Lymphatic Skin Sporotricosis: Case Report Volume 4 - Issue 1

Carlos Eduardo Cardoso*¹,Rayanne Barreto Lopes¹, Thais Rocha Salim, Marco Orsini^1,2, Eduardo Tavares Lima Trajano¹, Victor Hugo Bastos²,Marcos RG de Freitas³,Silmar Teixeira² and Marco Aurelio dos Santos Silva¹

• ¹Professional Master's Program Applied in Health Sciences and Medical Graduation Course of Vassouras University, Brazil
• ²Brain Mapping andPlasticity Laboratory (LAMPLACE), Federal University of Piaui (UFPI), Brazil
• ³Neurology Service - Rio de Janeiro Federal University - UFRJ, Brazil

Received: April 6, 2018;   Published: April 20, 2018

*Corresponding author: Carlos Eduardo Cardoso, Professional Master's Program Applied in Health Sciences of SeverinoSombra University, Vassouras, Rio de Janeiro, Brazil, Email: pesquisa.medicina@uss.br

DOI: 10.26717/BJSTR.2018.04.000984

Abstract PDF

Sporotrichosis is the most prevalent mycosis in Latin America. Its etiology has always been related to the dimorphic saprophytic fungus Sporothrixschenckii, but nowadays new species have been recognized. Sporothrixbrasiliensis is the most frequently found in Rio de Janeiro cases and is also related to atypical presentations of the disease. The main contaminated population are women and children and is transmitted by the bite or scratch of diseased felines. The main manifestations are cutaneous and present a benign course, although a long treatment of at least 90 days is usually necessary. The case reported is a 12-year-old girl living in Duque de Caxias, RJ, Brazil, with a history of cat bite and lesions on the proximal phalanx of the second left finger, caused by the bite of the animal, and a new lesion on the distal phalanx of the fourth left finger, and the presence of palpable lymphangitic cord ascending from the forearm to the left armpit, which led to the clinical- epidemiological diagnosis of lymphatic cutaneous sporotrichosis. Considering the difficulty in eradicating and controlling the vector of the disease, it is extremely important that people know how to achieve a reduction in the number of cases that have occurred, especially in the Metropolitan Region of Rio de Janeiro, where is an endemic disease.

Abbreviations: HFSE: Hospital Federal dos Servidores do Estado do Rio de Janeiro;HIV:Human Immunodeficiency Virus

Sporotrichosis, a subacute or chronic infectious disease caused by fungi of the genus Sporothrix sp. is the most common subcutaneous mycosis in Latin America. Historically, sporotrichosis has been attributed to a single species, Sporothrixschenckii, however, in 2014 four new disease-causing species were isolated[1].Its transmission, according to the classic literature, is mainly related to rural workers who have direct contact with the soil and organic derivatives that, if contaminated, can transmit the fungus by means of traumatic lesions[2]. However, sporotrichosis is seen as a zoonosis transmitted by the bite or scratching of the feline contaminated with Sporothrix sp. Barros et al and Freitas et al showed that the current epidemiological profile is composed of women of productive age and outside the labor market, which is related to a possible domiciliary transmission, unlike what is reported in the literature, which demonstrates the predominance of cases in men of advanced age and some relationship with land management[2-4]. From the epidemiological point of view, the state of Rio de Janeiro was one of the only places where the disease took on epidemic proportions and its incidence increased exponentially from the 2000s, and remained continuously elevated, forming an endemic disease[3].

K.S.B.R., 12 years old, natural and resident in Duque de Caxias, RJ, Brazil. Adolescent was admitted to the Hospital Federal dos Servidores do Estado do Rio de Janeiro (HFSE) brought by her mother, reporting that 34 days ago the patient was bitten by a street cat on the proximal phalanx of the second finger of the left hand. At the time of the accident, she sought medical attention where antirabies serum and eight doses of rabies vaccine were administered. In addition, Amoxicillin and Clavulanate were prescribed for 10 days. At the end of the antibiotic regimen, the mother reported that the initial lesion showed significant improvement, but a new lesion appeared in the distal phalanx of the 4th left hand finger, which drained purulent and bloody secretion. Concomitantly to the lesion, the patient reports that she started pain on the mobilization of the entire upper limb and appearance of a palpable lymph node in the left forearm. After 30 days, she returned to the place where she had been treated and was prescribed Itraconazole 100mg / day and Complex B, both for 30 days. She was re-consulted the next day at the same health center, when a dose of Benzathine Penicillin (1,200.00 IU / dose) was given, and prescribed Cephalexin for 10 days. Due to persistence of the lesions and lymph node chain in the upper left limb, the patient was brought by the mother to the HFSE. It presents a lymphatic path, more palpable than visible, with nodulations throughout the upper left limb from the forearm to the arm, palpable left axillary and submandibular lymph nodes and lesions in the proximal phalanx of the left 2nd finger and in the distal phalanx of the 4th left finger, both in ventral part of the left hand.

Remainder of the physical examination and anamnesis without changes worthy of note for the present case. At admission, culture of the secretion of the lesion present in the distal phalanx of the 4th left finger was performed. However, as the patient was already using the correct treatment, the culture was impaired, according to the HFSE microbiology department. Evaluated by the dermatology department, the adolescent was diagnosed with lymphatic cutaneous sporotrichosis confirmed by clinical-epidemiological criteria, which is sufficient for diagnosis. Thus, the case was notified as recommended by the Ministry of Health. Cephalexin was discontinued and since it was already in use for the systemic antifungal indicated for treatment, it only had the prolonged administration time for at least three months and continuous outpatient follow-up for the evaluation of side effects of long-term use of Itraconazole and increased treatment time according to the progression of the condition. After a month of treatment, there was little improvement of the lesions, however, each ascending lymphangitic cord in the left upper limb remained palpable with "rosary appearance". The treatment time required to achieve clinical cure, with lymph node regression and wound healing, was 132 days using Itraconazole 100 mg/day.

The manifestations most frequently reported are limited to cutaneous and lymphatic cutaneous forms, presenting a "rosary aspect" lymphatic chain, characterized by hardened nodulations and ulcers mainly in the face and upper limbs. Despite causing an exuberant dermatological clinical condition, this mycosis has, mostly, a self-limiting involvement and benign evolution[3]. In 2008, the first two deaths related to the disseminated form were reported and occurred in patients who had other associated comorbidities, such as human immunodeficiency virus (HIV) infection[5]. The diagnosis may be clinical-epidemiological, clinical or laboratorial[5]. The presence of characteristic lesions related to the history of contact with diseased feline or trauma with possibly contaminated organic material is used as clinical-epidemiological criteria; as a clinical criterion, are the characteristic lesions of the disease that respond to the treatment; and as a laboratory criterion, the most used method is the direct microbiological study of the purulent exudate and culture of the lesion with identification of the fungus Sporothrix sp[5]. The treatment of choice for cutaneous forms of sporotrichosis is Itraconazole at doses ranging from 100 to 200 mg/day with a minimum duration of three months and being maintained up to 30 days after complete clinical improvement[1,3]. Potassium Iodide, which was the first and most used drug to treat this ringworm, is another therapeutic option that has good efficacy, safety and cost, being the medicine of choice for some authors, especially in the treatment of children, since its presentation is in the liquid form[3,6].

Since sporotrichosis is a disease with a rather long treatment time, it is essential to follow the patient so that cure can be effectively achieved[1]. Even with the medication being done correctly, the lesions take a significant time to improve, and a treatment time bigger than the initially recommended one of three months may be necessary. The last epidemiological study carried out in Rio de Janeiro, between 2013 and 2016, showed that sporotrichosis endemic continues and observed that a geographic expansion of mycosis occurred in the state. The greatest difficulty in controlling sporotrichosis has been the fact that it is a zoonosis transmitted by cats, animals that are increasingly present inside the home and yet maintain contact with other felines on the street. In addition, the treatment time of animals is greater than in humans, making it difficult to perform fully.

1. Almeida-Paes R, de Oliveira MM, Freitas DF, do Valle AC, Zancope- Oliveira RM, et al. (2014) Sporotrichosis in Rio de Janeiro, Brazil: Sporothrixbrasiliensis Is Associated with Atypical Clinical Presentations. PLoSNegl Trop Dis 8(9): e3094.
2. Barros MBL, Schubach AO, Schubach TMP, Wanke B, Lambert-Passos SR (2008) An epidemic of sporotrichosis in Rio de Janeiro, Brazil: epidemiological aspects of a series of cases. EpidemiolInfect 136(9): 1192-1196.
3. Barros MBL, Tania Pacheco Schubach, Jesana Ornellas Coll, Isabella DibGremião, Bodo Wanke, et al. (2010) Esporotricose: a evolufao e os desafios de uma epidemia. Rev Pa-nam Salud Publica 27(6): 455-460.
4. Freitas DF, Antonio Carlos F do Valle, Rodrigo de Almeida Paes, Francisco I Bastos, Maria Clara G Galhardo (2010) Zoonotic sporotrichosis in Rio de Janeiro, Brazil: a protracted epidemic yet to be curbed. Clin Infect Dis 50(3): 453.
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6. Bernardes-Engemann AR, Leila M Lopes-Bezerra, Priscila M de Macedo, Rosane Orofino-Costa (2014) Esporotricose em crianfas e adolescentes atendidos no HUPE- UERJ entre 1997 e 2010: estudo clinicoepidemiologico. Revista HUPE, Rio de Janeiro 13(Supl 1): 50-54.