1	Case Presentation & Discussion April Tropical & Travel Medicine Seminar Jonathan Kirsch Hennepin County Medical Center 4/10/2002
2	Case HPI: 65 y.o. indigenous Mayan male walking barefoot scrapes foot on rock. The sore doesn’t heal, but breaks open 15 days later (Mayan unit of time) No fever Differential diagnosis
3	Case HPI: He presents 2 months later with similar sores, now slowly spread slowly up leg. PMH: Unknown. Hasn’t seen doctor. Binge EtOH on Sundays. No tobacco. ROS: Essentially negative, other than sores Exposures: Works as coffee farmer in temperate climate (cool cloud forest). Travels to tropical climate as seasonal worker. Doesn’t wear shoes. No sick contacts. No animal contacts.
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5	Progression A second lesion appeared 2 weeks later. Still no systemic symptoms. Over the next 6 weeks, multiple papules appeared, slowly becoming nodules, and then ulcerating. Lesions progressed proximally, each looking identical.
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9	What does he have in general? Lymphocutaneous Syndrome Differential Diagnosis Very broad Sporothrix schenkii Nocardia, especially brasiliensis Atypical mycobacteria, especially marinum, kansasii Tularemia (systemic systems almost always present) Leishmaniasis, especially brasiliensis Fixed cutaneous lesions have different Ddx Ulceroglandular Disease has different Ddx
10	Dx: Dimorphic fungus Sporothrix schenkii Mold at 25-30°, yeast at 37° Whiteàbrown/black (pigmented conidia) Worldwide distribution Common in tropical/subtropical Americas, Japan Sphagnum moss, decaying vegetation, soil, hay Hobbies: rose gardening, topiary, hay work, etc. Animal bites/scratches, mostly cats, armadillos Outbreaks: contaminated moss, etc. Often hobby, work related
11	Transmission Cutaneous Contact with infected moss, hay… and broken skin Animal scratch: esp. cat, armadillo, also bird, rodent dog, insect Wood splinters, etc. Pulmonary Inhalation of conidia from soil, decaying vegetation Rare Often associated with immunosuppression, EtOH
12	Clinical Features Subacute to chronic cutaneous, subcu. infection True pathogen: infects healthy hosts equal to not Disease extent affected by immunosuppression Strong association with alcoholism Disseminated, osteoarticular, meningeal, pulmonary
13	Clinical Features Primary cutaneous lesion 2-15mm Days to weeks at site of inoculation Papule slowly enlarges®nodule®ulcer Erythematous, minimal pain, non-purulent drainage Nodules progress proximally along lymphatics Similar to initial lesion Not self-limited, but rarely life-threatening Rarely systemic symptoms Arthritis, tenosynovitis, dissemination if cutaneous lesion and immunocomprimised
14	Clinical Features Fixed cutaneous lesions w/o lymphatic spread Persist for years if not treated Ddx: mycobacteria, nocardia, blasto, paracocci, cryptococcus, leishmaniasis, S. aureus, S. pyogenes, anthrax, vaccinia Pulmonary Clinically similar to tuberculosis Symptoms: fever, NS…, hemoptysis, dyspnea CXR: cavities in upper lobes Risk factors: EtOH, DM, COPD, AIDS, steroids Ddx: histo, blasto, cocci, Tb, sarcoidosis
15	in AIDS Disseminated, visceral, meningeal seen almost entirely in AIDS Only seen with CD4 <200 More likely to be invasive, widespread (think wherever Tb goes) Can be presenting O.I. More arthritis, tenosynovitis if skin lesions present Lifelong suppressive therapy with itraconazole
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17	Diagnosis Organisms isolated from infection site Swab, aspiration, biopsy Biopsy ideal for culture Should do culture with specific objective Tell lab to look specifically for nocardia, AFB, leishmania, tularemia, etc. Grows easily in 3-5 days ELISA, latex agglutination not readily avail.
18	Treatment Rarely life threatening, but not self-limited Pulmonary and disseminated are exceptions Lymphocutaneous and cutaneous Itraconazole is drug of choice x 3-6 months Success near 100% Fluconazole and ketoconazole less effective
19	Other Treatments Saturated Solution of Potassium Iodide (SSKI) Used for ~ 100 years Cheap, widely available Unpleasant side effects: metallic taste, salivary gland enlargement, rash Local hyperthermia ~ 1 hour/day for months Especially for fixed cutaneous lesions, can be curative Good for use during pregnancy as bridge until delivery Amphotericin B if disseminated No clinical trials, but very effective Terbinafine in ongoing trials
20	Outcome of Case Patient No diagnostic tests were performed Patient was given SSKI 5 drops t.i.d. increased to 40 t.i.d. without side effects noticed. Within one week, the lesions began to resolve and by 2 months, all lesions were dried and no ulcers remained. No bacterial superinfections occurred.