Cutaneous and meningeal sporotrichosis in a HIV patient.

Abstract

A male patient with HIV and past history of tuberculosis and suspected neurotoxoplasmosis was admitted to the hospital with vomiting and small nodules through all his body. Few of the nodules were found forming chains of enlarged lymphatic vessels, especially on lesions located on the limbs. Some of the nodules were ulcerated with a serosanguineous discharge. Collected samples from ulcerated and the nodular lesions showed the presence of Sporothrix schenckii in culture. Although all hemocultures were negative, a spinal fluid collected from this patient and cultures from the cutaneous lesions were both positive for S. schenckii. The patient showed improvement after treatment with Amphotericin B. Sadly, he later died of complications not related to the S. schenckii infection. This case of disseminated sporotrichosis is a remainder that in patients with immunological disorders exotic forms of this fungal clinical entity could be expected.

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161
Rev Iberoam Micol 2007; 24: 161-163
Cutaneous and meningeal
sporotrichosis in a HIV patient
Raquel Vilela2, Guenael F. Souza1, Gláucia Fernandes Cota1and
Leonel Mendoza3
Hospital Eduardo de Menezes, Department of Internal Medicine1and Medical Mycology Laboratory2,
Belo Horizonte, Brazil and Biomedical Laboratory Diagnostics Program, Department of Microbiology and
Molecular Genetics, Michigan State University, USA3
A male patient with HIV and past history of tuberculosis and suspected
neurotoxoplasmosis was admitted to the hospital with vomiting and small
nodules through all his body. Few of the nodules were found forming chains
of enlarged lynphatic vessels, especially on lesions located on the limbs.
Some of the nodules were ulcerated with a serosanguineos discharge.
Collected samples from ulcerated and the nodular lesions showed the
presence of Sporothrix schenckii in culture. Although all hemocultures were
negative, a spinal fluid collected from this patient and cultures from the
cutaneous lesions were both positive for S. schenckii. The patient showed
improvement after treatment with Amphotericin B. Sadly, he later died of
complications not related to the S. schenckii infection. This case of
disseminated sporotrichosis is a remainder that in patients with immunological
disorders exotic forms of this fungal clinical entity could be expected.
Sporotrichosis, HIV, Amphothericin B, Mycotic meningitis
Esporotricosis cutánea y meningea en un paciente
con VIH
Un paciente con VIH e historia de tuberculosis con sospecha de una
neurotoxoplasmosis, fue admitido en el hospital con vómitos y con pequeños
nódulos en todo el cuerpo. Algunos de los nódulos fueron observados
formando cadenas de vasos linfáticos agrandados, especialmente en las
extremidades. Muestras colectadas de las lesiones ulceradas y nodulares
fueron positivas en cultivo para Sporothrix schenckii. Aunque todos los
hemocultivos fueron negativos, muestras tomadas de líquido cefalorraquideo
y de las lesiones cutáneas fueron positivas para S. schenckii. El paciente
respondió al tratamiento con anfotericina B. Sin embargo, murió más tarde por
complicaciones no relacionadas con la infección. Este caso de esporotricosis
diseminada es un llamada de atención para recodar que en pacientes con
desordenes immunológicos pueden producirse formas exóticas de la
enfermedad.
Esporotricosis, VIH, Anfotericina B, Meningitis micótica
Sporotrichosis is a fungal infection caused by the
dimorphic fungal pathogen Sporothrix schenckii. The
disease is acquired after traumatic inoculation of the
pathogen with plant or organic materials containing propa-
gules of this fungus [14]. More rarely, S. schenckii can
Corresponding author:
Dr. Leonel Mendoza
Biomedical Laboratory Diagnostics Program
Department of Microbiology and Molecular Genetics
Michigan State University, 322 North Kedzie Hall
East Lansing, MI 48824-1031 U.S.A.
Tel.: (517) 353-7800
Fax: (517) 432-2006
E-mail: mendoza9:msu.edu
Aceptado para publicación el 4 de octubre de 2006
©2007 Revista Iberoamericana de Micología
Apdo. 699, E-48080 Bilbao (Spain)
1130-1406/01/10.00 €
also be acquired through inhalation [10,14]. The cutaneous
disease is characterized by the formation of single or mul-
tiple nodules that later become ulcerated and could spread
to the nearby tissues with the formation of enlarged lymph
nodes in chains. In recent years, the disease has been asso-
ciated to patients with immunological disorders, including
HIV patients, in which disseminated sporotrichosis seems
to be a common outcome [1,3,6,9,10,12,16-19]. Herein,
we described an unusual cutaneous and disseminated case
of sporotrichosis in a HIV patient.
Clinical Case
A 34 year old Brazilian male, HIV-positive since
1989, with past history of disseminated tuberculosis and a
suspected neurotoxoplasmosis, was admitted to the hospi-
tal in October 2004 with frequent vomiting, nausea, slee-
piness, fever, oral candidiasis, and a count of T-CD4
lymphocytes = 91 cell/mm3. During physical examination
numerous skin nodular lesions, some of them ulcerated,
Summary
Key words
Resumen
Palabras clave
Note

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through out his body, especially on his arms, were noted
(Figure 1). The ulcerated nodules were characterized by
the secretion of a serosanguineous discharge (Figure 2).
The formation of enlarged lymph nodes in chains was also
observed, especially on the limbs. Because the clinical
aspects of the lesions a tentative diagnosis of bacterial der-
matitis was suspected. However, samples collected from
multiple nodules and a set of blood cultures sent to the
laboratory did not reveal the etiologic agent. One week
after admission, a collected biopsy of the infected nodules
showed a granulomatous reaction with fibrosis and an
intense infiltrate of inflammatory mononuclear and giant
cells. Edema and vascular neoformation was also noted.
Despite the use of especial stains for fungi and other etio-
logic agents (Wade, Giemsa, and Grocott), the detection of
the pathogen was not possible. Thus, a clinical diagnosis
of atypical mycobacteriosis was presented.
Due to the granulomatous nature of the multicentric
(multifocal) nodules new samples, collected from several
enlarged lymph nodes, and a spinal fluid were sent to
the Mycology section to rule out fungal pathogens. After
one week of incubation at room temperature, S. schenckii
was isolated from the inoculated plates, including those
cultures plates inoculated with the patient’s spinal fluid.
Amphotericin B (1.0 mg/kg/day) was prescribed to a total
dose of 650 mg. The skin lesions and his neurological con-
dition improved one week after treatment. However, two
weeks later the patient clinical condition worsened, appa-
rently not related to the sporotrichosis or to the antifungal
therapy, and later the patient died. Unfortunately, a ne-
cropsy was not possible.
Discussion
Sporothrix schenckii is a dimorphic fungus usually
acquired by trauma in immunocompetent hosts. However,
in patients with impaired immunosystems the infec-
tion could be acquired by either skin trauma or by inhala-
tion [14]. Interestingly, in apparently healthy hosts, spo-
rotrichosis occurs as a single nodule that could ulcerate
and disseminated via lymphatic vessels to nearby tissues.
In contrast, in immunocompromissed hosts, especially
those with HIV infections, multicentric skin as well as dis-
seminated [extracutaneous] lesions have been reported
[4,5,11,16-19]. It is important to note that some reports of
disseminated sporotrichosis were only cases of multicen-
tric cutaneous sporotrichosis with not internal organs
involvement [6,12]. It is worthy of note that some HIV
patients with central nervous system S. schenckii infection
reported in the medical literature, were apparently secon-
dary to multifocal cutaneous sporotrichosis [7,16,18,19].
In the case discussed in this report, S. schenckii was
recovered in culture from both the lymphatic and cutane-
ous tissues as well as the spinal fluid. This suggests that
the fungus had disseminated to the central nervous system
from the cutaneous lesions, and that the original diagnosis
of neurotoxoplasmosis could be attributable to the pre-
sence of S. schenckii in the brain. Interestingly, some cases
S. schenckii infection in HIV patients reported in the me-
dical literature showed central nervous system involve-
ment as well as the presence of multicentric cutaneous
lesions [4,17]. However, anomalous cases of sporotrichosis
in AIDS patients with osteoarticular tissue, bone marrow,
epididymides, eyes, lungs, and pancreas involvement have
been also encountered [1,2,5,11].
Treatment of systemic sporotrichosis in AIDS
patients usually comprises the use of systemic imidazoles
or amphotericin B [5,7,10,13,14]. A failure of dissemina-
ted sporotrichosis management with itraconazole was
recently reported [18]. However, these investigators attri-
buted the failure to the patient’s inconsistency to take the
drug. The response to these antifungal could varied bet-
ween individuals, but it is well know that the systemic
management for sporotrichosis with itraconazole or am-
photericin B, is very effective in HIV patients with sporo-
trichosis [13,18]. Initial treatment with amphotericin B
followed by a long term itraconazole was reported highly
beneficial in this population of individuals [18]. In our
case we use amphotericin B with an initial response to the
treatment. However, due to his critical clinical condition,
by the time of the diagnosis and management the patient
passed away. Unfortunately, a necropsy was not perfor-
med, thus a final evaluation of his response to treatment
was not possible. This report reinforces the concept that
S. schenckii in HIV patients could lead to multicentric
cutaneous and central nervous system S. schenckii infec-
tion. Thus, the clinicians should be aware of this unusual
fungal infection diagnosed in AIDS patient as well as in
other individuals with induced immunosupression [8].
162
Rev Iberoam Micol 2007; 24: 161-163
Figure 1. The figure depicts some of the multicentric chains of
none-ulcerate nodular lesions found on the patient’s arm.
Figure 2. The figure shows an enlargement of a nodular ulcerate lesions in
one of the patient’s forearm. Note small lesions around the main ulcerate
area, a typical feature of the lesions in this patient [arrows].

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