Lymphocutaneous Sporotrichosis Refractory to First-Line Treatment

Abstract

Sporotrichosis is a fungal infection endemic in Latin America and has been attributed to the thermodimorphic fungus of the genus Sporothrix. Transmission to humans occurs during a traumatic injury with soil or organic material; additionally, lesions caused by infected cats play an important role in the epidemiology of the disease. The classic treatment of sporotrichosis is performed with itraconazole or potassium iodide; second-line medications, such as amphotericin B and terbinafine, can alternatively be used in cases of first-line drug failure. In the present study, a patient with lymphocutaneous sporotrichosis in the right upper limb exhibited intolerance to itraconazole and potassium iodide, additionally during the period of use; these drugs did not control skin lesions. In this patient, amphotericin B deoxycholate and its liposomal version were used in this patient; and complete recovery of the lesions was observed.

Figure 1

(a) Ulcerated lesions with borders showing erythema and infiltration. (b) Histological section showing the dense inflammatory infiltrate with the presence of granulomas; magnification 100x. (c) Focal necrosis and neutrophil exudation; magnification 200 ×. Histological sections were stained with hematoxylin and eosin. Bars = 5 μm.

Figure 2

Skin samples were cultured in an agar-dextrose Sabouraud medium. (a) (i) In the sample cultured at 37°C, the fungi presented whitish/yellowish color with leveduriform aspect, and (ii) at 25°C, the fungi presented a brownish color that corresponded to the filamentous form of (b) fungi with conidiophore bouquet-like structures (c), magnification of 400x and 200x, respectively. Bars = 5 μm.

Figure 3

(a) Morphological aspect of the lesions after infusion of 150 mg of amphotericin B deoxycholate and 2600 mg of liposomal amphotericin B presenting re-epithelization and absence of exudate. (b) Morphology of the lesion after infusion of 2600 mg of liposomal amphotericin B and 150 mg of amphotericin B deoxycholate, showing complete re-epithelization of ulcerated lesions and absence of exudation.

Figure 4

Timeline describing the appearance of the lesion (a); treatment with the first-line drugs potassium iodide and intraconazole (b); and treatment with amphotericin B (c).