Indian Journal of Dermatology, Venereology and Leprology Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) ISSN: 0378-6323 EISSN: 0973-3922 Vol. 69, Num. 3, 2003, pp. 239-240

Indian Journal of Dermatology, Venereology & Leprology, Vol. 69, No. 3, May-June, 2003, pp. 239-240

Case Report

Localized cutaneous sporotrichosis lasting for 10 years

Sanjay K. Rathi, M. Ramam,* C. Rajendran**

*Associate Professor, Departmant of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India; and
**Joint Director, National Institute of Communicable Diseases, Delhi, India.
Address for correspondence: Dr. Sanjay Rathi, MD, Dr. Rathi's Skin Clinic, 143, Hill Cart Road, Siliguri-734401, W. Bengal, India. E-mail: srathi2@rediffmail.com

Code Number: dv03016

Abstract

A case of localized cutaneous sporotrichosis lasting for 10 years is being reported. The fixed cutaneous variety creates diagnostic difficulty by mimicking other conditions, chiefly lupus vulgaris.

Key Words: Sporotrichosis, Lupus vulgaris

Introduction

Sporotrichosis is a fungal infection caused by Sporothrix schenckii.¹ Both cutaneous and systemic forms of sporotrichosis exist. Three clinical types are described: (i) fixed cutaneous, (ii) lymphocutaneous, and (iii) disseminated. Lymphocutaneous sporotrichosis is easy to recognize but fixed sporotrichosis can pose diagnostic problems.^2,3 The following report illustrates the diagnostic problem caused by the fixed type of cutaneous sporotrichosis mimicking lupus vulgaris.

Case Report

A 60-year-old woman presented with a single, well-defined, erythematous, mildly scaly plaque with central clearing and scarring on the extensor of the left forearm (Figure 1). Thickened lymphatic cords were not palpable in the vicinity nor was there any significant lymphadenopathy. The plaque began as a small papule 10 years earlier. It gradually increased in size for the first 2-3 years and had remained static since then. There was itching and superficial ulceration of the plaque off and on. She did not recall any history of thorn prick or any other injury at the site of the lesion. There was no history of cough, hemoptysis or weight loss. A biopsy had revealed granulomatous inflammation and she was treated with three antitubercular drugs for six months. However, there was no improvement with this treatment.

Her general physical and systemic examinations were normal. Her routine laboratory parameters, including the liver and renal function tests, and X-ray chest, were within normal limits. HBsAg, HCV and Mantoux test were negative. Ultrasonography of the abdomen was normal except for fatty infiltration of liver. A second skin biopsy showed extensive mixed cell granulomas in the upper and mid dermis with neutrophilic abscesses and many eosinophils. No organisms were seen. Tissue sent for fungal culture grew Sporothrix schenckii.

The patient was treated with a saturated solution of potassium iodide orally, with the dose gradually increased to 45 drops 3 times a day. The lesion resolved completely with scarring after 8-9 weeks of treatment. Potassium iodide was continued for two months after clinical resolution and then stopped. The patient did not report any adverse effects. There was no evidence of disease activity when she was reviewed one and half years after completing therapy.

Discussion

The lymphocutaneous variety of sporotrichosis presents a distinctive clinical picture, with nodules and ulcers arranged linearly along the lymphatics with thickened lymphatic cords between the nodules, usually on exposed skin.^1,3 The fixed variety, where the pathogen remains localized, is less common.^4,5 It may be a nodular, acneiform, ulcerated or verrucous form of variable duration.⁶ The fixed cutaneous type is more difficult to diagnose and may be mistaken for other causes of a persistent, non-healing ulcer or nodule, chiefly tuberculosis.^6-8 Many patients, like our case, are treated for cutaneous tuberculosis.

In our patient, the diagnosis of sporotrichosis was suspected by the finding of a mixed cell granuloma on biopsy and confirmed by fungal culture. She responded well to treatment with potassium iodide.

References

1. Hay RJ, Moore M. Mycology. In: Champion RH, Burton JL, Burns DA, Breathnach SM, editors. Textbook of dermatology. 6th edn. Oxford: Blackwell Science; 1998. p. 1277-376.
2. Chang G, Kantor G, Koblenzer P, et al. Fixed cutaneous sporotrichosis. Arch Dermatol 1999;126:399-400.
3. Itoh M, Okamoto S, Kanya S. Survey of 260 cases of sporotrichosis. Dermatologica 1986;172:203-13.
4. Hemashettar BM, Kuchabal DS, Hanchinamani Suman P. Fixed cutaneous sporotrichosis from North Karnataka. Indian J Dermatol Venereol Leprol 1992;58:45-7.
5. Singh P, Sharma RC, Gupta ML. Localised cutaneous sporotrichosis of face - a case report from India. Indian J Dermatol Venereol Leprol 1980;46:381.
6. Villaca-Neto CM, Rossetti RB, Fischman O, Paschoal LH. Localized cutaneous verrucous sporotrichosis of 26 years' duration. Mycoses 1988;31:353-5.
7. Sperling LC, Read SI. Localized cutaneous sporotrichosis. Int J Dermatol 1983;22:525-8.
8. Shiraishi H, Gomi H, Kawada A, et al. Solitary sporotrichosis lasting for 10 years. Dermatology 1999;198:100-1.

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