Human sporotrichosis: recommendations from the Brazilian Society of Dermatology for the clinical, diagnostic and therapeutic management

Abstract

Background: The increase in the zoonotic epidemic of sporotrichosis caused by Sporothrix brasiliensis, which started in the late 1990s in Rio de Janeiro and is now found in almost all Brazilian states, has been equally advancing in neighboring countries of Brazil. Changes in the clinical-epidemiological profile, advances in the laboratory diagnosis of the disease, and therapeutic difficulties have been observed throughout these almost 25 years of the epidemic, although there is no national consensus. The last international guideline dates from 2007.

Objectives: Update the clinical classification, diagnostic methods and recommendations on the therapeutic management of patients with sporotrichosis.

Methods: Twelve experts in human sporotrichosis were selected from different Brazilian regions, and divided into three work groups: clinical, diagnosis and treatment. The bibliographic research was carried out on the EBSCOHost platform. Meetings took place via electronic mail and remote/face-to-face and hybrid settings, resulting in a questionnaire which pointed out 13 divergences, resolved based on the opinion of the majority of the participants.

Results: The clinical classification and laboratory diagnosis were updated. Therapeutic recommendations were made for the different clinical forms.

Conclusion: Publication of the first national recommendation, carried out by the Brazilian Society of Dermatology, aimed at the Brazilian scientific community, especially dermatologists, infectologists, pediatricians, family medicine personnel, and laboratory professionals who work in the management of human sporotrichosis.

Keywords: Diagnosis; Laboratory; Recommendation; Sporothrix; Sporotrichosis; Treatment.

Figure 1

Clinical forms of human sporotrichosis. (A) Lymphocutaneous – inoculation chancre in the index finger and skin lesions in the ascending regional lymphatic pathway. (B) Fixed cutaneous form – verrucous lesion on the dorsum of the hand.

Figure 2

Clinical forms of human sporotrichosis. (A) Mucosal – bulbar conjunctiva lesion. (B) Mucosal – tarsal conjunctiva lesion, with pus.

Figure 3

Radiological images in human sporotrichosis. (A) Osteoarticular form – resorption of the distal phalanx of the little finger caused by a cat bite (plain radiography). (B) Systemic form with osteoarticular manifestation – osteolytic lesions in the tibial medulla by hematogenous spread in a patient with systemic sporotrichosis and AIDS (plain radiography). (C) Pulmonary – cavity in the upper lobe of the right lung and extensive pulmonary opacity with a fibroretractile appearance (computed tomography). (D) Neurosporotrichosis – meningitis in a patient with systemic sporotrichosis and AIDS. Increase in the dimensions of the ventricular system, mainly in the supratentorial region (tetraventricular hydrocephalus), ventriculoperitoneal shunt catheter (computed tomography).

Figure 4

Immunoreactive forms of human sporotrichosis. (A) Erythema nodosum in the lower limbs (specific sporotrichosis lesion near the knee). (B) Sweet syndrome.

Figure 5

Sampling. (A) Purulent exudate, sampled by puncturing a skin abscess, in human sporotrichosis. (B) Material (pus) to be sent for mycological examination.

Figure 6

Flowchart for the collection and transportation of material sampled by biopsy, for the diagnosis of human sporotrichosis. The illustration was partially based on Servier Medical Art elements, licensed by Creative Commons Attribution 3.0 Unported License.

Figure 7

Sporothrix ssp. (A) Macromorphological aspect of the colony on Mycosel agar, at room temperature. It has a membranous surface, with a pearly luster, whitish color, surrounded by a blackened halo. (B) Colony micromorphology, at room temperature, shows delicate, branched, septate hyaline hyphae and oval or rounded conidia in a “daisy” arrangement, at the conidiophore tip. Cotton blue stain, ×100. (C) Histopathological skin section showing suppurative granuloma and parasitic fungus. Epithelioid cells on the left, neutrophils and pyocytes on the right, round yeast-like (black arrow) and elongated or navicular fungal cells (red arrow) PAS, ×1000. (D) Detail of fungal cells.

Figure 8

Flowchart for the laboratory diagnosis of human sporotrichosis, with estimated time for the processing of each method. GMS (Gomori-Grocott silver methenamine); CMA (cornmeal agar); 'C'‘C’, Carbon source; ITS, Internal Transcript Spacer; PCR, Polymerase Chain Reaction; qPCR, real-time quantitative PCR; RCA, Rolling Circle Amplification; AFLP, Amplified Fragment Length Polymorphism; RAPD, Random amplification of polymorphic DNA. Modified from Orofino-Costa et al., 2017.