Sporotrichosis is a granulomatous/pyogenic disease commonly caused by pathogenic strains of the dimorphic fungus Sporothrix schenckii, although at least six other pathogenic Sporothrix species exist in various geographic regions, such as Sporothrix brasiliensis.

Lymphocutaneous sporotrichosis

Cutaneous sporotrichosis

Pulmonary sporotrichosis

• Cutaneous disease:
  1. Arises at the site of inoculation, often the site of soil exposure (Fig. E1)
  2. Initial lesion usually located on the distal part of an extremity (Fig. E2), although any area may be affected, including the face
  3. Variable incubation period of approximately 3 wk once introduced into the skin
  4. Granulomatous reaction provoked
  5. Lesion becomes papulonodular, erythematous, elastic, variable in size
  6. Subsequently, nodule becomes fluctuant, undergoes central necrosis, breaks down, discharges mucoid material from which fungus may be isolated
  7. Indolent ulcer with raised erythematous or violaceous borders
  8. Secondary lesions:
     1. Develop along superficial lymphatic channels
     2. Evolve in the same manner as the primary lesion, with subsequent inflammation, induration, and suppuration
• Fixed, or plaque form:
  1. Erythematous verrucous, ulcerated, or crusted lesions
  2. Does not spread locally
  3. Does not involve lymphatic vessels
  4. Rarely undergoes spontaneous resolution
  5. More often persists for years without systemic symptoms and within a setting of normal laboratory examinations
• Osteoarticular involvement:
  1. Most common extracutaneous form
  2. Usually presents as monoarticular arthritis
  3. Left untreated, may progress to:
     1. Synovitis
     2. Osteitis
     3. Periostitis
     4. All involving elbows, knees, wrists, and ankles
• Joint inflamed:
  1. Associated with an effusion
  2. Painful on motion
• Early pulmonary disease:
  1. Usually associated with a paucity of clinical findings:
     1. Low-grade fever
     2. Cough
     3. Fatigue
     4. Malaise
     5. Weight loss
  2. Untreated:
     1. Cavitary pulmonary disease
     2. Frank pulmonary dysfunction
     3. Hemoptysis
     4. Mimics tuberculosis
  3. Meningitis:
     1. Uncommon except perhaps in the immunocompromised patient
     2. Presents with few signs or symptoms of neurologic involvement, usually headache
  4. Few reported cases:
     1. Infection of the ocular adnexa
     2. Endophthalmitis without antecedent trauma
     3. Infection of the testes and epididymis
     4. Certain strains favor cooler body areas such as the scrotum, lower extremities

• Sporothrix schenckii:
• Sporothrix brasiliensis emerging in South America; increased virulence
  1. Global in distribution
  2. Often isolated from soil, plants, and plant products
  3. Majority of case reports from tropical and subtropical regions of the Americas
• Occupational or recreational exposure:
  1. Hay
  2. Straw
  3. Sphagnum moss
  4. Timber
  5. Thorny plants (e.g., roses and barberry bushes)
• Animal contact:
  1. Armadillos
  2. Cats
  3. Squirrels
• Tattooing

• Fixed, or plaque, sporotrichosis:
  1. Bacterial pyoderma
  2. Foreign body granuloma
  3. Tularemia
  4. Anthrax
  5. Other mycoses: Blastomycosis, chromoblastomycosis
• Lymphocutaneous sporotrichosis:
  1. Nocardia brasiliensis
  2. Leishmania braziliensis
  3. Atypical mycobacterial disease: Mycobacterium marinum, Mycobacterium kansasii
• Pulmonary sporotrichosis:
  1. Pulmonary tuberculosis (TB)
  2. Histoplasmosis
  3. Coccidioidomycosis
• Osteoarticular sporotrichosis:
  1. Pigmented villonodular synovitis
  2. Gout
  3. Rheumatoid arthritis
  4. Infection with Mycobacterium tuberculosis
  5. Atypical mycobacteria: Mycobacterium marinum, Mycobacterium kansasii, Mycobacterium avium-intracellulare
• Meningitis:
  1. Histoplasmosis
  2. Cryptococcosis
  3. TB

• The diagnosis should be considered in individuals who are occupationally exposed to soil, decaying plant matter, and thorny plants (gardeners, horticulturists, farmers) who present with chronic nonhealing ulcers or lesions with or without associated arthritis or pulmonary symptoms.
• Diagnosis is made by culture:
  1. Pus
  2. Joint fluid
  3. Sputum
  4. Blood
  5. Skin biopsy
• Isolation of the fungus from any site is considered diagnostic of infection.
• Saprophytic colonization of the respiratory tract has been described.
• A positive blood culture may indicate infection in an immunocompromised host.
• Increasingly sensitive laboratory culturing systems may detect the fungus in the normal host.
• Biopsy specimens are diagnostic if characteristic cigar-shaped, round, oval, or budding yeast forms are seen.
• Despite special staining, the yeast may remain difficult to detect unless multiple sections are examined, as organisms are rare.
• No standard method of serologic testing is available.

• CBCs and serum chemistries are generally normal.
• Elevated erythrocyte sedimentation rate is seen with extracutaneous disease.
• Cerebrospinal fluid analysis in meningeal disease reveals:
  1. Lymphocytic pleocytosis
  2. Elevated protein
  3. Hypoglycorrhachia
• Nested polymerase chain reaction assay represents a future clinical modality to rapidly detect Sporothrix schenckii.
• Matrix-assisted laser desorption ionization-time of flight has been used to identify Sporothrix grown in culture to the species level.

• Chest x-ray examination: Unilateral or bilateral upper lobe cavitary or noncavitary lesions
• Radiographic findings of affected joints:
  1. Loss of articular cartilage
  2. Periosteal reaction
  3. Periarticular osteopenia
  4. Cystic changes

Local heat and prevention of bacterial superinfection in cutaneous or plaque form. This treatment is important for pregnant women as azoles are teratogenic.

• For lymphocutaneous and visceral disease, therapy with itraconazole 200 mg/day for periods of 24 mo or greater. Sporothrix is resistant to voriconazole. It is sensitive in vitro to posaconazole, but existing data are very limited at present.
• Sporothrix appears to be resistant to isavuconazole.

• Prognosis for cutaneous disease is good.
• Prognosis is less satisfactory for extracutaneous disease, especially if associated with abnormal immunologic states or other underlying systemic diseases.

• To surgeon; with an established diagnosis of pulmonary sporotrichosis, cavitary lesions require resection of involved tissue and possible pretreatment with amphotericin
• To infectious disease physician

• In patients with underlying immunosuppression (e.g., hematologic malignancy or infection with HIV), progression of the initial infection may develop into multifocal extracutaneous sporotrichosis.
• In this subset of patients, dissemination of cutaneous lesions is accompanied by hematogenous spread to lungs, bone, mucous membranes, central nervous system.
• Osteoarticular and pulmonary manifestations predominate with the development of polyarticular arthritis and osteolytic bone lesions.
• In the absence of therapy, the infection is ultimately fatal.
• Patients with underlying immunosuppressive states should be carefully evaluated even when presenting with single cutaneous lesions.
• Diagnostic modalities should include:
  1. Radiographic examination of chest
  2. Technetium pyrophosphate bone scan
  3. Culture of synovial fluid, blood, skin lesion(s)
• In patients with acquired immunodeficiency syndrome (AIDS), itraconazole appears to be the drug of choice, although meningitis and pulmonary disease may warrant the use of amphotericin B.
• In patients with AIDS, lifetime suppressive therapy with itraconazole should follow initial therapy because of the potential for relapse and dissemination. Treatment may be terminated when CD4 counts exceed 200 for more than 1 yr.
• Disseminated cases have been reported with the use of tumor necrosis factor alpha inhibitors.