Ipoh, Malaysia
A 65-year old woman presents with multiple erythematous nodules arranged in a linear manner on her right forearm
HPI
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.
PE
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.
Images
Labs
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.
Differentials
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.
Ref:
Yamada K1, Zaitz C, Framil VM, Muramatu LH. Cutaneous 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 MB1, Schubach AO, de Vasconcellos Carvalhaes de Oliveira R, Martins EB, Teixeira JL, Wanke B. Treatment 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. |
We have generic itraconazole in New Zealand. 60 100-mg tablets cost the tax payer around NZ$12 (about US$9). Sporanox brand is not subsidised and costs NZ$100 for 60 100-mg capsules. Interesting how drug costs vary across the world!
ReplyDeleteHenry,
ReplyDeleteI have good luck with SSKI for sporotrichosis but it will take up to a year.
I use 5-10 gtts in half glass of water tid. Titrate up or down depending on response and tolerance.
If it fails, I would add terbinafine which has helped in some cases but dose has to be doubled. Continue till clear.
Then consider itraconizole 200/d till clear.
Dear Amanda and Doug
ReplyDeleteMany thanks for sharing your experiences with us.
The culture grew Sporothrix schenckii.
In Malaysia, the cost of sporanox 200mg daily for 2 weeks will cost RM 264 (approx USD 75) while potassium iodide solution 450mg daily for 2 weeks cost only RM 13 (approx. USD 4). We do have generic itraconazole that is much cheaper (about RM30 for 2 weeks) but the efficacy is questionable so I hardly use them.
My patient finds the taste of KI quite unpalatable but still adheres to the prescription. The other problem we face is the short expiry. Our freshly prepared KI can last only 2 weeks after which they have to get new stock again.