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Pediatric Sporotrichosis Workup

  • Author: William P Baugh, MD; Chief Editor: Russell W Steele, MD  more...
 
Updated: Jan 31, 2012
 

Laboratory Studies

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  • Sporotrichosis is a thermally dimorphic fungus that can be grown from infected tissues.
  • S schenckii is easy to grow and is not sensitive to cycloheximide, which is often added to fungal culture media to inhibit growth of saprophytes and to promote growth of dermatophytes.
  • At 25°C on Sabouraud agar, the fungus forms a white-to-cream–colored mold that turns dark brown or black as it ages, often forming a leathery, wrinkled surface.
  • Microscopic examination of a cotton blue or Scotch tape preparation reveals long and slender septate hyphae with hyaline pyriform conidia, often forming flowerlike arrangements.
  • In tissue at 37°C, S schenckii takes on an elongated yeast form, approximately 6-8 mm in length, with rounded ends resembling cigars. Budding from the main yeast bodies may be observed in the tissues.
  • To confirm the identity of this fungus, the hyphal form may be converted into the yeast phase. This is often best achieved by growing the fungus on brain-heart infusion agar supplemented with sheep's blood then raising the temperature from 25°C to 37°C.
  • Fine-needle aspiration of lymphocutaneous sporotrichosis can be followed by periodic-acid Schiff (PAS) and Grocott's methenamine silver (GMS) method.
  • Further laboratory studies (eg, tuberculosis test, antinuclear antibody test) may be needed to identify other potential infectious or noninfectious causes that may mimic sporotrichosis.
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Imaging Studies

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  • If primary pulmonary sporotrichosis is suspected, chest radiography may be helpful.
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Other Tests

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  • Immunoelectrophoresis and agglutination techniques are available in the serodiagnosis of this mycosis. A limitation of these tests, however, is their lack of sensitivity in diagnosing cutaneous sporotrichosis.
  • An enzyme-linked immunosorbent assay (ELISA) has been developed for specific antibody detection in serum specimens of patients with sporotrichosis, which has shown to have higher sensitivity; however, cross-reactions between S schenckii and Leishmania have been reported when using ELISA.
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Procedures

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  • Diagnosis must often await the results of tissue culture. Despite the usual difficulty in visualizing S schenckii yeast cells on routine hematoxylin and eosin (H&E) stains, the organism is usually cultured relatively easily. A punch biopsy or incisional biopsy may provide the best sample for these 2 tests. When tissue is obtained for culture, submit the specimen in (nonbacteriostatic) normal saline to the laboratory without delay.
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Histologic Findings

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  • S schenckii is often very difficult to recognize in regular H&E tissue sections or even when tissue is stained with PAS or GMS. The cigar-shaped yeast cells are usually quite sparse within the tissue. Although geographic differences have been reported in the abundance of S schenckii found in the tissues, as have differences in the ease of identifying them with special stains, the reasons for these differences are unknown.
  • Because these yeast cells are usually difficult to find in the tissue, seeking clues to their presence may increase the likelihood of finding the organism.
  • From a low-power view, the tissue often manifests a pseudoepitheliomatous hyperplasia with microabscess formation. This is a nonspecific finding but is often a clue to deep fungal infection, prompting the investigator to make a close survey of the tissue for infective organisms.
  • A diffuse, mixed, inflammatory cell infiltrate is often found throughout the dermis, extending into the subcutaneous fat. When found, the yeast often resides within microabscesses or within macrophages and giant cells.
  • Asteroid bodies may also be a clue to sporotrichosis. These entities are eosinophilic round bodies with pink material radiating outward from their center. Asteroid bodies most likely form as a result of accumulation of immunoglobulins surrounding a yeast cell.
  • A fluorescent antibody technique may enhance diagnostic specificity. This technique uses anti-Sporothrix immunoglobulins labeled with fluorescein dye to enhance identification of the yeast cells in tissue.
  • Fortunately, even if the fungus cannot be observed in the tissues, it is often very easy to grow in culture.
  • One case reported a histology mimicking that of cutaneous cryptococcosis.[9]
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Contributor Information and Disclosures
Author

William P Baugh, MD Assistant Clinical Professor of Dermatology, Western University of Health Sciences; Medical Director, Full Spectrum Dermatology; Consulting Staff, Department of Dermatology, St Jude Medical Center

William P Baugh, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Laser Medicine and Surgery, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Coauthor(s)

Brad S Graham, MD Consulting Staff, Dermatology Associates of Tyler

Brad S Graham, MD is a member of the following medical societies: Alpha Omega Alpha, Texas Dermatological Society, American Academy of Dermatology, American Society of Dermatopathology

Disclosure: Nothing to disclose.

Cynthia L Chen, DO, DO Intern, Pacific Hospital of Long Beach, California

Cynthia L Chen, DO, DO is a member of the following medical societies: American Osteopathic Association, California Medical Association, American Osteopathic College of Dermatology, Los Angeles County Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Larry I Lutwick, MD Professor of Medicine, State University of New York Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus

Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Gary J Noel, MD Professor, Department of Pediatrics, Weill Cornell Medical College; Attending Pediatrician, New York-Presbyterian Hospital

Gary J Noel, MD is a member of the following medical societies: Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

References
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Sporotrichosis with cutaneous necrosis and lymphangitic (sporotrichoid) spread. A 28-year-old white man presented for evaluation of a poorly healing, asymptomatic, round plaque acquired on the dorsum of his left hand. The lesion had been present for approximately 3 weeks.
Glucose-peptone agar culture plates revealing colony growth of Sporothrix schenckii. The left plate reveals older colonies as dark brown or black, and the right plate reveals younger white colonies with a brown center, characteristic of this fungus.
Microscopic examination of a blue dye preparation from the colony surface reveals elongated septate hyphae with groups of microconidia in a flowerlike arrangement.
A well-circumscribed, moderately elevated, erythematous plaque with central ulceration is found on the dorsum of this patient's left hand. Potassium chloride (KOH) stain was negative for fungal elements.
A 2 X 2 cm, dome-shaped, well-circumscribed, erythematous plaque is shown proximal to the left ring finger. The lesion was draining a serosanguineous fluid. No purulence was noted.
Biopsy rarely reveals the 6-mcg cigar-shaped yeast within tissue macrophages as shown in this histologic section. This is the morphology that Sporothrix schenckii assumes at 37°C.
Moist cream-colored colonies with a central, dark, leathery, and wrinkled surface growing at 25°C is highly suggestive of Sporothrix schenckii.
A fresh agar slant of Sporothrix schenckii reveals moist, white-to-cream–colored, yeastlike colonies.
Cutaneous, ulcerating, painless nodule on the hand and a classic sporotrichoid lymphangitic pattern spreading proximally up the arm.
 
 
 
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