Superficial cutaneous sporotrichosis in specific anergic patient
Authors: Bonifaz Alexandro , Mb . , Saúl Amado , Montes‐de‐Oca Griselda , Mercadillo Patricia 
Published: March 2003

A 25‐year‐old man from Coscomatepec, Veracruz (400 km south‐east of Mexico City), and currently resident at this location, presented with dermatosis on the face, affecting the frontal region, dorsum of the nose, and malar region, composed of two nodular or verrucose plaques with an irregular diameter and form, with infiltrated borders, ulcerations, and bloody and honey crusts; the plaques developed over 4 years after trauma due to a horse kick (Fig. 1a.)

(a) Initial appearance. (b) After 7 years of various treatments

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Symptoms were moderate pruritus and some pain on examination. The patient had previously received topical treatment with steroids and procaine penicillin in an irregular form. At the beginning, the presumptive clinical diagnosis was verrucose tuberculosis; thus a tuberculin skin test (purified protein derivative, PPD) was applied with a response of 3 × 2 cm of induration and erythema; later, a biopsy was taken to confirm the diagnosis. Based on these results, antituberculosis treatment with ethambutol, 1.2 g/day, and isoniazid, 300 mg/day, plus copper sulfate baths, was instituted for 1 month.

Histopathology revealed a parakeratotic epidermis with moderate irregular acanthosis; zones of spongiosis and exocytosis formed in some areas with crusts and cellular detritus. In the superficial and medial dermis layers, a wide inflammatory infiltrate formed from lymphocytes, epithelial histiocytes, some plasmocytes, and giant multinucleated Langhans‐type cells and some dilated and congested capillary vessels were observed. Through Schiff’s and Grocott’s stains, long yeast‐like structures of approximately 5–8 μm were observed. The histopathologic diagnosis was a tuberculoid granuloma with mycotic elements suggesting blastomycosis (Fig. 2).

Skin biopsy: yeast cells of Sporothrix schenckii (Grocott’s stain, original magnification ×100)

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Based on the histologic examination, the following mycologic tests were performed: direct examination with potassium hydroxide (KOH) and with Gram stain revealed yeast‐like, oval and elongated cells of approximately 5–10 μm. Cultures of Sabouraud and Micosel agar grew Sporothrix schenckii. Skin tests of sporotrichin M and Y (from mycelial and yeast antigens) were applied several times at different concentrations, always with negative results; therefore, the immunologic profile was performed (summary in Table 1).

Immunologic features

Antigens
Skin tests
MIF (%)

PPD (tuberculin)
3 × 2 cm
77

Candidin
2 × 2 cm
60

Trichophytin
1 × 1 cm
36

Streptokinase‐streptodornase (varidase)
Negative
20

Sporotrichin Y (yeast)
Negative
0

Sporotrichin M (mycelial)
Negative
0

MIF, macrophage inhibition factor.

Hematology, liver function tests, and urinalysis were within normal ranges. A chest X‐ray was normal. The CD4/CD8 lymphocyte ratio was 1.25 cell/mm3, i.e. within normal values. Two evaluations of human immunodeficiency virus (HIV) antibodies performed in two different periods were negative to Western blot (WB) and enzyme‐linked immunoabsorbent assay (ELISA) tests.

During the past 8 years, we have observed the patient; he has received several treatments and has achieved considerable clinical improvement; nevertheless, each time treatment is discontinued, new superficial and discrete lesions appear with positive cultures to S. schenckii; sporotrichin tests were applied every year (8 times), and yielded a positive result.

Figure 3
summarizes the treatment period as well as the drugs used. In summary, the patient was managed as follows: he initially received oral potassium iodide, 3–6 g/day for 8 months; this treatment was repeated many times in several episodes of reactivation of the disease or as supportive treatment; ketoconazole, 400 mg/day for 6 months; amphotericin B for 2 months at a dose level of 0.50 mg/kg/day; itraconazole, 300–

Treatment and course of the disease

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400 mg/day for several treatment periods; fluconazole, 300 mg/day for 4 months;

terbinafine, 500 mg/day for 4 months. During the use of all these systemic antimycotic agents, monitoring of hematology and renal and liver function tests were performed with no alterations observed.

As a consequence of the initial trauma and its cicatrization, the patient presented retraction of the left eyelid, for which he underwent a surgical process; bridal tissues were released and a graft was placed later on with a satisfactory functional and cosmetic result.

Currently, the patient is alternately taking, with resting periods of up to 3 months, potassium iodide at a dose of 0.5–1.0 g/day or itraconazole 100 mg/day. At the last visit (March 1998), the patient showed excellent clinical improvement; however, cultures are still positive.