Epidemiological and Clinical Aspects of Sporotrichosis in Espírito Santo State, Southeast Brazil: A Study of Three Decades (1982-2012)

Human and Feline Sporotrichosis in a Reference Center of Southeastern Brazil: Genetic Differentiation, Diversity, and Antifungal Susceptibility of Sporothrix Species

Sporotrichosis is a neglected subcutaneous fungal infection that affects humans and animals worldwide caused by species belonging to the genus Sporothrix. This study aims to examine the range of genetic variations, assess molecular epidemiology significance, and explore potential modes of transmission of the Sporothrix species associated with the current sporotrichosis outbreaks in Espírito Santo, Brazil. In this investigation, 262 samples were evaluated, including 142 from humans and 120 from felines, collected between 2016 and 2021. The isolates were identified based on morphological and molecular characteristics. Sexual idiomorphs were determined by mating-type PCR using primers specific to the MAT1-1 and MAT1-2 loci. Amplified fragment length polymorphism (AFLP) was employed to assess the genetic variability of Sporothrix spp. Finally, antifungal susceptibility testing was performed following the CLSI M38-A2 protocol. Of the 142 human samples, 125 were identified as S. brasiliensis and 17 as S. schenckii s. str. The presence of S. brasiliensis was overwhelming (100%) during outbreaks, highlighting the significant role of domestic cats in the emergence of this species. Heterothallism was the only observed mating strategy. However, the MAT1-2 idiomorph was predominant in cases of cat-transmitted sporotrichosis (χ2 = 202.976; p < 0.0001). Our AFLP results show significant intraspecific variability observed among S. brasiliensis isolates in Espírito Santo. Different genotypes forming subgroups within the same population suggest that these isolates do not originate from a single ancestor, indicating multiple emergences. Furthermore, terbinafine was the antifungal with the best results in vitro. However, in clinical practice, itraconazole remains the primary treatment choice. Sporotrichosis continues to advance in the state; therefore, the health system must outline one-health strategies to contain the disease to prevent future epidemics.

Epidemiological and clinical aspects of sporotrichosis in patients seen at a reference hospital in Madagascar

INTRODUCTION

Sporotrichosis is a subacute to chronic fungal infection of skin and subcutaneous tissues, caused by dimorphic fungi belonging to the genus Sporothrix, commonly seen in tropical and subtropical regions like Madagascar. This study describes the epidemiological, clinical, and the treatment outcomes with itraconazole for sporotrichosis.

METHODS

A descriptive retrospective study on patients suffering from sporotrichosis, from March 2013 to January 2019, was conducted, in the reference center for endemic mycoses. Patients with sporotrichosis who received itraconazole for at least 3 months were included in the study. Patients received itraconazole 200 mg daily for 3 to 6 months. Therapeutic responses were evaluated at months 3 and 6 after treatment. Outcomes were classified as minor response, major response, cure, and failure.

RESULTS

Forty-three cases of sporotrichosis were included. The median age of patients was 40 years. Most of them (62.8%) were rural workers. Men were more frequently infected (72%). At the end of 6th month of treatment, 20 patients (46.5%) were cured and a major response to itraconazole was observed in 8 patients (18.6%). The cure rate was higher in 12 patients (27.9%) who had disease durations of less than to one year than in those who had more time of disease (18.6%) (p = 0.01). Thirteen patients (30.2%) were lost to follow up. The rate of lost to follow-up was also higher (39.5%) in patients who had sporotrichosis of less than to one year than in those who had more time of disease.

CONCLUSION

The cure rate found in this study was inferior to that reported in the literature. However, it was higher in patients with early symptomatology.

A neglected disease. Human sporotrichosis in a densely populated urban area in São Paulo, Brazil: clinical-epidemiological and therapeutic aspects

Human sporotrichosis is caused by different Sporothrix species; however, Sporothrix brasiliensis is the main species, usually related to cat transmission in urban areas. A retrospective descriptive study was conducted at the Institute of Infectology Emílio Ribas from 2010 to 2018. Demography, clinical, diagnostic, and therapeutic data were obtained from medical records. Polymerase chain reaction of the calmodulin gene was performed to identify Sporothrix species. In addition, to evaluate the spread of the disease across São Paulo metropolitan region, TerraView version 4.2.2 software was used for geocoding cases according to residence addresses. Kernell's maps using QGIS software version 2.16.3 were constructed to determine the concentration of cases. Results: 260 cases of sporotrichosis were diagnosed between 2010 and 2018. We observed a 700% increment in the number of human cases in the 2016-2018 triennium compared with the 2013-2015 triennium. Female adults with a median age of 46 years old were the predominant infected group associated with cats' exposition at home care, although the age range of all patients was 01 to 86 years old. The main epidemiological risk of acquiring sporotrichosis was contact with cats, reported by 96.5% of the patients. Molecular identification showed that most of the tested isolates were Sporothrix brasiliensis. Lymphocutaneous form was observed in 59.2% and fixed cutaneous form in 37.5% of the patients. Regarding treatment, itraconazole was the main drug used (94.2%) with a cure rate of 98.8%. We observed an important spread of human sporotrichosis involving cat transmission caused by Sporothrix brasiliensis in a densely populated area of São Paulo state. These results are important to alert clinicians and dermatologists about the occurrence and progression of a neglected tropical disease in an urban area and the urgent necessity to include sporotrichosis as a differential diagnosis in the clinical investigation routine.

Epidemiology of Clinical Sporotrichosis in the Americas in the Last Ten Years

BACKGROUND

Sporotrichosis is a fungal infection caused by species of the Sporothrix genus. Presently, the prevalence of sporotrichosis in the Americas is unknown, so this study aims to analyze the cases reported in the past 10 years.

METHODS

An advanced search was conducted from 2012 to 2022 in English and Spanish in PUBMED, SciELO, and Cochrane, with the terms: "sporotrichosis", "lymphocutaneous sporotrichosis", "fixed sporotrichosis", "mycosis", "Sporothrix spp.", "Sporothrix complex", "S. schenckii sensu stricto", "S. schenckii sensu lato", "S. globose", "S. brasiliensis", "S. luriei". Sporotrichosis is a fungal infection caused by species of the Sporothrix genus associated with "pathogenicity" or "epidemiology".

RESULTS

A total of 124 articles were found in the Americas, corresponding to 12,568 patients. Of these, 87.38% of cases were reported in South America, 11.62% in North America, and 1.00% in Central America and the Caribbean. Brazil, Peru, and Mexico had the highest number of cases. The most prevalent etiological agents were S. schenckii complex/Sporothrix spp. (52.91%), S. schenckii (42.38%), others (4.68%), and Not Determined (ND) (0.03%). The most frequent form of the disease was lymphocutaneous infection; however, the infection type was not determined in 5639 cases. Among the diagnostic methods, culture was the most used.

CONCLUSIONS

There is a high occurrence of cases reported in the literature. South America is the region with the highest number of reports because of its environment (climate, inhalation of spores, etc.), zoonotic transmission (scratches and sneezes from contaminated animals), and possible traumatic inoculation due to outdoor activities (agriculture, gardening, and related occupations). Molecular diagnosis has not been sufficiently developed due to its high cost.

Treatment of Human Sporotrichosis Caused by Sporothrix brasiliensis

We describe the successful treatment of a series of 30 zoonotic sporotrichosis cases from southern Brazil. Sporothrix brasiliensis was the species genotypically identified in all 25 confirmed cases. Five other cases were classified as probable, without laboratory confirmation, but with clinical and epidemiological data of cat-transmitted sporotrichosis. Two isolates were sequenced by translation elongation factor-1 alpha (EF1α) loci in order to compare their sequences, and both of them showed distinct genotypes from S. brasiliensis strains from other Brazilian states. Itraconazole (ITZ) or potassium iodide (KI) were the first choice treatment in 28 and 2 cases, respectively. Microdilution assay showed a wild-type profile of S. brasiliensis isolates to ITZ. However, a lack of clinical response occurred in 42% of cases, especially those treated with ITZ 100 mg/day, and treatment needed modifications, by either increased doses or antifungal combinations. Clinical cure required a mean of 187 days of treatment, which was dependent on the clinical form of the disease and age of patients. Therapy, including dosages and durations, for cutaneous forms of sporotrichosis requires re-evaluation, since cases caused by S. brasiliensis may influence treatment efficacy.

Epidemiological and geographical distribution profile of urban sporotrichosis in the city of São Paulo

Background

Sporotrichosis is the most frequent subcutaneous mycosis in Latin America, where it is considered endemic. At the end of the 20th century, the first cases of zoonotic transmission were described in Rio de Janeiro, triggering an epidemic outbreak that spread to other regions of Brazil. The lack of disease notification omits its real occurrence in the country, which happens in its most populous city, São Paulo.

Objective

To evaluate the epidemiological aspects of the patients seen at a hospital in São Paulo aiming at establishing the geographic distribution of this disease.

Methods

This is a retrospective study that analyzed data from medical records of patients with a clinical and laboratory diagnosis of sporotrichosis attended at a tertiary hospital in the city of São Paulo between 2012 and 2020.

Results

Twenty patients were included. As for zoonotic surveillance, 30% denied contact with an animal, and 70% reported previous contact with a sick cat, with no other animals being mentioned. One case was allochthonous and the others autochthonous, showing a dissemination behavior from a focus in the eastern area of the capital.

Study limitations

The present study was based on data from only one hospital. Studies that include data from other hospitals and other regions must be carried out to obtain a complete picture of this disease.

Conclusions

As in other regions of the country, zoonotic sporotrichosis presents itself as an endemic disease with an increase in the number of cases. The findings highlight epidemiological characteristics of great importance so that public health policies can contain disease progression.

Molecular-based assessment of diversity and population structure of Sporothrix spp. clinical isolates from Espírito Santo-Brazil

BACKGROUND

Sporotrichosis is a subcutaneous mycosis caused by Sporothrix species that affects humans and animals. Little information on the genetic diversity and population structure of the pathogen is available for Brazil, which is needed to design effective strategies to tackle the advance of sporotrichosis in endemic areas.

OBJECTIVES

We assessed the genetic diversity and mating-type distribution of Sporothrix isolates recovered from human and feline cases of sporotrichosis in Espírito Santo-Brazil to better understand the population structure, epidemiology and diversification of this pathogen, as well as to explore the possible routes of transmission involved in the ongoing outbreaks.

METHODS

In all, 75 Sporothrix isolates were identified with phenotypic characteristics. Then, fungal DNA extraction was performed, and the species-specific PCR technique was applied, using markers directed to the calmodulin gene. The mating-type idiomorph of species was identified by PCR using primers targeting the MAT1-1 and MAT1-2 loci.

RESULTS

Among the 75 Sporothrix isolates, 76% were confirmed as S brasiliensis and 24% as S schenckii sensu stricto. S brasiliensis was more prevalent in the metropolitan area and S schenckii s. str. in the mountainous region of the state. In both species, the presence of the two sexual idiomorphs was detected, suggesting that they are heterothallic species.

CONCLUSIONS

Our data suggest that sporotrichosis takes on an epidemic-urban character involving S brasiliensis. This species in Espírito Santo is likely to originate from Rio de Janeiro, as most isolates harbour the same MAT 1-2 locus. We confirm that S brasiliensis has significantly broadened its area of occurrence, an essential feature of emerging pathogens.

The clinico-epidemiological characteristics and therapeutic experience of 152 patients with cutaneous sporotrichosis: a 10-year retrospective study from India

BACKGROUND

Cutaneous sporotrichosis, a subcutaneous mycosis because of Sporothrix schenckii, is sporadic worldwide with local hyperendemic pockets.

OBJECTIVES

To study clinico-epidemiological and therapeutic aspects of sporotrichosis in our clinic.

METHODS

We retrospectively analyzed medical records of 152 (M:F 52:100) patients with cutaneous sporotrichosis managed during 2010-2019.

RESULTS

All patients were involved in agricultural activities, and 63.2% were aged 21-60 years. Women outnumbered men by nearly two times. Fixed and lymphocutaneous sporotrichosis occurred in 54.6% and 43.4% patients, respectively. Only 2% of patients had multifocal sporotrichosis. Only 48% of patients imputed their disease to prior injuries. Extremities, upper in 53.9% and lower in 21% of patients, were mostly involved. Scrotum involvement in one patient was unusual. A mixed inflammatory infiltrate in 38.7%, chronic granuloma formation in 35%, and presence of spores in 48.9% biopsies was noted. S. schenckii grew on Sabouraud's dextrose agar in 40.2% of cases. Treatment with saturated solution of potassium iodide was curative in 76.8% patients, and lesions healed in 2-9 months (average 5.2 months). Metallic taste was experienced by 42.9% of patients. Itraconazole therapy was safe and effective in seven patients, and the response was better when combined with SSKI compared to either drug used alone.

CONCLUSION

Cutaneous sporotrichosis mostly affects persons during active years of life. The injuries predisposing to infection are mostly forgotten. Both fixed and lymphocutaneous sporotrichosis involving extremities remain common forms. SSKI alone or in combination with itraconazole is safe and effective treatment. Itraconazole is preferable in patients having preexisting hypothyroidism or intolerance to SSKI.

Spatial association between sporotrichosis in cats and in human during a Brazilian epidemics

Sporotrichosis is a subcutaneous granulomatous disease caused by the fungus Sporothrix spp. In Brazil, S. brasiliensis is reported in regions of outbreaks and epidemics in the zoonotic form of the disease where cats play an important role in the transmission of the disease to humans. Therefore, it is important to assess how the presence of infected cats impacts the risk for sporotrichosis in humans. The objective of this study was to analyze the spatial association of sporotrichosis in cats and in humans from Belo Horizonte, a Brazilian city where an epidemics of sporotrichosis occurs since the first human case register in 2015, through an inhomogeneous Poisson process model. Feline and human cases of sporotrichosis recorded between January 2016 and June 2019 were georeferenced by address and spatial point patterns were generated. Feline case intensity and human demographic density were calculated using a kernel smoothed estimate. The distance to the nearest feline case was also compute. Model parameters were estimated by Maximum Likelihood Estimate. The model validation was performed by the evaluation of partial residual, leverage and influence measure. There were 343 cases of cats and 135 human cases of sporotrichosis. The average incidence of human sporotrichosis in the period was 1.343 per 100 thousand inhabitants, which is relatively low in relation to the population, but higher than that observed in other regions in zoonotic outbreak of the disease. The southern region of the municipality has a higher intensity of feline cases. According to the fitted model, the risk for human sporotrichosis is greater when at distances very close to a feline case, with a virtually stable effect for distances greater than 1 km. Regarding the intensity of feline cases there is a gradual increase in risk as the intensity of cases increases. From the leverage analysis it was observed that the model was particularly sensitive to the occurrence of human cases in the south and east regions, places with extreme values ​​of covariates. Poisson point process model seems to be a reasonable approach in spatial epidemiology when multiple sources of infection are involved, and there is a low incidence of the disease as long as it is reasonable to assume independence between cases. Interventions for disease prevention and control in humans are suggested to encompass disease control in cats and the search for feline cases, focused on diagnosis and control, close to reported human cases.

Associated factors and spatial patterns of the epidemic sporotrichosis in a high density human populated area: A cross-sectional study from 2016 to 2018

An epidemiological characterization of human and feline sporotrichosis was carried out between 2016 and 2018, in a high density-populated area in Brazil. Professionals were trained to identify suspect cats and notify vets to interview the owners and collect swabs of the wounds from these animals. Mycological cultures were performed, and colonies identified as Sporothrix spp. Subsequently, data regarding the outcome from suspect animals were collected. Confirmed cases of human sporotrichosis (56) were also counted and analyzed for spatial distribution. 118 positive animals were observed. The prevalence of feline sporotrichosis was 8.36 ‰ (CI 95 %, 5.38-9.55 ‰). The odds for being positive in animals that lived only partially at home were 3.02 times greater than for those cats without access to the street (OR 3.02, CI 95 % 1,96-10,43). There was no statistically significant association between environmental variables and positive diagnosis, corroborating the hypothesis that direct transmission by infected cats plays a greater role in the occurrence and continuous outbreaks of sporotrichosis in Brazil. Among the positive animals, 61.90 % (CI 95 % 58.95-64.96) died, and they had an odds to die in the next six months 6.30 times greater than negative animals (p < 0.05, OR 6.30, CI 95 % 2,79-14,42). The case fatality rate was 55.08 % in cats (CI 95 % 49.20-51.15). The cause-specific death rate was 4.6 ‰ in cats (CI 95 % 3.4-6 ‰). Only 7.62 % (CI 95 % 7.12-8.16) positive cats were treated and cured. Among dead positive animals, 29.23 % were inappropriately discarded. In the study period 56 human cases were recorded in the Barreiro region. Regions with highest prevalence of feline sporotrichosis, had greater frequencies of both human and feline cases. This is the first report on the epidemic of sporotrichosis in Minas Gerais, Brazil. The free offer for treatment and veterinary care for these animals should be taken into consideration, as well as the collection and incineration of the dead ones, as measures of public health, followed by the guidance and care for the human patient.

One Health Education for Future Physicians: A Case Report of Cat-Transmitted Sporotrichosis

A healthy 35-year-old Brazilian woman presented with persistent redness, swelling, and multiple wounds on the hand 2 weeks after a cat bite in her home country. She was treated twice with amoxicillin-clavulanate but failed to demonstrate improvement. She then presented to our institution with a newly developed abscess on the right hand. Incision and drainage were performed and she was admitted to the hospital. She was subsequently treated with broad-spectrum antibiotics. Her symptoms improved but did not resolve. Four days after hospital discharge, a wound culture resulted as positive for Sporothrix schenchii. The patient was treated with itraconazole. Sporotrichosis is endemic in many countries including Brazil and is known to be transmitted by cat bites. Sporotrichosis should be considered in the differential diagnosis for patients who have symptoms of cellulitis after cat bites in an endemic area.