Saturday, January 3, 2015

A 68-year-old woman seeks evaluation for an ulcerative lesion on her right hand.

A 68-year-old woman seeks evaluation for an ulcerative lesion on her right hand. She reports that the area on the back of her right hand was initially red and not painful.

There appeared to be a puncture wound in the center of the area, and she thought she had a simple scratch acquired while gardening.

Over the next several days, the lesion became verrucous and ulcerated. Now the patient has noticed several nodular areas along the arm, one of which ulcerated and began draining a serous fluid today. She is also noted to have an enlarged and tender epitrochlear lymph node on the right arm.

A biopsy of the edge of the lesion shows ovoid and cigar-shaped yeasts.

Sporotrichosis is diagnosed.

What is the most appropriate therapy for this patient?

A. Amphotericin B intravenously
B. Caspofungin intravenously
C. Clotrimazole topically

D. Itraconazole orally

E. Selenium sulfide topically

The answer is D. Sporothrix schenckii is a thermally dimorphic fungus found
in soil, plants, and moss and occurs most commonly in gardeners, farmers, florists, and
forestry workers. Sporotrichosis develops after inoculation of the organism into the skin
with a contaminated puncture or scratch.

 The disease typically presents as a fixed cutaneous lesion or with lymphocutaneous spread. The initial lesion typically ulcerates and become verrucous in appearance. The draining lymphatic channels become affected in up to 80% of cases. This presents as painless nodules along the lymphatic channel, which ulcerate. A definitive diagnosis is made by culturing the organism. A biopsy of the lesion may show ovoid or cigar-shaped yeast forms. Treatment for sporotrichosis is systemic therapy. Options include oral itraconazole, saturated solution of potassium iodide, and terbinafine.

 However, terbinafine has not been approved for this indication in the United States. Topical antifungals are not effective. In cases of serious system disease such as pulmonary sporotrichosis,
amphotericin B is the treatment of choice. Caspofungin is not effective against S. schenckii.


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