Sunday, November 30, 2014

Presented by Henry Foong
Ipoh, Malaysia

A 65-year old woman presents with multiple erythematous nodules arranged in a linear manner on her right forearm

The lesion appeared 2 months ago as a small boil on the right index finger.  She was treated with oral antibiotics by an orthopaedic surgeon. It then became progressively larger and new lesions began to spread proximally toward the elbow. The patient had a history of diabetes and was managed with oral hypoglycaemic agents.

Vital signs normal.  Multiple erythematous nodules 1.0- by 1.0-cm distributed along the lymphatics from right index finger to the elbow.  No lymphadenopathy.


Blood counts and biochemistry normal. Skin biopsied tissue sent for fungal/ TB culture and sensitivity

Skin Biopsy
Skin biopsy reveals dermis and underlying tissue heavily infiltrated by lymphocytes, histiocytes and neutrophils.  Fungal spore are identified.

Sporotricosis - localised lymphocutaneous type

Discussion and Treatment
Sporotrichoid lymphocutaneous infection is characterised by subcutaneous nodules along lymphatics.  the differentials of such infection are sporotricosis, mycobacterium marinanum and Leishmania brasiliensis.  The organism is usually inoculated through minor skin injury or insect bites.

Recommended treatment is itraconazole 200mg daily for 2-4 weeks after the lesion has healed. The discounted cost of 60, 100 mg itraconazole in U.S. is ~$200 - 400. 
Other treatment available include potassium iodide 300-450 mg daily for 12-16 weeks. Cost of 2 cc of SSKI in U.S. is ~ $15.
for disseminated cases of sporotricosis, IV amphotericin 0.5mg/kg/day up to a total of 1-2 gm followed by itraconazole 200mg daily for 6-12 months.

Yamada K1, Zaitz C, Framil VM, Muramatu LHCutaneous sporotrichosis treatment with potassium iodide: a 24 year experience in São Paulo State, Brazil. Rev Inst Med Trop Sao Paulo. 2011 Mar-Apr;53(2):89-93.

de Lima Barros MB1Schubach AOde Vasconcellos Carvalhaes de Oliveira RMartins EBTeixeira JLWanke BTreatment of cutaneous sporotrichosis with itraconazole--study of 645 patients.
Clin Infect Dis. 2011 Jun 15;52(12):e200-6.

Comment: We will check the cost to the patient of itraconazole in Malaysia.