Successful treatment of sporotrichosis with oral fluconazole: a report of three cases

The Historical Burden of Sporotrichosis in Brazil: a Systematic Review of Cases Reported from 1907 to 2020

Sporotrichosis is a cosmopolitan subcutaneous mycosis caused by Sporothrix species. Recently, this mycosis has gained notoriety due to the appearance of new endemic areas, recognition of new pathogenic species, changes in epidemiology, occurrence of outbreaks, and increasing numbers of cases. The purpose of this study is to analyze the peculiarities of sporotrichosis cases in Brazil since its first report in the country until 2020. In this work, ecological, epidemiological, clinical, and laboratorial characteristics were compiled. A systematic review of human sporotrichosis diagnosed in Brazil and published up to December 2020 was performed on PubMed/MEDLINE, SciELO, Web of Science, and LILACS databases. Furthermore, animal sporotrichosis and environmental isolation of Sporothrix spp. in Brazil were also evaluated. The study included 230 papers, resulting in 10,400 human patients. Their ages ranged from 5 months to 92 years old and 55.98% were female. The lymphocutaneous form was predominant (56.14%), but systemic involvement was also notably reported (14.34%), especially in the lungs. Besides, hypersensitivity manifestations (4.55%) were described. Most patients had the diagnosis confirmed by isolation of Sporothrix spp., mainly from skin samples. Sporothrix brasiliensis was the major agent identified. HIV infection, cardiovascular diseases, and diabetes were the most common comorbidities. Cure rate was 85.83%. Concerning animal sporotrichosis, 8538 cases were reported, mostly in cats (90.77%). Moreover, 13 Sporothrix spp. environmental strains were reported. This review highlights the burden of the emergent zoonotic sporotrichosis in Brazil, reinforcing the importance of "One Health" based actions to help controlling this disease.

Sporotrichosis: an overview and therapeutic options

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.

Cutaneous sporotrichosis in Himachal Pradesh, India

During the period 1990-2002 in Himachal Pradesh, India, 103 new patients with cutaneous sporotrichosis were detected. Lymphocutaneous and fixed cutaneous varieties were the most common and seen in 49% and 43% respectively. Chronic non-specific inflammation without granuloma formation was seen in 46% skin biopsy specimens, 29% showed acute or chronic inflammation and tuberculoid granuloma formation was seen in 25%. In 32% of cases Sporothrix schenckii growth was seen on Sabouraud glucose agar. A saturated solution of potassium iodide was used as first-line treatment and in 93% patients healing of lesions occurred in 4-32 weeks (average 8.7 weeks) without significant side-effects. Itraconazole, used in 12 patients, was highly effective in recommended doses. Rapid healing was seen with higher than previously used doses of fluconazole in one patient who also had unusual exacerbation of lesional inflammation with saturated solution of potassium iodide.

Therapeutic approaches to subcutaneous mycoses

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.

Cutaneous sporotrichosis: an unusual clinico-pathologic and therapeutic presentation

This report presents a number of unusual clinico-histopathologic and therapeutic features in a culture proven case of cutaneous sporotrichosis. These include lymphocutaneous sporotrichosis involving face; its dissemination in an otherwise healthy patient; its histology mimicking cutaneous cryptococcosis; two episodes of severe purulent inflammatory reaction bordering the lesion during therapy with saturated solution of potassium iodide; no therapeutic response to potassium iodide therapy and rapid healing of lesion with high-dose of fluconazole.

Successful treatment of AIDS-related disseminated cutaneous sporotrichosis with itraconazole

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.

Case report. An unusual case of cutaneous sporotrichosis and its response to weekly fluconazole

Cutaneous sporotrichosis is clinically divided into two main types: lymphocutaneous and fixed plaque type. Our report represents an unusual case with both types simultaneously. Fluconazole 150 mg once weekly was used as the treatment. The fixed type lesions responded very well and were healed after 4 months, but the lymphocutaneous lesions were not controlled even after 6 months of the treatment.

Erysipeloid sporotrichosis in a woman with Cushing's disease

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.

Disseminated sporotrichosis with extensive cutaneous involvement in a patient with AIDS

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.

Dermatologic therapy: 1993

This article reviews some therapeutic results reported in the English-language literature during 1993. Readers should review the original article in full before attempting any experimental or controversial therapy.

Treatment of tropical mycoses

Several subcutaneous and deep-seated mycoses are either observed more frequently in the tropical areas or are restricted to certain regions within the tropics. These mycoses include sporotichosis, chromoblastomycosis, entomophthoromycosis, eumycetoma, lobomycosis, and paracoccidioidomycosis. In sporotrichosis and paracoccidioidomycosis, therapy often results in either complete resolution or marked improvement. For decades sporotrichosis has been treated successfully with potassium iodide, but recently the triazole compounds, especially itraconazole, have proved effective and free of major side effects. The usual therapy for paracoccidioidomycosis is sulfonamides or amphotericin B; the former requires prolonged treatment, whereas the latter causes a significant degree of toxicity. Various azole derivatives (ketoconazole, fluconazole, saperconazole, and itraconazole) allow shorter treatment courses, can be given orally, and are more effective. Presently, itraconazole is the drug of choice. Chromoblastomycosis is a difficult condition to treat, especially if it is caused by Fonsecaea pedrosoi. Several therapeutic approaches have been used, including heat, surgery, cryotherapy, thiabendazole, amphotericin B combined with flucytosine, and azole derivatives, but their success has been modest. A 65% response rate has been obtained with itraconazole given for periods of 6 to 19 months; in limited trials, saperconazole appears to be more effective and requires shorter treatment courses. Only a few patients with eumycetoma respond to therapy; 70% of patients with Madurella mycetomatis respond to prolonged treatment with ketoconazole. Griseofulvin has been tried in nonresponders with partial success. Limited data in patients with Fusarium species eumycetoma indicate good responses to itraconazole. Eumycetoma caused by Pseudallescheria boydii or Acremonium species has been refractory to therapy. Therapy of entomophthoromycosis is also difficult because the diagnosis is usually established late and not all patients respond to therapy; this situation applies to infection caused by either Basidiobolus haptosporus or Conidiobolus coronatus. Although there is no consensus, African physicians prefer to use potassium iodide or trimethoprim-sulfamethoxazole. Isolated reports indicate that the azole derivatives, including the triazoles, may be effective. As for lobomycosis, all attempts at medical treatment have failed. Surgery is successful only when the lesion is small and can be fully resected; repeated cryotherapy appears to be more successful.

A case of sporotrichosis treated successfully with oral fluconazole 200 mg once weekly

A case of fixed cutaneous sporotrichosis that developed on the extensor aspect of the left wrist of an 83-year-old woman was treated once a week with 200 mg of oral fluconazole. This dermatological lesion healed within 4 months, leaving a scar. No side-effects were seen. At the time of writing, 7 months after the end of treatment, there has been no recurrence. Reports on the efficacy of once-weekly fluconazole administration in cases of sporotrichosis have appeared, but it would be valuable to study more such cases.