Sporotrichosis Clinical Presentation

Updated: Mar 02, 2021
  • Author: Nelson Ivan Agudelo Higuita, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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Presentation

History

The presentation of sporotrichosis varies and is determined mainly by the immune status of the host and the location of the infection. Other factors such as the virulence of the infecting species and ability to grow at different temperatures may also play a role. [16, 2, 3]

Sporotrichosis is typically classified as cutaneous or extracutaneous. The cutaneous form is divided into lymphocutaneous, fixed, and disseminated.

Cutaneous sporotrichosis

Lymphocutaneous sporotrichosis: The primary lesion develops at the site of cutaneous inoculation, typically in the distal upper extremities. After several weeks, new lesions appear along the lymphatic tracts. Patients with this form are typically afebrile and not systemically ill. The lesions usually cause minimal pain. Many affected patients have received one or more courses of antibacterial therapy without benefit. [17, 18]

The fixed cutaneous form is characterized by a painless violaceous or erythematous plaque that may ulcerate or become verrucous. This presentation should be considered when a wound fails to heal. There are no satellite lesions. [19]

The disseminated cutaneous form is usually seen in immunosuppressed individuals. This form of the disease can be the initial presentation of HIV infection or may develop as part of an immune reconstitution syndrome. [20, 21, 22]

Hypersensitivity reactions such as erythema nodosum or erythema multiforme have been associated with the zoonotic species Sporothrix brasiliensis. [4]

Although not strictly a cutaneous presentation, S. brasiliensis is associated with ocular involvement which can lead to ocular sequelae. [23]  

Extracutaneous sporotrichosis

Pulmonary sporotrichosis

Patients with this form of sporotrichosis usually have severe underlying COPD and present with subacute or chronic pneumonia. [24] The presenting symptoms of pulmonary sporotrichosis are not specific but typically include increased cough and few constitutional symptoms.

Osteoarticular sporotrichosis

Sporotrichosis may present as a chronic arthritis that is often confused with rheumatoid arthritis or other chronic inflammatory arthritis. In many cases, the osteoarticular sporotrichosis persists for 30 or more years until destruction of adjacent bone or the development of draining fistulae encourages efforts to establish the microbial etiology of the chronic osteomyelitis with culture. Cutaneous or lymphocutaneous lesions are not prominent in these patients.

The process generally begins as a monoarticular arthritis, especially of the knee, but other joints may become involved successively. The patient usually has pain upon motion, but not the severe limitation characteristic of bacterial arthritis. Systemic illness is usually absent. Functional impairment due to osteoarticular sporotrichosis may become severe. [25]

Disseminated sporotrichosis

In rare cases, sporotrichosis involves other organs, including the eye, the prostate, the oral mucosa, the paranasal sinuses, and the larynx. In such patients, the clinical manifestations depend on the organs involved.

Central nervous system and meningeal involvement are more common in the AIDS era, but it remains rare. In some cases, the only symptom is subtle changes in mental status. Patients with AIDS who develop disseminated sporotrichosis may present with cutaneous dissemination, which manifests as nodules, ulcers, or both, with or without evidence of visceral involvement and meningitis. [26] Sporotrichosis in persons with AIDS can also manifest as multifocal tenosynovitis or arthritis resembling disseminated gonococcal infection or a seronegative spondyloarthropathy. [27]

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Physical

Cutaneous or lymphocutaneous sporotrichosis: An initial papule or nodule forms at the site of cutaneous inoculation, usually 1-10 weeks after inoculation. The initial small nodule enlarges, reddens, becomes pustular, and ulcerates. In the lymphocutaneous form, an ascending chain of nodules develops along skin lymphatic channels. Older distal lesions ulcerate and drain, while more proximal lesions appear as nodules and undergo the same evolution. 

Lymphocutaneous sporotrichosis. Lymphocutaneous sporotrichosis.
Lymphocutaneous sporotrichosis. Lymphocutaneous sporotrichosis.
Lymphocutaneous sporotrichosis. Lymphocutaneous sporotrichosis.
Ulcerated lesion in the cheek of a child. Note the Ulcerated lesion in the cheek of a child. Note the satellite lesions. Courtesy of Todd Mollet, MD, University of Texas Southwestern Medical Center.

Pulmonary sporotrichosis: The physical examination findings in patients with pulmonary sporotrichosis are typically dominated by their underlying COPD. No physical findings are specific for pulmonary sporotrichosis.

Osteoarticular sporotrichosis: Patients typically have a subacute or chronic inflammatory monoarticular arthritis. The involved joint has an effusion, may be warm, and may have overlying erythema. Draining sinus tracts that complicate adjacent osteomyelitis may be apparent.

Disseminated sporotrichosis: Physical findings vary depending on the site of involvement. Cutaneous dissemination may appear as subcutaneous mass lesions, diffuse purplish papules and nodules, or disseminated ulcerative lesions. 

This photo depicts cutaneous disseminated sporotri This photo depicts cutaneous disseminated sporotrichosis in a patient with AIDS before and after therapy. Courtesy of Leonard N. Slater, MD.
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Causes

Sporotrichosis is caused by infection with one of the species of the S schenckii complex. More than six species, such as S schenckii sensu stricto, S brasiliensis, Sporothrix globosa, Sporothrix mexicana, and Sporothrix albicans, have been identified via molecular techniques. [1, 28]

Splinters, thorns, or woody fragments of plants usually provide the penetrating trauma that introduces the fungal conidia into the human host; however, contact with any plant or plant product (eg, sphagnum peat moss, mulch, hay, timber) that causes minor skin trauma may initiate infection.

Activities associated with the acquisition of sporotrichosis include gardening, landscaping, farming, berry-picking, horticulture, and carpentry.

Zoonotic transmission can occur from infected animals (eg, cats, horses with extensive skin lesions) to their animal handlers.

Both pulmonary and disseminated sporotrichosis are more common in persons with a history of alcoholism.

Immunosuppressing states such as HIV infections and AIDS predispose to disseminated cutaneous sporotrichosis and hematogenously disseminated sporotrichosis, including sporotrichotic meningitis. [29, 26] This clinical observation, combined with studies in animal models, indicates the importance of cell-mediated immunity in the host defense against sporotrichosis.

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