Sporotrichosis during pregnancy: A retrospective study of 58 cases in a reference center from 1998 to 2023

Abstract

Background: Pregnant women constitute a vulnerable population occasionally affected by zoonotic sporotrichosis. Treatment is challenging due to potentially teratogenic oral medications (itraconazole and saturated potassium iodide solution) or lack of clinical experience during pregnancy (terbinafine). Literature is scarce on sporotrichosis and pregnancy, mainly consisting of case reports.

Methodology/principal findings: This study consists of a cohort of 58 cases of pregnant women with sporotrichosis attended in a reference center in Rio de Janeiro from 1998 to 2023. The median age was 27 years old; the majority were black (64.4%); comorbidities prior to pregnancy were reported by 20.7% (including two people living with HIV/AIDS-PLHIV) and 6.8% developed conditions that are unique to pregnancy. In 75.9% of patients, they were pregnant when they acquired sporotrichosis, with a median gestational age of 17 weeks, and 24.1% became pregnant during treatment for sporotrichosis. The lymphocutaneous form occurred in 63.8% of patients, followed by the fixed form (19%), disseminated cutaneous form (12%) and extracutaneous/disseminated forms (5.2%). Thermotherapy was indicated for all (except 2) patients and cryosurgery was performed in 22 (37.9%). Amphotericin B was indicated for a patient with external ocular sporotrichosis and for the PLHIV with osteomyelitis in the right tibia. Cure occurred in 100% of those followed (n = 44) with the remainder lost to follow-up (n = 14).

Conclusions: Pregnant women with cutaneous sporotrichosis in this study recovered following physical therapies, suggesting these therapies may be effective. In cases of extracutaneous and disseminated forms, amphotericin B was indicated due to its safety profile in this population. Management of sporotrichosis during pregnancy requires a delicate assessment of the balance between maternal benefit and fetal risks.

Fig 1. Annual frequency of the total number of cases of women of childbearing age (≥ 14 years and ≤ 45 years) with sporotrichosis and cases involving pregnant women attended at Fiocruz, INI, from 1998 to 2023.

Fig 2. Pregnant women with lymphocutaneous sporotrichosis.

A) Case 01 with nodular-ulcerated lesion and nodules/abscesses on the left hemiface. B) Case 48 with detail of the main lesion, with a very friable and inflammatory ulcerated plaque on the left leg.

Fig 3. Pregnant women with lymphocutaneous sporotrichosis in the right upper limb.

A) Case 14, who underwent three cryosurgery sessions (three months of treatment) and was cured; B) Her lesions in detail. C) Case 21, who was treated with thermotherapy and fine needle aspiration of nodules/abscesses.

Fig 4. Pregnant women with extracutaneous/disseminated sporotrichosis.

A) Case 52 with ocular sporotrichosis, presenting exuberant granulomatous conjunctivitis affecting the tarsal and bulbar conjunctiva of the left eye. B) Case 15 was a patient living with HIV with bone sporotrichosis lesion. Radiograph of the left foot and ankle showed a small lytic lesion in the distal tibia (red arrow), next to the lateral malleolus. Credit: Service of Image of Fiocruz, INI.

Fig 5. Pregnant woman with lymphocutaneous sporotrichosis in the left upper limb (case 40).

A) Ascending nodular-ulcerated lesions in a healing process. B) Some lesions immediately after cryosurgery, showing freezing.

Fig 6. Mothers with lymphocutaneous sporotrichosis scars on the right upper limb.

A, B) Case 16 with recent pink scar in the postpartum period. C) Scar 10 years later, flatter and normochromic. D) Case 54 with a hyperchromic scar on the right wrist taking her healthy 7-month-old daughter to the discharge consultation. Treatment lasted 35 days, with local heat at home and three outpatient cryosurgery sessions.

Fig 7. Case 10 with lymphocutaneous sporotrichosis on the right upper limb, where she had burn scars.

She was treated during pregnancy with cryosurgery and thermotherapy. After delivery, she did not breastfeed and used itraconazole 200 mg/day for six months until healing. The disease relapsed one month later and itraconazole was reintroduced at the same dosage, with cure after additional two months. A, B) Lesions at the beginning of treatment, during pregnancy. C) Postpartum, already cured.

Fig 8. Boxplot of age of pregnant women with sporotrichosis separated by who were (or not) exposed to sporotrichosis medications that are contraindicated for pregnant women, at Fiocruz, INI, from 2001 to 2023.

Patients exposed were older, with a median of 30 (IQR: 26.5–35.5, range 22–41) years old, than those who were not exposed (median of 27, IQR: 21.5–32, range: 15–40) (p < 0.019).

Fig 9. Boxplot of time to cure (days) of pregnant women with sporotrichosis separated by who were (or not) exposed to sporotrichosis medications that are contraindicated for pregnant women, at Fiocruz, INI, from 2001 to 2023.

Patients exposed took longer to cure, with a median of 194 (IQR: 108–249) days versus 113 (IQR: 64.5–164.5) days (p < 0.031).