Sporotrichosis in the Highlands of Madagascar, 2013-20171

Abstract

Sporotrichosis is a saprozoonotic fungal infection found mostly in tropical and subtropical areas. Few case reports in Madagascar have been published. To document sporotrichosis epidemiology in Madagascar, we conducted a cross-sectional study. During March 2013-June 2017, we recruited from select hospitals in Madagascar patients with chronic cutaneous lesions suggestive of dermatomycosis. Sporotrichosis was diagnosed for 63 (42.5%) of 148 patients. All but 1 patient came from the central highlands, where the prevalence was 0.21 cases/100,000 inhabitants. Frequency was high (64.7%) among patients <18 years of age. Sporotrichosis was diagnosed for 73.8% of patients with arm lesions, 32.3% with leg lesions, and 15.4% with lesions at other sites. Molecular identification identified 53 Sporothrix schenckii isolates. Among the 32 patients who were followed up, response to itraconazole was complete or major for 15 and minor for 17. Overall, endemicity of sporotrichosis in Madagascar was high, concentrated in the highlands.

Keywords: Madagascar; Sporothrix schenckii; Sporotrichosis; clinical presentation; epidemiology; fungi; highlands; molecular diagnosis; outcome; prevalence; zoonoses.

Figure 1

Recruitment of patients with chronic cutaneous and subcutaneous lesions and annual prevalence of sporotrichosis, Madagascar, March 2013–June 2017. A) Recruitment sites. Sava Region: a) Centre Hospitalier de Référence Régionale, Sambava District; b) Centre Hospitalier de District and Hôpital Adventiste, Andapa District; Analamanga Region: c) Centre de Santé de Base, Alakamisy-Anjozorobe, Anjozorobe District; d) Centre Hospitalier Universitaire Joseph Ravoahangy Befelatanana, Antananarivo District; e) Centre de Santé de Base, Andramasina District; Vatovavy Fitovinany Region: f) Fondation Médicale Ampasimanjeva, Manakara District; Anosy Region: g) Centre Médical Tolagnaro, Centre Hospitalier de Référence Régionale, Tolagnaro and Hôpital Luthérien Manambaro, Tolagnaro District. B) Patients’ region of origin, from north to south: D, Diana; S, Sava; I, Itasy; A, Analamanga; V, Vakinankaratra; B, Bongolava; So, Sofia; Bo, Boeny; Be, Betsiboka; Me, Melaky; Al, Alaotra-Mangoro; At, Atsinanana; An, Analanjirofo; Am, Amoron’I Mania; H, Haute Matsiatra; Va, Vatovavy-Fitovinany; Ato, Atsimo; Ih, Ihorombe; Mb, Menabe; Ats, Atsimo Andrefana; And, Androy; Ano, Anôsy. Number of patients recruited: dark brown, n>6; medium brown, n = 3–5; beige, n<3; white, missing. Black outlines indicate regional boundaries. C) Annual prevalence of sporotrichosis, showing origins of the 63 sporotrichosis patients described in this study. Prevalence per 100,000 inhabitants: dark brown, >0.2; medium brown, 0–0.2; light brown, <0.1; beige, 0; white, missing. Black outlines indicate regional boundaries.

Figure 2

Clinical manifestations of sporotrichosis in patients with chronic cutaneous and subcutaneous lesions, Madagascar, March 2013–June 2017. A–C) Lymphocutaneous lesions. D) Lymphocutaneous ulcerative budding and crusty lesion. E) Ulceroerosive and erythematosus lesion with irregular border, easily misdiagnosed as chromoblastomycosis.

Figure 3

Phylogenetic tree of internal transcribed spacer sequences of Sporothrix schenckii isolates from patients with sporotrichosis, Madagascar, March 2013–June 2017 (black triangles), and reference isolates (gray triangles). Fonsecaea pedrosoi was considered to be out of group. The tree was built by using MEGA7.0 software (https://www.megasoftware.net) and applying the maximum-likelihood method based on the Kimura 2-parameter model (100 bootstrap replicates). Strains are detailed in Appendix 1 Table 1. GenBank accession numbers for isolates from this study: MYC11015, MK342563; MYC12089, MK342536; MYC10008-S2, MK342530; MYC08007, MK342562; MYC08005, MK342529; MYC07064, MK342535; MYC07063, MK342534; MYC07060, MK342533; MYC05106, MK342564; MYC05030, MK342531; MYC04049, MK249820.