Sporothrix schenckii: Difference between revisions
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Sporothrix schenckii
(Created page with "* Dimorphic fungus that causes '''rose-handler's disease''' == Background == === Epidemiology === * Found in soil, decomposing plant matter, and peat moss * Acquired by inocu...") Â |
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− | * |
+ | *Dimorphic fungus that causes '''rose-handler's disease''' |
− | == |
+ | ==Background== |
− | === |
+ | ===Microbiology=== |
+ | |||
⚫ | |||
+ | *Dimorphic fungus with a hyaline, hyphated mold phase at 25ºC, and a round-to-oval budding yeast phase at body temperature |
||
⚫ | |||
+ | *Produces melanin, a virulence factor |
||
+ | |||
+ | ===Epidemiology=== |
||
+ | |||
⚫ | |||
+ | **Increasing frequency in Italy |
||
⚫ | |||
+ | *Can also be acquired by cat scratches |
||
+ | *Hosts include humans, cats, horses, dogs, rodents, cattle swine, camels, etc. |
||
+ | |||
+ | ==Clinical Manifestations== |
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+ | ===Lymphocutaneous=== |
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+ | |||
+ | *Common cause of [[nodular lymphangitis]] |
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+ | *Incubation period [[Usual incubation period::7 to 30 days]] |
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+ | *Nodules can be 2 to 4 cm, and appear along the lymphatics, typically in the arms and legs (and face, in children) |
||
+ | **They become indurated, then ulcerated |
||
+ | *May have regional lymphadenopathy |
||
+ | *Usually mild or no systemic symptoms |
||
+ | |||
+ | ===Fixed cutaneous=== |
||
+ | |||
+ | *Only a single lesion, fixed at the point of inoculation |
||
+ | *Lesions may be papular, plaques, nodular, verrucous, or ulcerated |
||
+ | |||
+ | ===Disseminated or multifocal=== |
||
+ | |||
+ | *Only occurs in patients with immunodeficiency, including alcoholism, diabetes, sarcoidosis, tuberculosis, transplantation, malignancy, immunosuppressive medication, or advanced HIV |
||
+ | **Can be in the context of HIV IRIS |
||
+ | *Lesions can include ulcerations, aceniform, plaques, or crusts |
||
+ | *Worst prognosis is with dissemination to lungs or meninges |
||
+ | |||
+ | ===Extracutaneous=== |
||
+ | |||
+ | *Rare presentation without skin lesions, caused either by inhalation or deep inoculation |
||
+ | *Musculoskeletal infections are the most common, with '''septic arthritis''' followed by osteomyelitis or tenosynovitis |
||
+ | *'''Pulmonary sporotrichosis''' is more common in men aged 30 to 60 years, and presents similarly to [[pulmonary tuberculosis]] |
||
+ | **Major risk factors: alcohol (1/3); sarcoidosis, TB, or diabetes (1/3); otherwise healthy (1/3) |
||
+ | *'''Sporotrichotic meningitis''' is rare and occurs in immunocompromised patients |
||
+ | *Can also affect eyes, genitals, or oropharyngeal mucosa |
||
+ | |||
+ | == Differential Diagnosis == |
||
+ | |||
+ | * See [[nodular lymphangitis]] |
||
+ | |||
+ | ==Diagnosis== |
||
+ | |||
+ | *Sample collection |
||
+ | **Deep swab or aspirate, if possible |
||
+ | **Punch biopsy, can be with sterile saline if needed (not in formalin) |
||
+ | *Direct microscopy |
||
+ | **May see yeast forms or characteristic asteroid bodies (especially from deep swabs) |
||
+ | *Culture |
||
+ | **Sab + chloramphenicol at 25ºC for 5 to 7 days for mold form followed by BHI at 35-37ºC for 5 to 7 days for yeast form |
||
+ | **Colony appearance is a white mold that becomes dark |
||
+ | *Molecular tests |
||
+ | **Some labs have developed PCR diagnostics |
||
+ | *Serology |
||
+ | **Tube or latex agglutination have specificity (95%) and sensitivity (98-100%) |
||
+ | **Immunoassays also exist |
||
+ | *Sporotrichin skin test |
||
+ | **Essentially like a TB skin test but for sporotrichosis |
||
+ | **Only useful for epidemiologic surveys |
||
+ | |||
+ | ==Management== |
||
+ | |||
+ | *First-line: [[Is treated by::itraconazole]] 100 to 200 mg po daily until 2 to 4 weeks after the lesions resolve (around 3 to 6 months) |
||
+ | **Dose may be increased to 400 mg if there's a poor response, there are extracutaneous infections including osteoarticular or pulmonary disease, or the host is immunocompromised |
||
+ | **Check for drug-drug interactions |
||
+ | *Alternatives include [[Is treated by::amphotericin B]], [[Is treated by::fluconazole]], and maybe [[Is treated by::terbinafine]] |
||
+ | *Can also do [[Is treated by::local hyperthermia]], especially for patients who are unable to take the above medications |
||
+ | |||
+ | ===Special populations=== |
||
+ | |||
+ | *For '''pregnant women''', use [[Is treated by::amphotericin B]] |
||
+ | *For '''osteoarticular infections''', use [[itraconazole]] 200 mg po bid |
||
+ | **Can use [[amphotericin B]] as induction |
||
+ | **Duration is at least 12 months |
||
+ | *For '''severe pulmonary infection''', use [[amphotericin B]] 3 to 5 mg/kg daily (liposomal), stepped down to [[itraconazole]] 200 mg po bid when better, to complete at least 12 months total |
||
+ | *Same treatment for '''disseminated disease''' |
||
+ | *For '''meningeal infection''', use [[amphotericin B]] 5 mg/kg daily for 4 to 6 weeks, followed by [[itraconazole]] 200 mg po bid until at least 12 months |
||
+ | *For '''children''', use [[itraconazole]] 6 to 10 mg/kg (max 400 mg) daily |
||
+ | *For '''severe disease in children''', use [[amphotericin B]] 0.7 mg/kg daily induction then [[itraconazole]] 6 to 10 mg/kg (max 400 mg) daily |
||
+ | |||
+ | ===Potassium iodide=== |
||
+ | |||
+ | *Used more outside of developed countries, since it is cheap |
||
+ | *Poorly tolerated, though, with numerous side effects |
||
+ | |||
+ | ==Further Reading== |
||
+ | |||
+ | *[https://www.canada.ca/en/public-health/services/laboratory-biosafety-biosecurity/pathogen-safety-data-sheets-risk-assessment/sporothrix-schenckii.html Pathogen Safety Data Sheets: Infectious Substances – Sporothrix schenckii]. |
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{{DISPLAYTITLE:''Sporothrix schenckii''}} |
{{DISPLAYTITLE:''Sporothrix schenckii''}} |
Latest revision as of 09:59, 5 August 2020
- Dimorphic fungus that causes rose-handler's disease
Background
Microbiology
- Dimorphic fungus with a hyaline, hyphated mold phase at 25ºC, and a round-to-oval budding yeast phase at body temperature
- Produces melanin, a virulence factor
Epidemiology
- Found in soil, decomposing plant matter, and peat moss worldwide (but most often in moist tropical or subtropical zones)
- Increasing frequency in Italy
- Acquired by traumatic implantation or inoculation of a preexisting wound
- Can also be acquired by cat scratches
- Hosts include humans, cats, horses, dogs, rodents, cattle swine, camels, etc.
Clinical Manifestations
Lymphocutaneous
- Common cause of nodular lymphangitis
- Incubation period 7 to 30 days
- Nodules can be 2 to 4 cm, and appear along the lymphatics, typically in the arms and legs (and face, in children)
- They become indurated, then ulcerated
- May have regional lymphadenopathy
- Usually mild or no systemic symptoms
Fixed cutaneous
- Only a single lesion, fixed at the point of inoculation
- Lesions may be papular, plaques, nodular, verrucous, or ulcerated
Disseminated or multifocal
- Only occurs in patients with immunodeficiency, including alcoholism, diabetes, sarcoidosis, tuberculosis, transplantation, malignancy, immunosuppressive medication, or advanced HIV
- Can be in the context of HIV IRIS
- Lesions can include ulcerations, aceniform, plaques, or crusts
- Worst prognosis is with dissemination to lungs or meninges
Extracutaneous
- Rare presentation without skin lesions, caused either by inhalation or deep inoculation
- Musculoskeletal infections are the most common, with septic arthritis followed by osteomyelitis or tenosynovitis
- Pulmonary sporotrichosis is more common in men aged 30 to 60 years, and presents similarly to pulmonary tuberculosis
- Major risk factors: alcohol (1/3); sarcoidosis, TB, or diabetes (1/3); otherwise healthy (1/3)
- Sporotrichotic meningitis is rare and occurs in immunocompromised patients
- Can also affect eyes, genitals, or oropharyngeal mucosa
Differential Diagnosis
Diagnosis
- Sample collection
- Deep swab or aspirate, if possible
- Punch biopsy, can be with sterile saline if needed (not in formalin)
- Direct microscopy
- May see yeast forms or characteristic asteroid bodies (especially from deep swabs)
- Culture
- Sab + chloramphenicol at 25ºC for 5 to 7 days for mold form followed by BHI at 35-37ºC for 5 to 7 days for yeast form
- Colony appearance is a white mold that becomes dark
- Molecular tests
- Some labs have developed PCR diagnostics
- Serology
- Tube or latex agglutination have specificity (95%) and sensitivity (98-100%)
- Immunoassays also exist
- Sporotrichin skin test
- Essentially like a TB skin test but for sporotrichosis
- Only useful for epidemiologic surveys
Management
- First-line: itraconazole 100 to 200 mg po daily until 2 to 4 weeks after the lesions resolve (around 3 to 6 months)
- Dose may be increased to 400 mg if there's a poor response, there are extracutaneous infections including osteoarticular or pulmonary disease, or the host is immunocompromised
- Check for drug-drug interactions
- Alternatives include amphotericin B, fluconazole, and maybe terbinafine
- Can also do local hyperthermia, especially for patients who are unable to take the above medications
Special populations
- For pregnant women, use amphotericin B
- For osteoarticular infections, use itraconazole 200 mg po bid
- Can use amphotericin B as induction
- Duration is at least 12 months
- For severe pulmonary infection, use amphotericin B 3 to 5 mg/kg daily (liposomal), stepped down to itraconazole 200 mg po bid when better, to complete at least 12 months total
- Same treatment for disseminated disease
- For meningeal infection, use amphotericin B 5 mg/kg daily for 4 to 6 weeks, followed by itraconazole 200 mg po bid until at least 12 months
- For children, use itraconazole 6 to 10 mg/kg (max 400 mg) daily
- For severe disease in children, use amphotericin B 0.7 mg/kg daily induction then itraconazole 6 to 10 mg/kg (max 400 mg) daily
Potassium iodide
- Used more outside of developed countries, since it is cheap
- Poorly tolerated, though, with numerous side effects