AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Sporotrichosis is caused by the acquisition of Sporothrix schenckii, a dimorphic, saprophytic, and geophilic fungus. Although this fungal infection has been reported in temperate and tropical climates around the world, the fungus is less common in semiarid environments. S schenckii usually grows amidst decaying vegetable matter and in the soil as a saprophyte.

Because sporotrichosis may be difficult to initially diagnose, a differential diagnosis should always be generated during the clinical evaluation (see Differentials).

The association between sporotrichosis and acquired immunodeficiency syndrome (AIDS) was first reported in 1985. Although it is not considered an AIDS marker, it is included in a list of AIDS-related conditions. In immunocompromised patients, especially those with an impaired cell-mediated immunity, it can become an opportunistic infection with a possible life-threatening course.

Pathophysiology

The fungus is most commonly acquired by traumatic implantation into the skin, causing a local pustule or ulcer with nodules developing proximally along the draining lymphatics. Once implanted, this saprophytic fungus can grow in human tissues. When recognized by the immune system, an inflammatory response occurs. Physical signs and symptoms relate to the location and degree of inflammation that ensues. Primary organ systems involved in sporotrichosis include the skin and the lungs, although infections at other sites have been reported. Little systemic illness usually occurs, unless the fungus is inhaled or acquired by a patient who is immunocompromised. Inhalation may cause a granulomatous pneumonitis. In a host who is immunocompromised, disseminated infection can occur from skin involvement or from primary pulmonary infection. For instance, one case has been reported of laryngeal and respiratory tract sporotrichosis after steroid inhaler use.¹

Clinically, sporotrichosis may manifest as either an acute or a chronic subcutaneous mycotic infection. Although the acute phase is most common, chronic nodular lymphangiitis also reportedly develops in some cases. A minor puncture wound or splinter is sufficient to inoculate the fungus into the tissue.

Frequency

United States

Sporotrichosis is an uncommon fungal infection of unknown frequency.

International

Distribution is global, but incidence is unknown. Deep mycoses have mainly been reported in the tropics and subtropics. A recent endemic of lymphocutaneous sporotrichosis were reported in Peru.² In Rio de Janeiro, a series of cat-transmitted sporotrichosis epidemics have occurred.³

Mortality/Morbidity

Sporotrichosis is usually associated with minimal morbidity. Increased morbidity and, rarely, mortality may occur if the diagnosis is delayed, if the fungus infects patients who are immunologically compromised, or if inadequate or inappropriate therapy is rendered.

Race

Sporotrichosis has no racial predilection.

Sex

Sporotrichosis occurs in men, women, and children. Men have a higher risk of acquiring this fungus because they have greater environmental exposure from outdoor occupations.

Age

Sporotrichosis may occur in people of any age. Yet, in children, sporotrichosis tends to present more frequently with a solitary ulcerative nodule. This is in contrast to adults in which a classic lymphocutaneous form is more common.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

To evaluate a patient with possible sporotrichosis, investigate the history of risk factors for acquiring the fungus. Several predisposing factors may place a person at increased risk for developing sporotrichosis. Contact with certain plants known to harbor this fungus (eg, roses, sphagnum moss, salt-marsh hay, prairie hay) places patients at increased risk for the disease. The risk of this contact-acquired infection is increased among people in certain occupations, such as farmers or florists. Typical introduction of S schenckii into the skin has been described as occurring via a thorn or wood splinter; infections have also been reported in medical technicians who were exposed to tissue or culture specimens of S schenckii.

Certain diseases, such as diabetes mellitus and alcoholism, also predispose a patient to develop localized disorders. In certain settings, patients who are immunocompromised are at risk for developing disseminated sporotrichosis.

Physical

Overall, this fungal infection most commonly affects the dorsum of the hands or fingers. Various primary lesions have been described, ranging from an erythematous papule or pustule to an ulcerating nodule.

Sporotrichosis can be divided clinically into 2 main categories: cutaneous and systemic.

• Cutaneous sporotrichosis
• • The primary lesion is typically a pustule at the site of implantation. Erythematous papules, nodules, and verrucous plaques may also develop, along with secondary features such as ulceration and serosanguineous fluid drainage. Surprisingly, these lesions produce relatively few symptoms.
  • Lymphangitic cutaneous sporotrichosis is the most common form of the disease.
  • • Lymphangitic cutaneous sporotrichosis is usually found on an exposed skin surface at the site of traumatic inoculation. A classic clinical setting would be an adult male who acquired a splinter that, despite removal, continued to produce an area of inflammation.
    • A pustule may slowly grow and may develop into a plaque or nodule. This nodule may eventually ulcerate. Examination proximally along the affected limb usually reveals small, deep-seated, satellite erythematous nodules along lymphatic drainage. If left untreated, the fungal infection continues to spread proximally, producing a significant amount of skin inflammation, abscesses, thickened lymphatic cords, lymphadenitis, and, eventually, systemic spread.
  • Spontaneous resolution may occur. Typically, early in the course of the disease, the patient's health is minimally affected, and the infection site bears minimal symptoms.
  • Cutaneous forms of sporotrichosis also include fixed cutaneous, cellulitic, and mycetomalike. Of these, fixed cutaneous sporotrichosis is the second main cutaneous form of the disease.
  • • In its fixed cutaneous form, the fungus remains localized to the implantation site and no proximal lymphangitis or lymphadenopathy develops.
    • The fixed cutaneous form may tend to take on more of a verrucous plaquelike appearance. This form may represent enhanced host immune response to the fungus, possibly because of prior exposure. Skin surveys using the sporotrichin skin test have demonstrated that a positive test result occurs in up to 10% of certain populations, suggesting a history of prior exposure to S schenckii.
• Systemic sporotrichosis
• • Less common systemic forms of sporotrichosis usually follow inhalation of the fungus. A pulmonary infection ensues, which serves as the primary dissemination route. Systemic sporotrichosis can be divided into a pulmonary form and a disseminated form, both causing higher morbidity and mortality than cutaneous sporotrichosis.
  • Pulmonary infection may remain localized to the lung or may disseminate to other body sites, including the skin, joints, bones, internal organs, and meninges. For instance, one case has been reported of laryngeal and respiratory tract sporotrichosis after steroid inhaler use.
  • This clinical situation has often been found in persons with alcoholism.
  • Erythema nodosum and vascular lesions resembling polyarteritis nodosum have also been reported in patients with sporotrichosis.
• Clinical types of sporotrichosis
• • Localized cutaneous (chancriform) type: A subcutaneous papule or pustule develops at the site of inoculation after several weeks. Surrounding skin develops a pink-to-violaceous papulonodule, which may subsequently develop into a painless ulcer. The ulcer border is often ragged and undermined and draining a serosanguineous exudate. Draining lymph nodes may become tender and swollen.
  • Chronic lymphangitic (sporotrichoid) type: This is the most common and best recognized form of sporotrichosis; it may follow the chancriform type described above. Lymphangitic spread of the fungus produces nodular swellings in a linear array, spreading proximally up the affected extremity. Palpable lymphadenopathy is often an associated finding.
  • Fixed cutaneous sporotrichosis: Crusted verrucous plaques may occur in this type and are often found on the faces of children or the upper extremities of adults.
  • Disseminated sporotrichosis: The fungus spreads hematogenously to the skin, joints, eyes, and CNS. Multiple crusted and ulcerating papulonodules may occur. This form may have a widespread distribution (sparing the palms of the hands and the soles of the feet). The primary source of infection may be the lungs, or dissemination may occur from a cutaneous site in a patient who is immunocompromised.

Causes

Sporotrichosis is typically acquired by inoculation of the fungus into the skin during contact with certain plants or animals. Classic scenarios include skin puncture by a splinter or rose thorn. Bites or scratches from sick animals such as cats, dogs, birds, and armadillos represent another source of infection.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Cutaneous tuberculosis
Keratoacanthoma
Lupus vulgaris
Mycobacterium marinum infection
Nocardia infection

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Sporotrichosis is a thermally dimorphic fungus that can be grown from infected tissues.
• S schenckii is easy to grow and is not sensitive to cycloheximide, which is often added to fungal culture media to inhibit growth of saprophytes and to promote growth of dermatophytes.
• At 25°C on Sabouraud agar, the fungus forms a white-to-cream–colored mold that turns dark brown or black as it ages, often forming a leathery, wrinkled surface.
• Microscopic examination of a cotton blue or Scotch tape preparation reveals long and slender septate hyphae with hyaline pyriform conidia, often forming flowerlike arrangements.
• In tissue at 37°C, S schenckii takes on an elongated yeast form, approximately 6-8 mm in length, with rounded ends resembling cigars. Budding from the main yeast bodies may be observed in the tissues.
• To confirm the identity of this fungus, the hyphal form may be converted into the yeast phase. This is often best achieved by growing the fungus on brain-heart infusion agar supplemented with sheep's blood then raising the temperature from 25°C to 37°C.
• Fine-needle aspiration of lymphocutaneous sporotrichosis can be followed by periodic-acid Schiff (PAS) and Grocott's methenamine silver (GMS) method.
• Further laboratory studies (eg, tuberculosis test, antinuclear antibody test) may be needed to identify other potential infectious or noninfectious causes that may mimic sporotrichosis.

Imaging Studies

• If primary pulmonary sporotrichosis is suspected, chest radiography may be helpful.

Procedures

• Diagnosis must often await the results of tissue culture. Despite the usual difficulty in visualizing S schenckii yeast cells on routine hematoxylin and eosin (H&E) stains, the organism is usually cultured relatively easily. A punch biopsy or incisional biopsy may provide the best sample for these 2 tests. When tissue is obtained for culture, submit the specimen in (nonbacteriostatic) normal saline to the laboratory without delay.

Histologic Findings

• S schenckii is often very difficult to recognize in regular H&E tissue sections or even when tissue is stained with PAS or GMS. The cigar-shaped yeast cells are usually quite sparse within the tissue. Although geographic differences have been reported in the abundance of S schenckii found in the tissues, as have differences in the ease of identifying them with special stains, the reasons for these differences are unknown.
• Because these yeast cells are usually difficult to find in the tissue, seeking clues to their presence may increase the likelihood of finding the organism.
• From a low-power view, the tissue often manifests a pseudoepitheliomatous hyperplasia with microabscess formation. This is a nonspecific finding but is often a clue to deep fungal infection, prompting the investigator to make a close survey of the tissue for infective organisms.
• A diffuse, mixed, inflammatory cell infiltrate is often found throughout the dermis, extending into the subcutaneous fat. When found, the yeast often resides within microabscesses or within macrophages and giant cells.
• Asteroid bodies may also be a clue to sporotrichosis. These entities are eosinophilic round bodies with pink material radiating outward from their center. Asteroid bodies most likely form as a result of accumulation of immunoglobulins surrounding a yeast cell.
• A fluorescent antibody technique may enhance diagnostic specificity. This technique uses anti-Sporothrix immunoglobulins labeled with fluorescein dye to enhance identification of the yeast cells in tissue.
• Fortunately, even if the fungus cannot be observed in the tissues, it is often very easy to grow in culture.
• One case reported a histology mimicking that of cutaneous cryptococcosis.⁴

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

Medical therapy is the standard of care for sporotrichosis. Patients are commonly treated with an oral antifungal agent on an outpatient basis. Surgical therapy, other than to perform a biopsy from a lesion for establishing the diagnosis, is rarely used as a form of treatment. Aggressive treatments are seldom necessary. This fungus does not grow well in temperatures higher than 38.5°C, so warm compresses are often used as adjunctive therapy. See the Medication section for a suggested pharmaceutical approach to treating sporotrichosis.

Consultations

Consult with a dermatologist.

Activity

Activity limitations, determined on a case-by-case basis, may be necessary for optimal care. Wearing long sleeves and gloves is recommended when gardening or handling plant matter that may cause sporotrichosis.

MEDICATION

Section 7 of 11  

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Approach the treatment of sporotrichosis based upon each patient's clinical presentation and severity of illness. Most patients are treated with some form of antifungal therapy. Many agents are reported to be successful. For simple cutaneous forms, a saturated solution of potassium iodide is often used and is the least expensive form of treatment.

Systemic antifungal medications, such as amphotericin B, itraconazole, terbinafine, or fluconazole, may be used to treat more severe forms of sporotrichosis (eg, lymphonodular, pulmonary, osteoarticular, disseminated). For all clinical types of sporotrichosis, continue the treatment course for at least 1 week after clinical cure.

Drug Category: Antifungal agents

The mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.

FOLLOW-UP

Section 8 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
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• Follow-up
• Miscellaneous
• Multimedia
• References

Further Inpatient Care

• Sporotrichosis is usually managed on an outpatient basis. A few patients with the more severe forms (eg, disseminated sporotrichosis) may require hospitalization.

Further Outpatient Care

• The primary therapeutic approach to managing cutaneous lesions of sporotrichosis involves administration of systemic medications to eradicate the fungus. If a cutaneous plaque, nodule, or ulcer is present, consider teaching the patient about supportive local wound care to facilitate healing. Such education typically involves instruction on keeping lesions clean and free from further contamination. If the lesion is ulcerated, a topical ointment may be applied to prevent occurrence of secondary bacterial infections. Follow up with the patient in the clinic every 1-2 weeks to monitor progress. Instruct the patient about potential sources of this fungus to help avoid further infections.

In/Out Patient Meds

• See Medical Care.
  

Deterrence/Prevention

• Educate every patient who has acquired sporotrichosis about the fungus and provide information about how to prevent occurrence of further infections. S schenckii is a saprophytic fungus, usually found in the soil. Instruct patients to be careful when working with soils, sphagnum moss, decaying wood, roses, thorn bushes, and salt marsh or prairie hay. If exposure to these materials or plants is anticipated, instruct patients to wear personal protective equipment, particularly gloves, to minimize thorn or splinter punctures of the skin.
• Sporotrichosis has also been acquired from pets, particularly cats, so the physician should consider this potential source of acquisition if the aforementioned soil and plant exposures do not apply.

Prognosis

Prognosis for patients with sporotrichosis depends on its clinical type (eg, fixed cutaneous, localized cutaneous, lymphocutaneous, disseminated), associated underlying diseases, and the patient's immune response to this fungus.

• Patients with fixed cutaneous and lymphocutaneous sporotrichosis have an excellent prognosis. These lesions usually respond well to therapy and typically resolve after 4-6 weeks of therapy.
• Patients with the osteoarticular form of sporotrichosis usually have a moderately good prognosis, but they may require higher doses of medication, longer courses of therapy to achieve cure, or both.
• Patients with pulmonary or disseminated forms of sporotrichosis usually have some underlying medical condition or immune deficit that allows the fungus to grow and spread unchecked. For example, patients who have insulin-dependent diabetes mellitus, chronic alcoholism, or AIDS may be unable to mount an adequate immune response to keep this fungal infection localized. Such patients typically have a worse prognosis and require longer courses of therapy.

Patient Education

• See Deterrence/Prevention.
• For excellent patient education resources, visit eMedicine's Yeast and Fungal Infections Center. Also, see eMedicine's patient education article Sporotrichosis.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Medicolegal problems associated with clinical cases of sporotrichosis are unusual but may occur for a few basic reasons.
• • Failure to establish the appropriate diagnosis, resulting in delay of care or provision of inappropriate care, may result in litigation.
  • The dome-shaped nature of a cutaneous ulcer produced by sporotrichosis, combined with its abrupt clinical course, may mimic a keratoacanthoma. This may result in an unnecessary surgical procedure or inadvertent use of an injectable chemotherapeutic agent to treat the suspected skin cancer. These procedures only worsen the situation.
  • Failure to provide appropriate treatment or medications is another example of a medicolegal pitfall because resolution of this fungal infection may be delayed, resulting in unnecessary inflammation and scarring.
  • Failure to follow up with the affected patient to assure complete resolution of sporotrichosis may result in recurrence or undue morbidity or mortality. Patients should be scheduled for follow-up after clinical resolution of sporotrichosis to monitor for recurrence.

MULTIMEDIA

Section 10 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
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• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Sporotrichosis with cutaneous necrosis and lymphangitic (sporotrichoid) spread. A 28-year-old white man presented for evaluation of a poorly healing, asymptomatic, round plaque acquired on the dorsum of his left hand. The lesion had been present for approximately 3 weeks.
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Media type:  Photo

Media file 2:  Glucose-peptone agar culture plates revealing colony growth of Sporothrix schenckii. The left plate reveals older colonies as dark brown or black, and the right plate reveals younger white colonies with a brown center, characteristic of this fungus.
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Media type:  Photo

Media file 3:  Microscopic examination of a blue dye preparation from the colony surface reveals elongated septate hyphae with groups of microconidia in a flowerlike arrangement.
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Media type:  Electron Microscopy

Media file 4:  A well-circumscribed, moderately elevated, erythematous plaque with central ulceration is found on the dorsum of this patient's left hand. Potassium chloride (KOH) stain was negative for fungal elements.
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Media type:  Photo

Media file 5:  A 2 X 2 cm, dome-shaped, well-circumscribed, erythematous plaque is shown proximal to the left ring finger. The lesion was draining a serosanguineous fluid. No purulence was noted.
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Media type:  Photo

Media file 6:  Biopsy rarely reveals the 6-mcg cigar-shaped yeast within tissue macrophages as shown in this histologic section. This is the morphology that Sporothrix schenckii assumes at 37°C.
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Media type:  Photo

Media file 7:  Moist cream-colored colonies with a central, dark, leathery, and wrinkled surface growing at 25°C is highly suggestive of Sporothrix schenckii.
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Media type:  Photo

Media file 8:  A fresh agar slant of Sporothrix schenckii reveals moist, white-to-cream–colored, yeastlike colonies.
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Media type:  Photo

Media file 9:  Cutaneous, ulcerating, painless nodule on the hand and a classic sporotrichoid lymphangitic pattern spreading proximally up the arm.
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Media type:  Photo

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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21. Sandhu K, Gupta S. Potassium iodide remains the most effective therapy for cutaneous sporotrichosis. J Dermatolog Treat. Dec 2003;14(4):200-2. [Medline].
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Article Last Updated: Nov 15, 2007