Sporotrichosis in a liver transplant patient: A case report and literature review

Sporothrix brasiliensis Causing Atypical Sporotrichosis in Brazil: A Systematic Review

Zoonotic sporotrichosis, a subcutaneous mycosis caused by Sporothrix brasiliensis, has become hyperendemic and a serious public health issue in Brazil and an emerging disease throughout the world. Typical sporotrichosis is defined as fixed or lymphocutaneous lesion development, however, reports of atypical presentations have been described in hyperendemic areas, which may result in a worse prognosis. Thus, considering an increase in atypical cases and in more severe extracutaneous cases and hospitalizations reported in Brazil, we aimed to perform a systematic review to search for hypersensitivity reactions (HRs) and extracutaneous presentations associated with zoonotic sporotrichosis. A systematic review was performed, following the PRISMA guidelines to search for atypical/extracutaneous cases (mucosal, osteoarthritis, HRs, pulmonary, meningeal) of zoonotic sporotrichosis. A total of 791 published cases over 26 years (1998-2023) in eleven Brazilian states were reviewed. Most cases corresponded to a HR (47%; n = 370), followed by mucosal (32%; n = 256), multifocal (8%; n = 60), osteoarthritis (7%; n = 59), meningeal (4%; n = 32), and pulmonary (2%; n = 14) infections. When available (n = 607), the outcome was death in 7% (n = 43) of cases. Here, we show a frequent and worrisome scenario of zoonotic sporotrichosis in Brazil, with a high and dispersed incidence of atypical/extracutaneous cases throughout the Brazilian territory. Therefore, educational measures are necessary to make health professionals and the overall population aware of this fungal pathogen in Brazil as well as in other countries in the Americas.

Fixed Cutaneous Sporotrichosis Due to Sporothrix globosa

Purpose

This report describes a case of a skin sporotrichosis infection and the steps taken to identify an effective antifungal treatment.

Patients and Methods

A 50-year-old woman from Jilin province, China, presented complaining of a small mass that had been on her right upper eyelid for two years. A skin biopsy was taken and submitted for bacterial and mycological assessment. Bacterial culture from the lesion was negative, but a fungal culture was positive. In vitro susceptibility test was performed to assess its susceptibility to antifungal drugs.

Results

The skin biopsy showed infectious granuloma. Fungal culture was identified as Sporothrix globosa based on both the morphological features and confirmation by the molecular method; it was resistant to many kinds of antifungal drugs, including amphotericin B, voriconazole, fluconazole, and caspofungin. However, it was relatively sensitive to itraconazole. The patient was prescribed 0.2 g itraconazole to be taken twice per day. One month later, she had almost completely recovered from her symptoms. The treatment lasted for 3 months and her liver function and renal function were normal at the endpoint.

Conclusion

Itraconazole was an effective treatment in this case of a multidrug-resistant sporotrichosis caused by S. globosa.

Sporotrichosis in renal transplant patients: two case reports and a review of the literature

INTRODUCTION

Sporotrichosis is a rare fungal infection in transplant patients; among these patients, it occurs mostly in renal transplant patients. Sporothrix schenkii is the primary pathogen responsible. A high index of suspicion is required to make the diagnosis keeping important differential diagnoses in mind. History of trauma through recreational or occupational exposure to the fungus may assist in making the diagnosis. Treatment is difficult, with long-term use of potentially nephrotoxic and cytochrome P450 inhibitor antifungal agents leading to potential calcineurin inhibitors toxicity. We describe two renal transplant patients presenting with distinct sporotrichosis infection: "Case 2" being only the second reported case ever of meningeal sporotrichosis. We subsequently review the general aspects of sporotrichosis, specifically in renal transplant patients as described in the medical literature.

CASE PRESENTATION

Case 1, a 43-year-old mixed ancestry male patient presented with a non-healing ulcer on the left arm for 1 year, he was diagnosed with cutaneous sporotrichosis and was successfully treated with itraconazole monotherapy. Case 2, a 56-year-old mixed ancestry male patient presented with a slow decline in functions, confusion, inappropriate behavior, rigors and significant loss of weight and appetite over the past 4 months, he was diagnosed with meningeal sporotrichosis and was successfully treated with a combination of deoxycholate amphotericin B and itraconazole.

CONCLUSION

Physicians taking care of renal transplant patients should have a high index of suspicion for sporotrichosis infection particularly when conventional therapy for common conditions fails. Susceptibility testing is recommended to identify the most effective antifungal agent and its dose. The slow nature of growth of Sporothrix schenkii necessitates patients to be on amphotericin B until the time results are available. Finally, there is a need to be aware of potential drug-drug interactions of the azoles with calcineurin inhibitors and the required dose adjustments to prevent therapy related adverse events.

Disseminated Sporotrichosis in a Liver Transplant Patient: A Case Report

Sporotrichosis is an infection caused by the fungus of the Sporothrix schenckii complex and can be particularly harmful in immunocompromised patients. We report the case of a 26-year-old male patient with a previous history of pulmonary infection who underwent a liver transplant for Budd-Chiari syndrome. After the procedure, he presented with persistent fever and leukocytosis. On the 13th post-operative day, he was diagnosed with thrombosis of the hepatic artery and underwent a second liver transplant 15 days after the first procedure. After the retransplant, he presented daily episodes of fever, even after the use of several antimicrobial, antiviral, and antifungal agents. A number of negative cultures from different sites were obtained. After an acute episode of mental confusion, the growth of S schenckii was observed in cultures from cerebrospinal fluid and ascites obtained from a diagnostic paracentesis. Treatment with amphotericin B was started but the patient died on the fourth day of antifungal treatment, from a massive gastrointestinal hemorrhage. We found no previous report in the literature of spontaneous dissemination of S schenckii to the abdominal cavity causing peritonitis.

Sporotrichosis In Immunocompromised Hosts

Sporotrichosis is a global implantation or subcutaneous mycosis caused by several members of the genus Sporothrix, a thermo-dimorphic fungus. This disease may also depict an endemic profile, especially in tropical to subtropical zones around the world. Interestingly, sporotrichosis is an anthropozoonotic disease that may be transmitted to humans by plants or by animals, especially cats. It may be associated with rather isolated or clustered cases but also with outbreaks in different periods and geographic regions. Usually, sporotrichosis affects immunocompetent hosts, presenting a chronic to subacute evolution course. Less frequently, sporotrichosis may be acquired by inhalation, leading to disseminated clinical forms. Both modes of infection may occur in immunocompromised patients, especially associated with human immunodeficiency virus (HIV) infection, but also diabetes mellitus, chronic alcoholism, steroids, anti-TNF treatment, hematologic cancer and transplanted patients. Similar to other endemic mycoses caused by dimorphic fungi, sporotrichosis in immunocompromised hosts may be associated with rather more severe clinical courses, larger fungal burden and longer periods of systemic antifungal therapy. A prolonged outbreak of cat-transmitted sporotrichosis is in progress in Brazil and potentially crossing the border to neighboring countries. This huge outbreak involves thousands of human and cats, including immunocompromised subjects affected by HIV and FIV (feline immunodeficiency virus), respectively. We reviewed the main epidemiologic, clinical, diagnostic and therapeutic aspects of sporotrichosis in immunocompromised hosts.

Cutaneous Complications in Recipients of Lung Transplants: A Pictorial Review

Lung transplant is now an established modality for a broad spectrum of end-stage pulmonary diseases. According to the International Society for Heart and Lung Transplantation Registry, more than 50,000 lung transplants have been performed worldwide, with nearly 11,000 recipients of lung transplants alive in the United States. With the increasing use of lung transplant, pulmonologists must be cognizant of the common as well as the unique posttransplant dermatologic complications. Immunosuppression, infections, and a variety of medications and environmental exposures can contribute to these complications. This review aims to provide representative pictures and describe the pathogenesis, epidemiologic characteristics, and clinical manifestations of dermatologic complications encountered among recipients of lung transplants.

Immunopathogenesis of Human Sporotrichosis: What We Already Know

Sporotrichosis is a subacute/chronic mycosis caused by dimorphic fungus of the genus Sporothrix. This mycosis may affect both human and domestic animals and in the last few years, the geographic dispersion and increase of sporotrichosis worldwide has been observed. The occurrence of cases related to scratching/bites of domestic felines have increased, characterizing the disease as predominantly a zoonosis. In humans, sporotrichosis mainly involves the cutaneous tegument of infected patients, but other tissues may also present the infection. The main forms of clinical presentation are lymphocutanous sporotrichosis (LC) and fixed sporotrichosis (F). Although less common, mucosal, cutaneous disseminated, and extracutaneous forms have also been described. Multiple factors from the fungus and host can play a role in driving the clinical evolution of sporotrichosis to benign or severe disease. In this review, we discuss the immunopathological aspects involved in human sporotrichosis. Putting together the two branches of knowledge—host immune response and fungal evading mechanisms—we may perceive new possibilities in understanding the fungus–host interaction in order to be in a position to go further in the control of sporotrichosis.

Sporotrichosis by Sporothrix schenckii senso stricto with itraconazole resistance and terbinafine sensitivity observed in vitro and in vivo: Case report

We report a case of a patient with lymphocutaneous sporotrichosis in the right upper limb. The fungus was identified as Sporothrix schenckii senso stricto by calmodulin gene sequencing. The initial treatment was itraconazole (200 mg/day), but in vitro antifungal susceptibility demonstrated high resistant to this and another six antifungals, with exception to terbinafine. The lesions did not regress with itraconazole treatment. Thus, 500 mg/day of terbinafine was prescribed and clinical cure was obtained after four months.