente seca y, durante muchos meses del año, fría, es decir, una zona no apta para el desarrollo del hongo Sporothrix schenckil. Uno de nuestros pacientes se infectó, aparentemente, debido a una herida punzante con una astilla de material plástico. Exhortamos a los clínicos y dermatólogos de nuestra región a pensar en la esporotricosis como diagnóstico diferencial etiológico de todas las úlceras y abscesos "fríos" que no curen con los tratamientos habituales y por lo tanto su evolución crónica (AU)

Comunicación de tres casos de esporotricosis en San Luis: una micosis de diagnóstico infrecuente en esta zona geográfica / Sporotrichosis in the province of San Luis: three cases presentation of an infrequent mycosis in our area

Presentamos a tres pacientes afectados de esporotricosis linfangítico-nodular, con las características comunes en lo concerniente a la clínica y el laboratorio. Lo distintivo estaría que nuestra área geográfica es naturalmente seca y, durante muchos meses del año, fría, es decir, una zona no apta para el desarrollo del hongo Sporothrix schenckil. Uno de nuestros pacientes se infectó, aparentemente, debido a una herida punzante con una astilla de material plástico. Exhortamos a los clínicos y dermatólogos de nuestra región a pensar en la esporotricosis como diagnóstico diferencial etiológico de todas las úlceras y abscesos "fríos" que no curen con los tratamientos habituales y por lo tanto su evolución crónica

[A case of cutaneous pseudallescheriosis resembling sporotrichosis].

An 83-year-old man with aplastic anemia and steroid induced diabetes mellitus developed multiple nodules with pus on the back of his right hand and forearm. He had been treated with a daily dose of 30mg prednisolone for 2 months. These lesions had appeared a month before his visit. The histopathological findings revealed dermal abscesses containing hyphal structures, lymphocytes, histiocytes and giant cells. Grocott-Methenamine stain demonstrated abundant fungal elements. In culture, colonies grow rapidly and produce a white, cottony mycelium which later becomes gray in color. Microscopically, ovoid and pyriform conidia are produced at the ends of long slender conidiophores. On PCA agar, synnemata with small conidal heads developed at 37 degrees C but cleistothecia did not appear. The patient did not respond to itraconazole therapy, however, with hyperthermic treatment, the eruptions gradually healed. Based on these findings, this fungal infection was diagnosed as pseudallescheriosis.

[Experience with 241 sporotrichosis cases in Chiba/Japan]. / Erfarungen mit 241 Sporotrichose-Fällen in Chiba/Japan.

Between 1965 and 1991, 241 cases of sporotrichosis have been seen in the Department of Dermatology at Chiba University Hospital. Children under the age of 12 and patients older than 40 years had a higher rate of infection. Most affected were the upper extremities, followed by lesions of the face. One hundred twenty-four patients (51.5%) were farmers. The decrease in the number of patients observed since 1983 is attributed mainly to a drop in the percentage of the local population involved in agriculture. There was no correlation between the number of infections and the amount of precipitation, as had been suggested earlier. The patients were treated with potassium iodide and in some cases with additional thermotherapy.

Eight cases of sporotrichosis.

About 1,100 cases of sporotrichosis were reported in Japan between 1955 and 1973. From February 1975, when our hospital opened, to November 1979, we encountered eight cases of this disease. The patients, two males and six females, were aged from 6 months to 90 years old. Among the clinical types, three cases were of the lymphangitic type and five cases were of the localized type. Seven cases treated with oral potassium iodine and one case treated with topical thermotherapy were cured or improved by such treatments. We report here these eight cases with a discussion on clinical manifestations in previous reports of cases in Japan.