Disseminated sporotrichosis mimicking sarcoidosis

Oral treatment with 10% potassium iodide solution for refractory cutaneous-disseminated sporotrichosis in an immunocompetent adult: Case report

Sporotrichosis has multiple clinical manifestations, and its cutaneous-disseminated form is uncommon and, in most cases, related to immunosuppressive conditions. We report the case of a 47-year-old male patient who presented with multiple cutaneous nodules and ulcers on the left upper limb and the right thigh, with no other comorbidities. Until the diagnosis was confirmed, the patient was initially given empiric antifungal treatment with itraconazole, which showed unsatisfactory results at a local hospital. Then, he was treated with voriconazole, which led to the slow improvement of his skin lesions. At one point during the voriconazole treatment course, the patient briefly self-discontinued voriconazole for economic reasons, and the lesions recurred and worsened. The patient was finally diagnosed with cutaneous-disseminated sporotrichosis based on the isolation and identification of Sporothrix globosa. Susceptibility testing revealed that the isolate was resistant to itraconazole, fluconazole, voriconazole, terbinafine, and amphotericin. Considering the patient's poor financial condition, potassium iodide was administered. After 1-month of therapy with potassium iodide, he reported rapid improvement of his skin lesions. The patient continued potassium iodide treatment for another 5 months until the full resolution of lesions was achieved.

Sarcoid-like reaction in patients with malignant tumors: Long-term clinical course and outcomes

Background

The development of non-caseating epithelioid cell granulomas in cancer patients who do not fulfill the systemic sarcoidosis criteria is termed sarcoid-like reaction (SLR). Little is known about this condition's natural course and impact on the prognosis of malignancy. We aimed to investigate the natural course and prognostic value of cancer-associated SLR.

Methods

Clinical data were retrospectively analyzed in 32 patients with biopsy-proven cancer-associated SLR. Among patients with non-small cell lung cancer (NSCLC), SLR cases (n = 8) were matched with non-SLR cases (n = 78) for survival analysis.

Results

Among the included patients, the mean age was 59.7 years, and 68.8% were female. The median follow-up period was 35.6 months [interquartile range (IQR): 14.0–61.4 months]. Of all the included malignancies (n = 32), breast cancer (25.0%) and NSCLC (25.0%) were the most common, with stage I being the most frequent tumor stage (59.4%). During follow-up, SLR progression to overt sarcoidosis was not observed. In the 28 patients with available follow-up computed tomography images (median interval: 24.9 months; IQR: 14.4–41.7), 4 patients received corticosteroids (n = 4), resulting to a decrease of SLR lesions. Meanwhile, among those who did not receive treatment (n = 24), the extent of SLR decreased or did not change in 85.7% of them, whereas 3.6% had increased SLR extent. Furthermore, among patients with NSCLC, SLR was not associated with overall survival [hazard ratio (HR) = 1.28, 95% confidence interval (CI): 0.02–67.71, P = 0.882] and recurrence of malignancy (HR = 1.27, 95% CI 0.21–7.51, P = 0.793) in the Cox proportional hazard regression model.

Conclusions

During the follow-up of cancer-related SLR, we found no further evidence for systemic sarcoidosis, and most of the lesions decreased or did not change. Development of SLR was also not associated with overall survival or disease-free survival in patients with NSCLC.

A case of sporotrichosis infection mimicking pyoderma gangrenosum and the role of tissue culture in diagnosis: A case report

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.

Disseminated sporotrichosis following iatrogenic immunosuppression for suspected pyoderma gangrenosum

Sporotrichosis is an infection caused by the dimorphic fungus Sporothrix schenckii and related species that often arises from traumatic inoculation of inhabited soil and organic debris into skin. The infection is usually limited to the skin in immunocompetent patients, usually as lymphocutaneous sporotrichosis. Accurate diagnosis rests on clinical data and culture, and might be facilitated by biopsy identification of suppurative and granulomatous inflammation with fungal elements. In this Grand Round, we present a dramatic case of cutaneous sporotrichosis initially presented with an atypical large ulcer without associated lymphocutaneous spread, clinically mimicking pyoderma gangrenosum, and subsequently progressed to disseminated sporotrichosis in the setting of iatrogenic immunosuppression. We further review the clinical features, risk factors, and treatment of these disseminated sporotrichosis cases, and discuss the need for improved awareness of this fungus' potential link to cause disseminated and invasive fungal infections.

Endemic pulmonary fungal diseases in immunocompetent patients: an emphasis on thoracic imaging

INTRODUCTION

Systemic endemic mycoses are prevalent in specific geographical areas of the world and are responsible for high rates of morbidity and mortality in these populations, and in immigrants and travelers returning from endemic regions. The most common fungal infections that can affect the lungs of immunocompetent patients include histoplasmosis, coccidioidomycosis, paracoccidioidomycosis, blastomycosis, sporotrichosis, aspergillosis, and cryptococcosis. Diagnosis and management of these diseases remain challenging, especially in non-endemic areas due to the lack of experience. Therefore, recognition of the various radiologic manifestations of pulmonary fungal infections associated with patients' clinical and epidemiologic history is imperative for narrowing the differential diagnosis. Areas covered: This review discusses the clinical and radiological findings of the main endemic fungal diseases affecting the lungs in immunocompetent patients. Specific topics discussed are their etiology, epidemiology, pathogenesis, clinical manifestations, methods of diagnosis, pathology and main imaging findings, especially in computed tomography. Expert commentary: Imaging plays an important role in the diagnosis and management of pulmonary fungal infection and may reveal useful signs. Although definitive diagnosis cannot be made based on imaging features alone, the use of a combination of epidemiologic, clinical and imaging findings may permit the formulation of an adequate differential diagnosis.

Sporotrichosis In Immunocompromised Hosts

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

[Opportunistic infections and sarcoidosis]

Opportunistic infections (OI) are uncommon in sarcoidosis (1 to 10%) and mostly occur in patients with previously diagnosed disease or can rarely be the presenting manifestation. The most common OIs are, in descending order: aspergillosis, cryptococcosis, and mycobacterial infections. Treatment with corticosteroids is the most frequent risk factor for OI occurrence during sarcoidosis but immunosuppressive drugs and therapy with anti-TNFα are also risk factors. Overall, clinical presentation, treatment, and outcome are identical to that occur in other conditions complicated with the occurrence of OIs. However, some atypical presentations of OIs can mimic sarcoidosis exacerbation and misdiagnosis may lead clinicians to increase immunosuppression, causing worsening of the OI. The meticulous collection of patient's history along with factors differentiating OI from sarcoidosis exacerbation is key factor to optimally manage these patients.

Etiologies of Sarcoidosis

Since sarcoidosis was first described more than a century ago, the etiologic determinants causing this disease remain uncertain. Studies suggest that genetic, host immunologic, and environmental factors interact together to cause sarcoidosis. Immunologic characteristics of sarcoidosis include non-caseating granulomas, enhanced local expression of T helper-1 (and often Th17) cytokines and chemokines, dysfunctional regulatory T-cell responses, dysregulated Toll-like receptor signaling, and oligoclonal expansion of CD4+ T cells consistent with chronic antigenic stimulation. Multiple environmental agents have been suggested to cause sarcoidosis. Studies from several groups implicate mycobacterial or propionibacterial organisms in the etiology of sarcoidosis based on tissue analyses and immunologic responses in sarcoidosis patients. Despite these studies, there is no consensus on the nature of a microbial pathogenesis of sarcoidosis. Some groups postulate sarcoidosis is caused by an active viable replicating infection while other groups contend there is no clinical, pathologic, or microbiologic evidence for such a pathogenic mechanism. The authors posit a novel hypothesis that proposes that sarcoidosis is triggered by a hyperimmune Th1 response to pathogenic microbial and tissue antigens associated with the aberrant aggregation of serum amyloid A within granulomas, which promotes progressive chronic granulomatous inflammation in the absence of ongoing infection.

Increased antifungal antibodies in bronchoalveolar lavage fluid and serum in pulmonary sarcoidosis

The recent studies suggest a role of fungi in development of sarcoidosis. Moreover, the immune response in sarcoidosis and fungal infection shows a striking similarity. We formulated a hypothesis of the possible increase in antifungal antibodies in bronchoalveolar lavage fluid (BALF) and serum in pulmonary sarcoidosis. BALF and serum levels of IgG-, IgM- and IgA-specific antibodies against the cell wall β-D-glucan and mannan of Candida albicans and Saccharomyces cerevisiae were tested in 47 patients (29 pulmonary sarcoidosis patients and 18 patients with other interstitial lung diseases (ILD - control group)) and 170 healthy controls. Our results proved: (1) an increase in IgG-, IgM- and IgA-specific antifungal antibodies in BALF in pulmonary sarcoidosis compared with the control group (C. albicans: IgG: P = 0.0329, IgM: P = 0.0076, IgA: P = 0.0156; S. cerevisiae: IgG: P = 0.0062, IgM: P = 0.0367, IgA: P = 0.0095) and (2) elevated levels of serum antifungal antibodies in pulmonary sarcoidosis compared with healthy controls (C. albicans: IgG: P = 0.0329, IgM: P = 0.0076, IgA: P = 0.0156; S. cerevisiae: IgG: P > 0.05, IgM: P < 0.05, IgA: P < 0.001). The study showed increased serum and BALF levels of antifungal antibodies in pulmonary sarcoidosis. The hypothesis that fungal infection is one of the possible aetiologic agents of sarcoidosis is interesting and deserves further attention.

Mycosis fungoides-like lesions in a patient with diffuse cutaneous sporotrichosis

BACKGROUND

Sporotrichosis is a subacute or chronic mycosis acquired by traumatic inoculation or inhalation of fungal conidia. It is caused by the dimorphic fungus Sporothrix, which causes different clinical presentations, being the cutaneous and lymphocutaneous variants being the most frequent. The disseminated cutaneous form is a rare presentation occurring in a minority of cases in Mexico.

CASE REPORT

We report an atypical case of disseminated sporotrichosis in an alcoholic and iatrogenically immunosuppressed patient, whose clinical lesions resembled tumoral-stage mycosis fungoides. Histological examination and culture revealed the presence of Sporothrix schenckii.

CONCLUSIONS

The patient was treated with itraconazole 200mg per day for 4 months with clinical resolution. To the best of our knowledge, this is the first report of this type of clinical manifestation.

Rare diagnosis of nodular lymphangitis caused by Mycobacterium marinum: MDCT imaging findings

Mycobacterium marinum is an atypical mycobacterium that usually causes a solitary nodule on the hand (“fish tank granuloma”) or less commonly, secondary erythematous channels and nodules spread along lymphatic drainage of the extremity, mimicking sporothricoid skin lesions of nodular lymphangitis. This report presents a case of this rare entity, a nodular lymphangitis caused by Mycobacterium marinum. Multidetector computed tomography (MDCT) imaging was very useful in determining the morphology (cellulitis with a few small subcutaneous nodules and channels) and the extension of the lesion.

Pulmonary sporotrichosis: case series and systematic analysis of literature on clinico-radiological patterns and management outcomes

Pulmonary infections by Sporothrix spp. manifest radiologically as cavitary or non-cavitary disease depending on whether the infection is primary pulmonary or multifocal sporotrichosis. Despite current guidelines, the optimal management for pulmonary sporotrichosis remains unclear. In order to clarify this, we present two cases of pulmonary sporotrichosis, as well as the results of a comprehensive literature review of treatment outcomes based on clinico-radiological presentation patterns of the disease. A literature search of all case reports in English language over the last 50 years (1960-2010) was conducted. Data on patient characteristics, risk factors, clinico-radiological patterns, treatment modalities and outcomes were collected and analyzed. A total of 86 cases were identified, i.e., 64 (74.4%) primary pulmonary and 22 (25.6%) multifocal sporotrichosis. Radiologically, primary pulmonary disease was commonly characterized by cavity formation which was lacking in multifocal infections (P = 0.0001). Immunosuppressant use was more common in multifocal sporotrichosis (P = 0.0001), while hemoptysis was more common in primary pulmonary form (P = 0.01). No other differences in patient characteristics or risk factors were noted. Extra-pulmonary multifocal sporotrichosis most commonly involved skin (81.8%) and joints (45.4%). For patients with cavitary primary pulmonary sporotrichosis, outcomes from medical therapy alone were inferior to surgical intervention (P = 0.02). However, for both primary pulmonary and multifocal sporotrichosis with non-cavitary disease, medical therapy alone provided good outcomes. Only 12 (16.7%) cases were treated with itraconazole. Treatment of pulmonary sporotrichosis should be guided by the clinico-radiological patterns of presentation. Medical therapy alone is likely sufficient for non-cavitary disease while early surgery should be considered for cavitary primary pulmonary sporotrichosis. The experience in treating cavitary disease with itraconazole alone is limited and further data are required.

Sporothrix schenckii and Sporotrichosis

Sporotrichosis, which is caused by the dimorphic fungus Sporothrix schenckii, is currently distributed throughout the world, especially in tropical and subtropical zones. Infection generally occurs by traumatic inoculation of soil, plants, and organic matter contaminated with the fungus. Certain leisure and occupational activities, such as floriculture, agriculture, mining, and wood exploitation, are traditionally associated with the mycosis. Zoonotic transmission has been described in isolated cases or in small outbreaks. Since the end of the 1990s there has been an epidemic of sporotrichosis associated with transmission by cats in Rio de Janeiro, Brazil. More than 2,000 human cases and 3,000 animal cases have been reported. In humans, the lesions are usually restricted to the skin, subcutaneous cellular tissue, and adjacent lymphatic vessels. In cats, the disease can evolve with severe clinical manifestations and frequent systemic involvement. The gold standard for sporotrichosis diagnosis is culture. However, serological, histopathological, and molecular approaches have been recently adopted as auxiliary tools for the diagnosis of this mycotic infection. The first-choice treatment for both humans and cats is itraconazole.