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Pereira-Oliveira GR, Gremião IDF, Corrêa ML, Caroline Dos Santos Honorato C, Gonçalves Viana P, Figueiredo ABF, Boechat JS, Guerino Dos Reis É, Oliveira RDVC, da Silva ACDA, Novotny TS, Guaraldo L, Pereira SA. Plasma itraconazole concentrations during treatment of feline sporotrichosis. Med Mycol 2024; 62:myae076. [PMID: 39049454 DOI: 10.1093/mmy/myae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/12/2024] [Accepted: 07/23/2024] [Indexed: 07/27/2024] Open
Abstract
Itraconazole (ITZ) is the most used drug to treat feline sporotrichosis; however, little is known about its pharmacokinetics in cats with this mycosis. The aim of this study was to determine plasma ITZ concentrations in cats with sporotrichosis treated with ITZ as monotherapy or in combination with potassium iodide (KI). Cats diagnosed with sporotrichosis received orally ITZ (100 mg/cat/day) or combination therapy with ITZ (100 mg/cat/day) and KI (2.5-5 mg/kg/day) in the case of worsening or stagnation of the clinical condition. At each monthly visit, blood samples were collected at an interval of 4 h for analysis of trough and peak plasma ITZ concentrations by HPLC. Clinical features and laboratory parameters were evaluated during follow-up. Sixteen cats were included in the study. The median plasma ITZ concentration of all cats was 0.75 µg/mL. The median plasma ITZ concentration was 0.5 µg/mL in cats that received ITZ monotherapy (n = 12) and 1.0 µg/mL in those treated with ITZ + KI (n = 4). The clinical cure rate was 56.3% (n = 9) and the median treatment duration was 8 weeks. Nine cats (56.3%) developed adverse clinical reactions, and hyporexia was the most frequent (n = 8; 88.9%). Serum alanine aminotransferase was elevated in four cats (25%). The median plasma ITZ concentration detected in cats was considered to be therapeutic (>0.5 µg/mL) and was reached after 4 weeks of treatment. Plasma ITZ concentrations were higher in cats that received ITZ + KI compared to those treated only with ITZ, suggesting pharmacokinetic synergism between these drugs.
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Affiliation(s)
- Gabriela Reis Pereira-Oliveira
- Laboratory of Clinical Research on Dermatozoonoses in Domestic Animals, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
| | - Isabella Dib Ferreira Gremião
- Laboratory of Clinical Research on Dermatozoonoses in Domestic Animals, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
| | - Maria Lopes Corrêa
- Laboratory of Clinical Research on Dermatozoonoses in Domestic Animals, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
| | | | - Paula Gonçalves Viana
- Laboratory of Clinical Research on Dermatozoonoses in Domestic Animals, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
| | | | - Jéssica Sepúlveda Boechat
- Laboratory of Clinical Research on Dermatozoonoses in Domestic Animals, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
| | - Érica Guerino Dos Reis
- Biosafety Advisory, Quality Vice-Directory, The Institute of Technology on Immunobiologicals (Bio-Manguinhos), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
| | | | | | - Thiago Santana Novotny
- Medicines Sector, National Institute for Quality Control in Health (INCQS), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
| | - Lusiele Guaraldo
- Clinical Research Laboratory on Acute Febrile Illnesses, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
| | - Sandro Antonio Pereira
- Laboratory of Clinical Research on Dermatozoonoses in Domestic Animals, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
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2
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Wellington T, Hauschild J, Krauland KJ, Verwiebe EG, Markelz AE. Sporotrichosis in a U.S. Army Basic Trainee. Mil Med 2021; 188:usab463. [PMID: 34755864 DOI: 10.1093/milmed/usab463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/14/2021] [Accepted: 10/22/2021] [Indexed: 11/13/2022] Open
Abstract
Lymphocutaneous sporotrichosis is a mycotic disease caused by traumatic inoculation of the dimorphic fungus Sporothrix schenckii, found ubiquitously in decaying vegetation. The potential for outbreaks, difficulty with timely diagnosis, as well as the prolonged treatment course and recovery from surgical intervention can have a substantial impact on the medical readiness of service members. Treatment with the antifungal therapy of choice, itraconazole, requires close patient monitoring for the duration of treatment for clinical response, drug tolerance, as well as therapeutic drug levels. We present a case of a U.S. Army enlistee with sporotrichosis contracted during basic training, highlighting the impact of delayed diagnosis and prolonged treatment course and recovery on medical readiness.
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Affiliation(s)
- Trevor Wellington
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Jordan Hauschild
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Kevin J Krauland
- Department of Pathology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Eric G Verwiebe
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Ana E Markelz
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
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3
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Tshisevhe V, Skosana L, Motse K, Maphosa T, Mitton B. Disseminated sporotrichosis in a person with human immunodeficiency virus disease. Access Microbiol 2021; 3:000262. [PMID: 34712907 PMCID: PMC8549385 DOI: 10.1099/acmi.0.000262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/13/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Disseminated sporotrichosis is an incapacitating infection caused by the dimorphic fungus Sporothrix schenckii. Because this condition may mimic the presentation of tuberculosis, syphilis and other bacterial infections, the diagnosis may be missed or delayed. Case Presentation We describe a case of disseminated sporotrichosis in a patient with poorly controlled human immunodeficiency virus infection. The patient was initially treated for bacterial skin infections. The differential diagnosis also included tuberculosis and syphilis. Only after appropriate specimens had been sent for microbiological and histopathological investigations was the diagnosis of disseminated sporotrichosis made and appropriate treatment started. The patient showed a good clinical response to itraconazole. Conclusion This report highlights the importance of having a high index of suspicion of endemic mycoses when managing immunocompromised patients. The report also demonstrates that a delay in the diagnosis of sporotrichosis increases morbidity and results in unnecessary and inappropriate treatment with associated costs and adverse effects.
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Affiliation(s)
- Vhudzani Tshisevhe
- Lancet Laboratories, Rustenburg, South Africa.,Faculty of Health Sciences, Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Lebogang Skosana
- Faculty of Health Sciences, Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa.,Tshwane Academic Division, National Health Laboratory Service, Pretoria, South Africa
| | - Kagiso Motse
- Department Internal Medicine, Job Shimankana Tabane Hospital, Rustenburg, South Africa.,Faculty of Health Sciences, Department Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Tinashe Maphosa
- Faculty of Health Sciences, Department Dermatology, University of Pretoria, Pretoria, South Africa
| | - Barend Mitton
- Faculty of Health Sciences, Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa.,Tshwane Academic Division, National Health Laboratory Service, Pretoria, South Africa
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4
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Tai F, Jakubovic H, Alabdulrazzaq S, Alavi A. A case of sporotrichosis infection mimicking pyoderma gangrenosum and the role of tissue culture in diagnosis: A case report. SAGE Open Med Case Rep 2020; 8:2050313X20919600. [PMID: 32523696 PMCID: PMC7235660 DOI: 10.1177/2050313x20919600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Sporotrichosis infections may cause cutaneous lesions mimicking other infectious or non-infectious causes such as pyoderma gangrenosum. We present a case of cutaneous sporotrichosis misdiagnosed as pyoderma gangrenosum and treated with immunosuppressants for 17 months leading to exacerbation and atypical morphology mimicking Histoplasma organisms on biopsy. Exclusion of infection prior to diagnosing pyoderma gangrenosum is important to prevent iatrogenic immunosuppression, demonstrating the challenges with application of the updated pyoderma gangrenosum diagnostic criteria.
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Affiliation(s)
- Felicia Tai
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Henry Jakubovic
- Department of Laboratory Medicine & Pathobiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Shaikhah Alabdulrazzaq
- Division of Dermatology, Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Afsaneh Alavi
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Women's College Hospital, University of Toronto, Toronto, ON, Canada
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5
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Duani H, Palmerston MF, Rosa Júnior JF, Ribeiro VT, Alcântara Neves PL. Meningeal and multiorgan disseminated sporotrichosis: A case report and autopsy study. Med Mycol Case Rep 2019; 26:47-52. [PMID: 31737471 PMCID: PMC6849419 DOI: 10.1016/j.mmcr.2019.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 09/21/2019] [Accepted: 10/27/2019] [Indexed: 11/10/2022] Open
Abstract
This case report presents a 36-year old man with a disseminated sporotrichosis who presented with seizures and crusted lesions all over the body. Imaging studies revealed acute ischemic brain event with haemorrhagic transformation in right frontal lobe. Skin biopsy showed Sporothrix schenckii. He was treated with standard amphotericin B. Despite therapy, he developed consciousness loss, multiorgan-failure and eventually expired. Necropsy findings showed renal, hepatic, splenic, prostate, testicles and meningeal/cerebral involvement.
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Affiliation(s)
- Helena Duani
- Tropical Medicine and Infectious Diseases Section, Hospital das Clínicas, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Marina Fernandes Palmerston
- Tropical Medicine and Infectious Diseases Section, Hospital das Clínicas, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Jésus Faria Rosa Júnior
- Department of Pathologic Anatomy and Legal Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Vitor Teatini Ribeiro
- Tropical Medicine and Infectious Diseases Section, Hospital das Clínicas, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Pedro Lobo Alcântara Neves
- Department of Pathologic Anatomy and Legal Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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6
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Arora P, Raihan M, Kubba A, Gautam RK. Lymphocutaneous Sporotrichosis Treated with Potassium Iodide with Development of Subclinical Hypothyroidism: Wolff-Chaikoff Effect? Indian Dermatol Online J 2017; 8:475-477. [PMID: 29204393 PMCID: PMC5707842 DOI: 10.4103/idoj.idoj_3_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Sporotrichosis is a subcutaneous mycotic infection caused by Sporothrix schenckii that is acquired by traumatic implantation. The diagnosis is established by demonstration of fungal elements on histopathology and culture. Potassium iodide, azole antifungals, and terbinafine are the treatment options available. In this article, we report a 60-year-old female with lymphocutaneous sporotrichosis that responded well to potassium iodide. However, subclinical hypothyroidism (Wolff–Chaikoff effect) was encountered as a side effect of therapy which was managed with thyroxine replacement. Knowledge about the Wolff-Chaikoff effect (WCE) is important for the dermatologist and reinforces the need for screening and monitoring of thyroid stimulating hormone (TSH) in patients where long duration therapy is being planned.
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Affiliation(s)
- Pooja Arora
- Department of Dermatology, Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - M Raihan
- Department of Dermatology, Rama Medical College, Ghaziabad, Uttar Pradesh, India
| | - Asha Kubba
- Department of Pathology, Delhi Dermpath Laboratory, Delhi Dermatology Group, New Delhi, India
| | - Ram K Gautam
- Department of Dermatology, Dr Ram Manohar Lohia Hospital, New Delhi, India
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7
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Hassan K, Turker T, Zangeneh T. Disseminated sporotrichosis in an immunocompetent patient. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2016; 3:44-7. [PMID: 27583270 PMCID: PMC4996056 DOI: 10.3109/23320885.2016.1168703] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 03/17/2016] [Indexed: 11/13/2022]
Abstract
Sporothrix schenckii, the causative agent of sporotrichosis, is a relatively rare infection. Local infection usually occurs through direct inoculation of the organism through the skin; disseminated disease is rarely seen. This article describes a case of disseminated sporotrichosis in a middle-aged man without the commonly seen risk factors for dissemination.
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Affiliation(s)
- Kareem Hassan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago , Chicago , IL , USA
| | - Tolga Turker
- Department of Orthopaedic Surgery, The University of Arizona , Tucson , AZ , USA
| | - Tirdad Zangeneh
- Division of Infectious Diseases, Department of Medicine , Tucson , AZ , USA
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8
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Fixed cutaneous sporotrichosis treated with topical amphotericin B in an immune suppressed patient. Med Mycol Case Rep 2015; 7:23-5. [PMID: 27330943 PMCID: PMC4909862 DOI: 10.1016/j.mmcr.2015.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 01/07/2015] [Accepted: 01/23/2015] [Indexed: 01/19/2023] Open
Abstract
Both fixed cutaneous and lymphocutaneous sporotrichosis are associated with significant morbidity due to chronicity. Although treatment with itraconazole, saturated solution of potassium iodide or terbinafine is recommended in most cases, the described patient with fixed cutaneous sporotrichosis could not tolerate any of these. Her lesion healed after 8weeks of topical amphotericin-B (0.1% w/w). Topical amphotericin-B appears useful treatment modality for uncomplicated cutaneous sporotrichosis when systemic treatment needs deferment, remains contraindicated, or in pediatric patients.
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9
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Sporotrichosis: an overview and therapeutic options. Dermatol Res Pract 2014; 2014:272376. [PMID: 25614735 PMCID: PMC4295339 DOI: 10.1155/2014/272376] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 12/12/2014] [Indexed: 01/19/2023] Open
Abstract
Sporotrichosis is a chronic granulomatous mycotic infection caused by Sporothrix schenckii, a common saprophyte of soil, decaying wood, hay, and sphagnum moss, that is endemic in tropical/subtropical areas. The recent phylogenetic studies have delineated the geographic distribution of multiple distinct Sporothrix species causing sporotrichosis. It characteristically involves the skin and subcutaneous tissue following traumatic inoculation of the pathogen. After a variable incubation period, progressively enlarging papulo-nodule at the inoculation site develops that may ulcerate (fixed cutaneous sporotrichosis) or multiple nodules appear proximally along lymphatics (lymphocutaneous sporotrichosis). Osteoarticular sporotrichosis or primary pulmonary sporotrichosis are rare and occur from direct inoculation or inhalation of conidia, respectively. Disseminated cutaneous sporotrichosis or involvement of multiple visceral organs, particularly the central nervous system, occurs most commonly in persons with immunosuppression. Saturated solution of potassium iodide remains a first line treatment choice for uncomplicated cutaneous sporotrichosis in resource poor countries but itraconazole is currently used/recommended for the treatment of all forms of sporotrichosis. Terbinafine has been observed to be effective in the treatment of cutaneous sporotrichosis. Amphotericin B is used initially for the treatment of severe, systemic disease, during pregnancy and in immunosuppressed patients until recovery, then followed by itraconazole for the rest of the therapy.
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10
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Costa RO, Macedo PMD, Carvalhal A, Bernardes-Engemann AR. Use of potassium iodide in dermatology: updates on an old drug. An Bras Dermatol 2014; 88:396-402. [PMID: 23793210 PMCID: PMC3754371 DOI: 10.1590/abd1806-4841.20132377] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 01/04/2013] [Indexed: 11/22/2022] Open
Abstract
Potassium iodide, as a saturated solution, is a valuable drug in the dermatologist's therapeutic arsenal and is useful for the treatment of different diseases due to its immunomodulatory features. However, its prescription has become increasingly less frequent in dermatology practice. Little knowledge about its exact mechanism of action, lack of interest from the pharmaceutical industry, the advent of new drugs, and the toxicity caused by the use of high doses of the drug are some possible explanations for that. Consequently, there are few scientific studies on the pharmacological aspects, dosage and efficacy of this drug. Also, there is no conventional standard on how to manipulate and prescribe the saturated solution of potassium iodide, which leads to unawareness of the exact amount of the salt being delivered in grams to patients. Considering that dosage is directly related to toxicity and the immunomodulatory features of this drug, it is essential to define the amount to be prescribed and to reduce it to a minimum effective dose in order to minimize the risks of intolerance and thus improve treatment adherence. This review is relevant due to the fact that the saturated solution of potassium iodide is often the only therapeutic choice available for the treatment of some infectious, inflammatory and immune-mediated dermatoses, no matter whether the reason is specific indication, failure of a previous therapy or cost-effectiveness.
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Affiliation(s)
- Rosane Orofino Costa
- Universidade do Estado do Rio de Janeiro, Faculdade de Ciências Médicas, Rio de Janeiro, RJ, Brazil.
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11
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Abstract
Itraconazole (Sporanox) is a triazole antifungal agent with a broad activity spectrum and favorable pharmacokinetic and safety profiles. Numerous clinical trials have established the efficacy and safety of itraconazole in the treatment of superficial fungal infections. In this field, full exploitation of its pharmacokinetics in keratinized tissues has led to the development of intermittent (pulse) treatment regimens that allow similar efficacy with lower overall drug exposure as well as a reduction in treatment costs. The additional anti-inflammatory action of itraconazole also makes it suitable for application in difficult-to-treat inflammatory skin disorders, such as seborrheic dermatitis. Recently, a new oral liquid formulation and an intravenous formulation have been developed, extending the therapeutic application of itraconazole to systemic fungal infections. Due to its broad activity spectrum and excellent tolerability, itraconazole is a valuable addition to the antifungal armamentarium used for prophylactic and empiric treatment in immunocompromised hosts.
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Affiliation(s)
- R Caputo
- Institute of Dermatological Sciences, University of Milan, IRCCS Ospedale Maggiore of Milan, Milan, Italy.
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12
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Stopiglia CDO, Heidrich D, Sorrentino JM, Vieira FJ, Landell MF, Valente P, Scroferneker ML. Susceptibility of species within theSporothrix schenckiicomplex to a panel of killer yeasts. J Basic Microbiol 2013; 54:578-84. [DOI: 10.1002/jobm.201200516] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 01/26/2013] [Indexed: 12/19/2022]
Affiliation(s)
- Cheila Denise Ottonelli Stopiglia
- Programa de Pós-Graduação em Medicina: Ciências Médicas; Universidade Federal do Rio Grande do Sul; Porto Alegre RS Brazil
- Departamento de Microbiologia, Imunologia e Parasitologia; ICBS, Universidade Federal do Rio Grande do Sul; Porto Alegre RS Brazil
| | - Daiane Heidrich
- Programa de Pós-Graduação em Medicina: Ciências Médicas; Universidade Federal do Rio Grande do Sul; Porto Alegre RS Brazil
| | - Julia Medeiros Sorrentino
- Departamento de Microbiologia, Imunologia e Parasitologia; ICBS, Universidade Federal do Rio Grande do Sul; Porto Alegre RS Brazil
| | - Fabiane Jamono Vieira
- Departamento de Microbiologia, Imunologia e Parasitologia; ICBS, Universidade Federal do Rio Grande do Sul; Porto Alegre RS Brazil
| | - Melissa Fontes Landell
- Centro de Biotecnologia; Universidade Federal do Rio Grande do Sul; Campus do Vale, Porto Alegre RS Brazil
| | - Patrícia Valente
- Departamento de Microbiologia, Imunologia e Parasitologia; ICBS, Universidade Federal do Rio Grande do Sul; Porto Alegre RS Brazil
| | - Maria Lúcia Scroferneker
- Programa de Pós-Graduação em Medicina: Ciências Médicas; Universidade Federal do Rio Grande do Sul; Porto Alegre RS Brazil
- Departamento de Microbiologia, Imunologia e Parasitologia; ICBS, Universidade Federal do Rio Grande do Sul; Porto Alegre RS Brazil
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13
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Mata-Essayag S, Delgado A, Colella MT, Landaeta-Nezer ME, Rosello A, Perez de Salazar C, Olaizola C, Hartung C, Magaldi S, Velasquez E. Epidemiology of sporotrichosis in Venezuela. Int J Dermatol 2013; 52:974-80. [PMID: 23621481 DOI: 10.1111/j.1365-4632.2012.05849.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Sporotrichosis is one of the most common subcutaneous mycoses in Venezuela. It is a granulomatous chronic infection with cutaneous or subcutaneous tissue lesions. Regional lymphatic involvement may be present; extracutaneous disease is rare. The causal fungus Sporothrix schenckii has been isolated from soil, vegetation, and animals on numerous occasions and in many localities throughout the world. The aim of this study is to describe clinical and epidemiological features of cases of sporotrichosis observed in Venezuela and review of the literature. PATIENTS AND METHODS We included the demographic data, clinical features, diagnostic methods, treatment, and follow-up of patients with sporotrichosis from 1963 to 2009, diagnosed at the Department of Medical Mycology. RESULTS One-hundred and thirty-three sporotrichosis cases were diagnosed. Most patients were under the age of 30 years (66.15%). In 61.6% of them, the mode of transmission was not identified. The predominant clinical form in this population was lymphocutaneous (63.15%). Direct microscopic diagnosis was performed in 123 cases, and 57.9% yielded positive results for asteroid body. CONCLUSIONS Sporotrichosis is an endemic subcutaneous mycosis in Venezuela. There are no reports to this date of disseminated forms of the disease, even amongst patients with acquired immunodeficiency syndrome. Direct microscopic examination of wet mount slides with saline solution or distilled water in the search for asteroid bodies is paramount. Saturated sodium and potassium iodine solutions continue to be extremely efficacious and affordable to most of our patients, therefore our treatment of choice.
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Affiliation(s)
- Sofia Mata-Essayag
- Sección de Micología Médica Dr Dante Borelli, Instituto de Medicina Tropical, Universidad Central de Venezuela, Caracas, Venezuela.
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14
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Tang MM, Tang JJ, Gill P, Chang CC, Baba R. Cutaneous sporotrichosis: a six-year review of 19 cases in a tertiary referral center in Malaysia. Int J Dermatol 2012; 51:702-8. [PMID: 22607289 DOI: 10.1111/j.1365-4632.2011.05229.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Sporotrichosis is a subcutaneous fungal infection caused by a thermally dimorphic aerobic fungus, Sporothrix schenckii. It results from traumatic inoculation or contact with animals. Most cases were reported mainly in the tropics and subtropics. OBJECTIVE The objective of our study is to assess the clinical characteristic of cutaneous sporotrichosis among our patients. METHODOLOGY We performed a retrospective review of all cases diagnosed with cutaneous sporotrichosis from July 2004 to June 2010. Patients' medical records were retrieved and analyzed according to demography, preceding trauma, sites of lesions, clinical subtypes, treatment, and clinical response. RESULTS Nineteen cases were diagnosed with cutaneous sporotrichosis with a male/female ratio of 9:10. Thirteen cases (68.4%) were able to recall preceding trauma, and seven of them reported cat scratches or cat bites. Lymphocutaneous sporotrichosis was observed in 13 cases (68.4%) followed by four cases of fixed cutaneous sporotrichosis and two cases of disseminated sporotrichosis. Histologically, 11 cases (57.8%) demonstrated a granulomatous reaction. Sporothrix schenckii was cultured in 12 cases (63.2%). Thirteen cases (68.4%) were successfully treated with oral itraconazole alone for a mean duration of 15.6 weeks. Two cases with disseminated cutaneous sporotrichosis were treated with intravenous amphotericin B. CONCLUSION Lymphocutaneous sporotrichosis was the most common subtype of cutaneous sporotrichosis in our series, with cat scratches or bites being the most common preceding trauma. Oral itraconazole was highly effective for the localized subtypes, whereas intravenous amphotericin B was required in disseminated cutaneous sporotrichosis.
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Affiliation(s)
- Min Moon Tang
- Department of Dermatology, Kuala Lumpur Hospital, Jalan Pahang, Kuala Lumpur, Malaysia.
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15
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Cutaneous Manifestations of Infectious Diseases. ATLAS OF DERMATOLOGY IN INTERNAL MEDICINE 2012. [PMCID: PMC7178861 DOI: 10.1007/978-1-4614-0688-4_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Skin infections account for a significant portion of dermatologic diseases. Infections of the skin and subcutaneous tissues are highly diverse in respect to incidence, etiologic organisms, and clinical manifestations. Most cases are potentially treatable, thus, it is vital for the clinician to become familiar with the cutaneous expression of local and systemic processes. This chapter covers the clinical presentation, diagnosis, and treatment of the most common bacterial, viral, and fungal mucocutaneous infections encountered in internal medicine.
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16
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Limper AH, Knox KS, Sarosi GA, Ampel NM, Bennett JE, Catanzaro A, Davies SF, Dismukes WE, Hage CA, Marr KA, Mody CH, Perfect JR, Stevens DA. An official American Thoracic Society statement: Treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med 2011; 183:96-128. [PMID: 21193785 DOI: 10.1164/rccm.2008-740st] [Citation(s) in RCA: 367] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
With increasing numbers of immune-compromised patients with malignancy, hematologic disease, and HIV, as well as those receiving immunosupressive drug regimens for the management of organ transplantation or autoimmune inflammatory conditions, the incidence of fungal infections has dramatically increased over recent years. Definitive diagnosis of pulmonary fungal infections has also been substantially assisted by the development of newer diagnostic methods and techniques, including the use of antigen detection, polymerase chain reaction, serologies, computed tomography and positron emission tomography scans, bronchoscopy, mediastinoscopy, and video-assisted thorascopic biopsy. At the same time, the introduction of new treatment modalities has significantly broadened options available to physicians who treat these conditions. While traditionally antifungal therapy was limited to the use of amphotericin B, flucytosine, and a handful of clinically available azole agents, current pharmacologic treatment options include potent new azole compounds with extended antifungal activity, lipid forms of amphotericin B, and newer antifungal drugs, including the echinocandins. In view of the changing treatment of pulmonary fungal infections, the American Thoracic Society convened a working group of experts in fungal infections to develop a concise clinical statement of current therapeutic options for those fungal infections of particular relevance to pulmonary and critical care practice. This document focuses on three primary areas of concern: the endemic mycoses, including histoplasmosis, sporotrichosis, blastomycosis, and coccidioidomycosis; fungal infections of special concern for immune-compromised and critically ill patients, including cryptococcosis, aspergillosis, candidiasis, and Pneumocystis pneumonia; and rare and emerging fungal infections.
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Song Y, Zhong SX, Yao L, Cai Q, Zhou JF, Liu YY, Huo SS, Li SS. Efficacy and safety of itraconazole pulses vs. continuous regimen in cutaneous sporotrichosis. J Eur Acad Dermatol Venereol 2011; 25:302-5. [DOI: 10.1111/j.1468-3083.2010.03785.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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18
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Pereira Silveira C, Torres-Rodríguez JM, Alvarado-Ramírez E, Murciano-Gonzalo F, Dolande M, Panizo M, Reviakina V. MICs and minimum fungicidal concentrations of amphotericin B, itraconazole, posaconazole and terbinafine in Sporothrix schenckii. J Med Microbiol 2009; 58:1607-1610. [PMID: 19679687 DOI: 10.1099/jmm.0.007609-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The in vitro susceptibility of 62 isolates of Sporothrix schenckii in its mycelial form, from Latin-American countries (Peru, Venezuela, Brazil and Uruguay) and Spain, to amphotericin B (AB), itraconazole (IZ), posaconazole (PZ) and terbinafine (TB) was determined by measuring the MICs and minimum fungicidal concentrations (MFCs) using a standardized Clinical and Laboratory Standards Institute method. In general, TB was the most active drug, with the lowest geometric mean (GM) MIC and MFC values amongst isolates from the five countries tested. IZ and PZ showed almost the same activity against all strains tested, except for isolates from Uruguay where IZ gave the highest GM MIC (10.68 mg l(-1)). AB showed the widest MIC range (0.03-16.0 mg l(-1)); however, this drug was less active against 79 % of isolates (MICs above 1 mg l(-1)). MFCs were 5 to 20 times higher than the MICs, but the lowest GM MFC and range values were found for TB. IZ and PZ gave the highest GM MFC. MFC may be a better predictor of therapeutic response than MIC, especially in immunosuppressed patients, making the use of IZ and PZ an inappropriate treatment. There were some differences in susceptibility according to the geographical source of the isolates, with the MIC being lower for TB in Venezuelan strains (P=0.066) and the MFC higher for PZ in Peruvian strains (P=0.02). Thus, geographical origin may be important for appropriate treatment, and may relate to the identification of species of the S. schenckii complex.
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Affiliation(s)
- Carolina Pereira Silveira
- Centro de Biotecnologia, Universidade Federal do Rio Grande do Sul, PO Box 15005, 91501-970 Porto Alegre, RS, Brazil
| | - Josep M Torres-Rodríguez
- UDIMAS, Autonomous University of Barcelona, Barcelona, Spain.,Unitat de Recerca en Malalties Infeccioses i Micologia, Institut Municipal d'Investigació Médica, Barcelona, Spain
| | - Eidi Alvarado-Ramírez
- UDIMAS, Autonomous University of Barcelona, Barcelona, Spain.,Unitat de Recerca en Malalties Infeccioses i Micologia, Institut Municipal d'Investigació Médica, Barcelona, Spain
| | - Francisca Murciano-Gonzalo
- Unitat de Recerca en Malalties Infeccioses i Micologia, Institut Municipal d'Investigació Médica, Barcelona, Spain
| | - Maribel Dolande
- Mycology Department, Natonal Institute of Hygiene Rafael Rangel, Caracas, Bolivarian Republic of Venezuela
| | - Mercedes Panizo
- Mycology Department, Natonal Institute of Hygiene Rafael Rangel, Caracas, Bolivarian Republic of Venezuela
| | - Vera Reviakina
- Mycology Department, Natonal Institute of Hygiene Rafael Rangel, Caracas, Bolivarian Republic of Venezuela
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Sandhu K, Gupta S. Potassium iodide remains the most effective therapy for cutaneous sporotrichosis. J DERMATOL TREAT 2009; 14:200-2. [PMID: 14660263 DOI: 10.1080/09546630310020452] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Sporotrichosis is a subcutaneous fungal infection caused by the dimorphic fungus Sporothrix schenckii. Itraconazole has largely replaced older therapies, but we present a case of lymphocutaneous sporotrichosis that failed to respond to an adequate course of itraconazole yet responded dramatically to treatment with saturated solution of potassium iodide (SSKI).
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Affiliation(s)
- K Sandhu
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India.
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20
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Pereira JCB, Grijó A, Pereira RRM, Oliveira ANS, de Andrade AC, Ferreira ACM, Machado CCB, Coutinho DV, Rios DV, Pires BP. Esporotricose disseminada – Caso clínico e discussão. REVISTA PORTUGUESA DE PNEUMOLOGIA 2008. [DOI: 10.1016/s0873-2159(15)30252-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
Skin ulcers are a commonly encountered problem at departments of tropical dermatology in the Western world. Furthermore, the general dermatologist is likely to be consulted more often for imported chronic skin ulcers because of the ever-increasing travel to and from tropical countries. The most common cause of chronic ulceration throughout the world is probably pyoderma. However, in some parts of the world, cutaneous leishmaniasis is one of the most prevalent causes. Mycobacterium ulcerans is an important cause of chronic ulcers in West Africa. Bacterial infections include pyoderma, mycobacterial infections, diphtheria, and anthrax. Pyoderma is caused by Staphylococcus aureus and/or beta-hemolytic streptococci group A. This condition is a common cause of ulcerative skin lesions in tropical countries and is often encountered as a secondary infection in travelers. The diagnosis is often made on clinical grounds. Antibacterial treatment for pyoderma should preferably be based on culture outcome. Floxacillin is generally active against S. aureus and beta-hemolytic streptococci. Infection with Mycobacterium ulcerans, M. marinum, and M. tuberculosis may cause ulcers. Buruli ulcers, which are caused by M. ulcerans, are endemic in foci in West Africa and have been reported as an imported disease in the Western world. Treatment is generally surgical, although a combination of rifampin (rifampicin) and streptomycin may be effective in the early stage. M. marinum causes occasional ulcerating lesions in humans. Treatment regimens consist of combinations containing clarithromycin, rifampin, or ethambutol. Cutaneous tuberculosis is rare in travelers but may be encountered in immigrants from developing countries. Treatment is with multiple drug regimens consisting of isoniazid, ethambutol, pyrazinamide, and rifampin. Cutaneous diphtheria is still endemic in many tropical countries. Cutaneous diphtheria ulcers are nonspecific and erythromycin and penicillin are both effective antibacterials. Antitoxin should be administered intramuscularly in suspected cases. Anthrax is caused by spore-forming Bacillus anthracis. This infection is still endemic in many tropical countries. Eschar formation, which sloughs and leaves behind a shallow ulcer at the site of inoculation, characterizes cutaneous anthrax. Penicillin and doxycycline are effective antibacterials. Cutaneous leishmaniasis is caused by different species belonging to the genus Leishmania. The disorder is one of the ten most frequent causes of skin diseases in travelers returning from (sub)tropical countries. The clinical picture is diverse, ranging from a painless papule or nodule to an ulcer with or without a scab. Treatment depends on the clinical manifestations and the species involved.Sporotrichosis, chromo(blasto)mycosis, and mycetoma are the most common mycoses that may be accompanied by ulceration. Infections are restricted to certain regions and often result from direct penetration of the fungus into the skin. Anti-mycotic treatment depends on the microorganism involved. The most common causes of infectious skin ulceration encountered in patients from tropical countries who present at a department of tropical dermatology are reviewed in this article.
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Affiliation(s)
- Jim E Zeegelaar
- Department of Dermatology, Academic Medical Centre, Amsterdam, the Netherlands.
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Kauffman CA, Bustamante B, Chapman SW, Pappas PG. Clinical practice guidelines for the management of sporotrichosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis 2007; 45:1255-65. [PMID: 17968818 DOI: 10.1086/522765] [Citation(s) in RCA: 286] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Accepted: 08/21/2007] [Indexed: 10/17/2023] Open
Abstract
Guidelines for the management of patients with sporotrichosis were prepared by an Expert Panel of the Infectious Diseases Society of America and replace the guidelines published in 2000. The guidelines are intended for use by internists, pediatricians, family practitioners, and dermatologists. They include evidence-based recommendations for the management of patients with lymphocutaneous, cutaneous, pulmonary, osteoarticular, meningeal, and disseminated sporotrichosis. Recommendations are also provided for the treatment of sporotrichosis in pregnant women and in children.
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Affiliation(s)
- Carol A Kauffman
- Infectious Diseases Section, Veterans Affairs Medical Center, University of Michigan Medical School, Ann Arbor, MI 48105, USA.
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23
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Bonifaz A, Saúl A, Paredes-Solis V, Fierro L, Rosales A, Palacios C, Araiza J. Sporotrichosis in childhood: clinical and therapeutic experience in 25 patients. Pediatr Dermatol 2007; 24:369-72. [PMID: 17845157 DOI: 10.1111/j.1525-1470.2007.00452.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Alexandro Bonifaz
- Mycology Department, Hospital General de Mexico, Mexico City, Mexico.
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24
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Abstract
A 40-year-old man visited Haiti in the winter. His visit was uneventful, and he went swimming in the ocean. A week after his return he developed a small "pimple" on his right fifth finger. This condition progressed for several weeks, with new lesions developing over the extensor surface of his forearm and in the antecubital fossa. He had tender axillary adenopathy. The patient started a new job when he returned from Haiti, working 4 days per week in a greenhouse. He denied any fever, chills, or night sweats. He was in good health without any underlying chronic health problems. Physical examination revealed a small eschar over the distal phalanx of the patient's right fifth finger (Figure 1). There were 2 erythematous nodules over the extensor surface of his right forearm (Figure 2) as well as over the antecubital fossa (Figure 3). A punch biopsy was performed and results showed suppurative granulomatous dermatitis. Sporothrix schenckii was grown from the specimen.
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Affiliation(s)
- Jodie Engle
- Wright State University School of Medicine, 4100 West Third Street, Dayton, OH 45428, USA
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25
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Alvarado-Ramírez E, Torres-Rodríguez JM. In vitro susceptibility of Sporothrix schenckii to six antifungal agents determined using three different methods. Antimicrob Agents Chemother 2007; 51:2420-3. [PMID: 17438048 PMCID: PMC1913275 DOI: 10.1128/aac.01176-06] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The in vitro susceptibility of Sporothrix schenckii to antifungal drugs has been determined with three different methods. Nineteen Peruvian clinical isolates of S. schenckii were tested against amphotericin B (AB), flucytosine (FC), fluconazole (FZ), itraconazole (IZ), voriconazole (VZ), and ketoconazole (KZ). Modified NCCLS M38-A, Sensititre YeastOne (SYO), and ATB Fungus 2 (ATBF2) methods were used to determine the MICs. ATCC isolates of Candida parapsilosis, Candida krusei, and Aspergillus flavus were used for quality control. Sporothrix inocula were prepared with the mycelial form growing on potato dextrose agar at 28 +/- 2 degrees C. MICs of AB, FC, FZ, and IZ were determined with all three methods, VZ with M38-A and SYO, and KZ with only SYO. The three methods showed high MICs of FZ and FC (MIC(90) of 0.5 microg/ml), being homogeneously lower than those of IZ and KZ. The M38-A method showed a variable MIC range of VZ (4.0 to 16 microg/ml); the geometric mean (GM) was 9.3 mug/ml. The MIC range of AB was wide (0.06 to 16 microg/ml), but the GM was 1.2 microg/ml, suggesting that the MIC is strain dependent. Agreement (two log(2) dilutions) between commercial techniques and the modified M38-A method was very high with FZ, IZ, and FC. In AB and VZ, the agreement was lower, being related to the antifungal concentrations of each method. The highest activity against S. schenckii was found with IZ and KZ. Lack of activity was observed with FZ, VZ, and FC. When AB is indicated for sporotrichosis, the susceptibility of the strain must be analyzed. Commercial quantitative antifungal methods have a limited usefulness in S. schenckii.
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Affiliation(s)
- Eidi Alvarado-Ramírez
- Infectious Diseases and Mycology Research Unit (URMIM), Institut Municipal d'Investigació Mèdica, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
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26
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Abstract
Sporotrichosis is a deep fungal disease caused by a dimorphic fungus, Sporothrix schenckii. It occurs more frequently in the tropical and subtropical areas and is mainly characterized by nodular lesions of cutaneous and subcutaneous tissues and adjacent lymphatics that suppurate and ulcerate. Infection occurs by manipulation of contaminated soil, cats, or some wild animals or by inhalation of spores. Itraconazole is the best drug for treatment of sporotrichosis.
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Affiliation(s)
- Marcia Ramos-e-Silva
- Sector of Dermatology, School of Medicine and HUCFF-UFRJ, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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27
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Abstract
A 40-year-old Caucasian man presented to the dermatology clinic at Baylor College of Medicine, Houston, Texas, in February 2003, for the evaluation of three nonhealing ulcers. The patient's past medical history was significant for hypothyroidism and pulmonary sarcoidosis, the diagnosis of which was made in June 2000. In March 2000, the patient had complained of cough and shortness of breath. A purified protein derivative (PPD) (Mantoux text) was negative. Computed tomography (CT) scans of the chest revealed diffuse hilar and mediastinal adenopathy and bilateral interstitial and alveolar infiltrates. Although consistent with sarcoidosis, these findings were insufficient to exclude other etiologies, including disseminated fungal infection. Cultures and stains of subsequent bronchoscopy specimens failed to reveal any organisms, and histopathologic evaluation of the specimens was nondiagnostic. Based on the imaging studies and the negative cultures, a diagnosis of sarcoidosis was made, and the patient was started on therapy with prednisone. Before coming to our clinic, the patient had been on several courses of prednisone. In May 2002, the patient had presented to a private dermatologist with a 1-year history of a nonhealing 2.4 cm x 2.0 cm ulcer on the left medial forearm. Two biopsies were reported as nondiagnostic. The patient's presentation was interpreted as most consistent with Mycobacterium marinum infection, and so he was empirically treated with minocycline. This treatment was continued for almost 3 months without improvement in the ulcer. A few months after the minocycline had been discontinued, the patient was treated empirically for 2 months with ciprofloxacin. This treatment was also unsuccessful in ameliorating the ulcer. In between the two courses of antibiotics, specimens from the lesion were sent for bacterial and fungal cultures, which revealed normal skin flora. In January 2003, the patient returned to his private dermatologist with three ulcerations. In addition to the nonhealing ulcer on his left forearm, which he had acquired several months earlier, he had also developed a 3.0 cm ulcer on his right arm and a 3.0 cm ulcer on his central back. The patient refused biopsies at this visit. Given the patient's previous diagnosis of pulmonary sarcoidosis, it was thought that the skin lesions might represent ulcerative cutaneous sarcoidosis. Pyoderma gangrenosum was also considered to be a likely diagnosis. Therefore, the patient was started on a course of oral prednisone, an effective therapy for both sarcoidosis and pyoderma gangrenosum. Despite 1 month of treatment with 60 mg/day of prednisone, the ulcers increased, and the patient was subsequently referred to our clinic. Physical examination at the time of presentation revealed steroid acne on the trunk and upper extremities and three non-tender ulcers with erythematous, undermined borders (Figs 1-3). On the left arm, there was an adjacent nodule which the patient attributed to a scar from a previously healed ulcer. Histologic examination of biopsy specimens from all three sites showed similar findings. The lesion contained diffuse, suppurative, granulomatous, inflammatory infiltrates with extensive central necrosis. The infiltrates were composed of histiocytes, multinucleated foreign-body-type giant cells, plasma cells, lymphocytes, neutrophils, and neutrophil fragments. No organisms were seen in the initial, routinely stained sections. However, periodic acid-Schiff (PAS) staining demonstrated small fungal spores (Fig. 4) morphologically consistent with sporotrichosis, within the cytoplasm of multinucleated histiocytic giant cells (Fig. 5). Additional stains for bacteria and acid-fast organisms were negative. Cultures of the biopsy specimens from all three sites grew Sporothrix schenckii. Further questioning of the patient failed to reveal an obvious source of the infection. The patient denied any history of traumatic skin inoculation and did not engage in gardening or other outdoor activities that are classically associated with sporotrichosis. The patient did admit to blackberry picking on detailed retrospective questioning. Once the diagnosis of sporotrichosis was made, the patient was given 200 mg/day of itraconazole. After 2 months, the patient's ulcers were almost completely healed. The patient's pulmonary complaints were also much improved.
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Affiliation(s)
- Deborah J Yang
- Department of Dermatology, Baylor College of Medicine, Houston, Cockerell and Associates, Dallas, Texas 77030, USA
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Abstract
The endemic mycoses are diverse group of fungi that share several characteristics. They are able to cause disease in healthy hosts, they each occupy a specific ecologic niche in the environment, and they exhibit temperature dimorphism, existing as molds in the environment at temperature of 25 degrees C to 30 degrees C, and as yeasts, or spherules in the case of coccidioidomycosis, at body temperatures. This article discusses histoplasmosis and blastomycosis. Sporotrichosis, which differs in that it is usually a localized lymphocutaneous infection, is included because it shares the characteristics of endemic mycoses.
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Affiliation(s)
- Carol A Kauffman
- University of Michigan Medical School, Ann Arbor, MI 48109, USA.
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Koëter S, Jackson RW. Successful total knee arthroplasty in the presence of sporotrichal arthritis. Knee 2006; 13:236-7. [PMID: 16542846 DOI: 10.1016/j.knee.2006.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Revised: 02/01/2006] [Accepted: 02/06/2006] [Indexed: 02/02/2023]
Abstract
Articular sporotrichosis, a chronic granulomatous fungal infection, is a rare entity but when present may lead to significant joint destruction. Severe knee arthrosis due to sporotrichal arthritis has traditionally been treated with arthrodesis. Total knee arthroplasty in the presence of sporotrichal arthritis has been treated with long-term suppressive antifungal agents or 1-stage exchange total knee arthroplasty. We present a case in which primary total knee arthroplasty in the presence of sporotrichal arthritis resulted in good functional outcome at 2.5 years of follow-up.
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Affiliation(s)
- S Koëter
- Department of Orthopaedic Surgery, UMC St Radboud, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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Abstract
For a long time sporotrichosis has been regarded to have a low incidence in Brazil; however, recent studies demonstrate that not only the number of reported cases but also the incidence of more severe or atypical clinical forms of the disease are increasing. Recent data indicate that these more severe forms occur in about 10% of patients with confirmed diagnosis. The less frequent forms, mainly osteoarticular sporotrichosis, might be associated both with patient immunodepression and zoonotic transmission of the disease. The extracutaneous form and the atypical forms are a challenge to a newly developed serological test, introduced as an auxiliary tool for the diagnosis of unusual clinical forms of sporotrichosis.
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Affiliation(s)
- Leila M Lopes-Bezerra
- Departamento de Biologia Celular e Genética, Instituto de Biologia Roberto Alcantara Gomes, Universidade do Estado do Rio de Janeiro, 20550-013 Rio de Janeiro, RJ, Brazil.
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Chapman SW, Pappas P, Kauffmann C, Smith EB, Dietze R, Tiraboschi-Foss N, Restrepo A, Bustamante AB, Opper C, Emady-Azar S, Bakshi R. Comparative evaluation of the efficacy and safety of two doses of terbinafine (500 and 1000 mg day-1) in the treatment of cutaneous or lymphocutaneous sporotrichosis. Vergleichende Bewertung der Wirksamkeit und Sicherheit zweier Terbinafin-Dosierungen (500 und 1000 mg/Tag) in der Therapie der kutanen und lymphokutanen Sporotrichose. Mycoses 2004; 47:62-8. [PMID: 14998402 DOI: 10.1046/j.1439-0507.2003.00953.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of this study was to evaluate the safety and efficacy of oral terbinafine (500 and 1000 mg day(-1)) in the treatment of cutaneous or lymphocutaneous sporotrichosis. A culture for Sporothrix schenckii was required for inclusion into this multicentre, randomized, double-blind, parallel-group study. Patients received either 250 mg b.i.d. or 500 mg b.i.d. oral terbinafine for up to a maximum of 24 weeks and were assessed up to 24 weeks post-treatment. The main efficacy outcome measure was cure, defined as no lesion and absence of adenopathy at the end of follow-up. Adverse events (AEs), laboratory tests, vital signs and ophthalmological examinations were also assessed. Sixty-three patients (14-85 years of age) were treated with 500 mg day(-1) (n = 28) or 1000 mg day(-1) terbinafine (n = 35). The majority of patients were cured after 12-24 weeks of treatment, and the response was dose-dependent throughout the study and at the end of follow-up. The cure rate was significantly higher in patients treated with 1000 mg day(-1) terbinafine compared with those treated with 500 mg day(-1) terbinafine (87% vs. 52%, respectively; P = 0.004). There were no cases of relapse after 24 weeks of follow-up in the 1000 mg day(-1) terbinafine group, compared with six relapses in the terbinafine 500 mg day(-1) group. Terbinafine was well tolerated and the frequency of drug-related AEs was slightly higher in the 1000 mg treatment group. Both doses of terbinafine were well-tolerated and effective for the treatment of sporotrichosis. The 1000 mg day(-1) terbinafine dose was more efficacious than 500 mg day(-1) in the treatment of cutaneous or lymphocutaneous sporotrichosis.
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Affiliation(s)
- S W Chapman
- University of Mississippi Medical Center, Jackson, MS, USA
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Abstract
Subcutaneous mycoses, which are much less common than superficial fungal infections, are characterized by a heterogeneous group of infections that often result from direct penetration of the fungus into the dermis and subcutaneous tissue through traumatic injury. The fungus spreads by local deep tissue invasion from the inoculation site. The disease usually remains localized and then slowly spreads to adjacent tissue and eventually to the lymphatics. More rarely, hematogenous dissemination is observed. There are usually various clinical features and thus a broad range of differential diagnoses. The common subcutaneous mycoses are sporotrichosis, chromoblastomycosis, phaeohyphomycosis, eumycotic mycetoma, and hyalohyphomycosis. Many subcutaneous mycoses are confined to the tropical and subtropical regions, but some, such as sporotrichosis, are also prevalent in temperate regions. Subcutaneous mycoses can occur in healthy individuals. In immunocompromised individuals, these infections can disseminate widely. Treatment usually involves use of antifungal agents and/or surgical excision. Treatment of some serious subcutaneous mycoses remains unresolved, and there have been reports of relapses or progression during therapy and problems with lack of tolerability of antifungal drugs. Identification of the etiologic agent by culture is essential for prognostic and management considerations, since some fungi are more frequently associated with dissemination. Results of antifungal susceptibility tests may provide valuable information for deciding the appropriate method of treatment. Development of new antifungal agents and combination therapies may result in improvement in the management of subcutaneous mycoses in the future.
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Affiliation(s)
- Tetsuya Koga
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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de Lima Prearo CA, Daniguchi DP, Martinez MAR, Landman G, Paschoal LHC. Case Report. Bilateral sporotrichosis. Mycoses 2002; 45:415-7. [PMID: 12421294 DOI: 10.1046/j.1439-0507.2002.00782.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We describe a rare case of sporotrichosis, clinically exuberant, with bilateral distribution.
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34
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Abstract
PURPOSE To describe a patient with conjunctivitis. METHODS Case report and review of the literature. RESULTS A 34-year-old cattle farmer with no history of trauma developed gradual onset of an inflamed bulbar conjunctival mass associated with ipsilateral preauricular lymphadenopathy. Excisional biopsy of the conjunctival mass and subsequent histopathologic examination revealed suppurative granulomatous inflammation and small budding yeasts. Electron microscopy confirmed the presence of small intracellular and extracellular yeast organisms. Cultures grew the dimorphic fungi Treatment with oral itraconazole and topical fluconazole resulted in complete resolution of the infection. CONCLUSION characteristically infects the skin and regional lymphatics after penetrating trauma, but atraumatic infection of pulmonary mucosal surfaces can occur upon inhalation of the fungal spores. Our case report suggests that atraumatic exposure to may be sufficient to establish conjunctival infection.
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Affiliation(s)
- Diana E Hampton
- Molecular Pathogenesis of Eye Infection Research Center, Dean A. McGee Eye Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104, USA
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35
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Affiliation(s)
- T De Araujo
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, FL, USA
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Bonifaz A, Peniche A, Mercadillo P, Saúl A. Successful treatment of AIDS-related disseminated cutaneous sporotrichosis with itraconazole. AIDS Patient Care STDS 2001; 15:603-6. [PMID: 11788073 DOI: 10.1089/108729101753354581] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Sporotrichosis is a chronic granulomatous mycosis caused by a dimorphic fungus, Sporothrix schenckii. The most common manifestations of infection are lymphocutaneous and fixed-cutaneous types. In the case of immunosuppressed patients, and particularly in patients with acquired immune deficiency syndrome (AIDS), it occurs as disseminated cutaneous disease. This is a report of a 28-year-old male patient who presented with disseminated cutaneous and hematogenous sporotrichosis involving multiple ulcerative, nodular lesions in various body areas. Treatment consisted of 300 mg/d of itraconazole, which resulted in clinical and mycological cure.
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Affiliation(s)
- A Bonifaz
- Dermatology Service and Mycology Department, Hospital General de México OD, Mexico City, Mexico.
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37
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Kauffman CA, Hedderwick SA. Treatment of systemic fungal infections in older patients: achieving optimal outcomes. Drugs Aging 2001; 18:313-23. [PMID: 11392440 DOI: 10.2165/00002512-200118050-00002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Systemic fungal infections are an increasing problem in older adults. For several of the endemic mycoses, this increase is the result of increased travel and leisure activities in areas endemic for these fungi. Immunosuppressive agents, care in an intensive care unit, and invasive devices all contribute to infection with opportunistic fungi. Treatment of systemic fungal infections is usually with an azole or amphotericin B. The preferred regimen depends on the specific fungal infection, the site and the severity of the infection, the state of immunosuppression of the patient and the possible toxicities of each drug for a specific patient. In older adults, drug-drug interactions between the azoles and drugs commonly prescribed for older persons may lead to serious toxicity, and absorption of itraconazole can be problematic. Amphotericin B is associated with significant nephrotoxicity, especially in older adults with pre-existing renal disease, and infusion-related adverse effects. Newer lipid formulations of amphotericin B can obviate some of these toxicities, but their role in the treatment of systemic fungal infections in older adults has not yet been clarified.
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Affiliation(s)
- C A Kauffman
- Infectious Diseases Section, Veterans Affairs Ann Arbor Healthcare System, University of Michigan Medical School, 48105, USA.
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Abstract
A thorn puncture to the hand is a common, usually minor childhood injury. A 6-year-old boy developed Alternaria tenosynovitis as a complication of thorn penetration into the digital flexor tendon sheath. He was successfully treated with tenosynovectomy and a prolonged course of itraconazole.
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Affiliation(s)
- R C Brady
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati, OH, USA.
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39
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Abstract
Although first reported more than a century ago, sporotrichosis, caused by Sporothrix schenckii, still remains a poorly studied disease. Results from recently published studies on sporotrichosis in endemic areas are summarised and assembled with previous findings, providing a comprehensive review that highlights the needs for further research.
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Affiliation(s)
- B Bustamante
- Alexander von Humboldt' Institute of Tropical Medicine, Cayetano Heredia University, Lima, Peru.
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40
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Sterling JB, Heymann WR. Potassium iodide in dermatology: a 19th century drug for the 21st century-uses, pharmacology, adverse effects, and contraindications. J Am Acad Dermatol 2000; 43:691-7. [PMID: 11004629 DOI: 10.1067/mjd.2000.107247] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- J B Sterling
- Division of Dermatology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson School of Medicine, Marlton, New Jersey 08053, USA
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41
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Kauffman CA, Hajjeh R, Chapman SW. Practice guidelines for the management of patients with sporotrichosis. For the Mycoses Study Group. Infectious Diseases Society of America. Clin Infect Dis 2000; 30:684-7. [PMID: 10770730 DOI: 10.1086/313751] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/1999] [Revised: 06/14/1999] [Indexed: 11/03/2022] Open
Abstract
UNLABELLED The recommendations for the treatment of sporotrichosis were derived primarily from multicenter, nonrandomized treatment trials, small retrospective series, and case reports; no randomized, comparative treatment trials have been reported. Most cases of sporotrichosis are non life-threatening localized infections of the skin and subcutaneous tissues that can be treated with oral antifungal agents. The treatment of choice for fixed cutaneous or lymphocutaneous sporotrichosis is itraconazole for 36 months. The preferred treatment for osteoarticular sporotrichosis also is itraconazole, but therapy must be continued for at least 12 months. Pulmonary sporotrichosis responds poorly to treatment. Severe infection requires treatment with amphotericin B; mild to moderate infection can be treated with itraconazole. Meningeal and disseminated forms of sporotrichosis are rare and usually require treatment with amphotericin B. AIDS patients most often have disseminated infection and require life-long suppressive therapy with itraconazole after initial use of amphotericin B. OVERVIEW Sporotrichosis is caused by the dimorphic fungus Sporothrix schenckii, which is found throughout the world in decaying vegetation, sphagnum moss, and soil. The usual mode of infection is by cutaneous inoculation of the organism. Pulmonary and disseminated forms of infection, although uncommon, can occur when S. schenckii conidia are inhaled. Infections are most often sporadic and usually associated with trauma during the course of outdoor work. Infection can also be related to zoonotic spread from infected cats or scratches from digging animals, such as armadillos. Outbreaks have been well-described and often are traced back to activities that involved contaminated sphagnum moss, hay, or wood. Most cases of sporotrichosis are localized to the skin and subcutaneous tissues. Dissemination to osteoarticular structures and viscera is uncommon and appears to occur more often in patients who have a history of alcohol abuse or immunosuppression, especially AIDS. Spontaneous resolution of sporotrichosis is rare, and treatment is required for most patients. Although sporotrichosis localized to skin and subcutaneous tissues is readily treated, management of osteoarticular, other localized visceral, and disseminated forms of sporotrichosis is difficult. OBJECTIVE The objective of these guidelines is to provide recommendations for the treatment of various forms of sporotrichosis. OUTCOMES The desired outcomes of treatment include eradication of S. schenckii from tissues, resolution of symptoms and signs of active infection, and return of function of involved organs. In persons with AIDS, eradication of the organism may not be possible, but clinical resolution should be attained and subsequently maintained with suppressive antifungal therapy. EVIDENCE The English-language literature on the treatment of sporotrichosis was reviewed. Although randomized, blinded, controlled treatment trials were sought, none were found to have been performed for the treatment of sporotrichosis. Therefore, most weight was placed on those reports that were derived from multicenter trials of specific treatment modalities for sporotrichosis. Small series from a single institution and individual case reports were accorded less importance. VALUES The highest value was placed on clinical efficacy and the ability of the antifungal regimen to eradicate the organism, but safety, tolerability, and cost of therapy were also valued. BENEFITS AND COSTS: The benefits of successfully treating sporotrichosis accrue primarily for the patient. Because this infection is not spread from person-to-person, public health aspects of treatment are of minor importance. Most forms of sporotrichosis are not life-threatening; thus, therapy is aimed at decreasing morbidity, improving quality of life, and allowing the patient to return to occupational and familial pursuits. (ABSTRACT TRUNCATED)
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Affiliation(s)
- C A Kauffman
- Division of Infectious Diseases, University of Michigan Medical School and Veterans Affairs Medical Center, Ann Arbor 48105, USA.
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Abstract
The inhibition of organic binding of iodide in the thyroid gland by excess iodide, resulting in the cessation of thyroid hormone synthesis, is known as the Wolff-Chaikoff effect. This review explores the nature of the Wolff-Chaikoff effect, both in terms of its potential mechanisms and its relevance to dermatologists who use potassium iodide as a therapeutic agent.
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Affiliation(s)
- W R Heymann
- Division of Dermatology, UMDNJ-Robert Wood Johnson School of Medicine, Marlton, NJ 08053
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43
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Sanchez MR. Miscellaneous treatments: thalidomide, potassium iodide, levamisole, clofazimine, colchicine, and D-penicillamine. Clin Dermatol 2000; 18:131-45. [PMID: 10701095 DOI: 10.1016/s0738-081x(99)00103-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- M R Sanchez
- New York University School of Medicine, Ronald O. Perelman Department of Dermatology, NY 10016, USA
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Pappas PG, Tellez I, Deep AE, Nolasco D, Holgado W, Bustamante B. Sporotrichosis in Peru: description of an area of hyperendemicity. Clin Infect Dis 2000; 30:65-70. [PMID: 10619735 DOI: 10.1086/313607] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Sporotrichosis is a sporadic and rare mycotic infection in most of the developed world. In many parts of the developing world, sporotrichosis is much more commonly recognized, but epidemiological data are generally lacking from these regions. We report epidemiological, clinical, and treatment data from 238 cases of culture-proven sporotrichosis occurring in a relatively remote area of the south central highlands of Peru that were retrospectively collected during 1995-1997. Most cases (60%) occurred in children aged </=14 years, and the most commonly affected anatomic site was the face. Disease was clinically confined to the skin and subcutaneous tissue in all patients. The incidence of sporotrichosis in this region ranged from 48 to 60 cases per 100,000 persons and was highest among children aged 7-14 years, approaching 1 case per 1000 persons. Sporotrichosis is a significant mycosis in the rural highlands of Peru, with an incidence exceeding those of other invasive mycoses in individuals without human immunodeficiency virus infection.
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Affiliation(s)
- P G Pappas
- Division of Infectious Diseases, University of Alabama at Birmingham School of Medicine, Birmingham, AL 35294-0006, USA. ppappas@uabid. dom.uab.edu
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46
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Abstract
A woman presented with a swollen red leg of 2 weeks' duration. Culture of the skin biopsy specimen confirmed this to be an infection caused by Sporothrix schenckii. Systemic evaluation led to the diagnosis of Cushing's disease and explained the unusual morphology. Treatment-related complications are also discussed.
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Affiliation(s)
- S Kim
- Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, USA
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47
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Ware AJ, Cockerell CJ, Skiest DJ, Kussman HM. Disseminated sporotrichosis with extensive cutaneous involvement in a patient with AIDS. J Am Acad Dermatol 1999; 40:350-5. [PMID: 10025867 DOI: 10.1016/s0190-9622(99)70484-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Sporotrichosis most commonly presents as a localized, lymphocutaneous infection that follows trauma, such as an injury from a rose thorn. In patients infected with HIV, it may be widespread and disseminated. We describe a patient with AIDS who developed disseminated sporotrichosis, a rare opportunistic fungal infection that may affect these patients. The condition remained undiagnosed because of failure to recognize characteristic histopathologic findings and failure of clinicians to interface closely with the microbiology laboratory. The condition was difficult to treat, requiring systemic administration of amphotericin. While localized sporotrichosis is an innocuous disorder that responds well to therapy, in immunocompromised hosts, it is potentially life-threatening and may require prolonged therapy with potentially toxic medications such as amphotericin B. It is important that clinicians be aware of the presentation of this unusual opportunistic infection and that they maintain close communication with pathology and clinical microbiology laboratories to ensure that proper stains and cultures are performed to avoid potential misdiagnosis.
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Affiliation(s)
- A J Ware
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, USA
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48
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Abstract
The lymphocutaneous syndrome can be caused by a number of diverse microorganisms requiring very different antimicrobial therapy for resolution. The epidemiology and geographic occurrence of the infection often can provide important first clues to the microbiologic etiology. Accurate diagnosis can be accomplished usually by punch or wedge biopsy of a primary lesion or proximal subcutaneous nodule submitted for histopathologic examination and culture. The microbiology laboratory staff should be alerted to the diagnostic possibilities so that appropriate cultural and incubation techniques, procedures, and precautions can be initiated. Provision of a correct microbiologic diagnosis and institution of appropriate antimicrobial therapy will result in a complete cure in almost all instances. Adjunctive surgical debridement may be required for certain organisms such as Nocardia or Mycobacterium chelonae.
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Affiliation(s)
- R A Smego
- Department of Infectious Diseases and Clinical Microbiology, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, Republic of South Africa
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49
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Abstract
The cutaneous manifestations of thirteen unusual infections and parasitic diseases are described. Their geographic distribution, morphologic features of the causative organism, histopathologic changes, criteria for diagnosis, and treatment are included.
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Affiliation(s)
- F M Lemons-Estes
- Parasitic Diseases Pathology Branch, Armed Forces Institute of Pathology, Washington, DC, USA
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50
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Affiliation(s)
- I Al-Mohsen
- Pediatric Cancer Branch, National Cancer Institute, Bethesda, MD, and the Department of Infectious Diseases, St. Jude Children's Research Hospital, N. Lauderdale, Memphis, TN, USA
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