Sporotrichosis

(Sporothrix schenckii)
Subcutaneous Mycoses
Disease process usually starts with traumatic injury
(sole source of infection)
It includes
Mycetoma
Sporotrichosis
Chromoblastomycosis
Pheohyphomycosis
Rhinosporidiosis
Lobomycosis
Introduction
Sporotrichosis is chronic, pyogranulomatous
fungal infection of Cutaneous and Sub-cutaneous
tissues, which remain localized or may show
lymphatic spread with occasional dissemination
Also called
Schenck’s disease
Rose Garderner’s disease
Originally described by a medical student, Benjamin
Schenk at Johns Hopkins Hospital in 1898
Causative organism: Sporothrix schenckii
Mycology
Belongs to Basidiomycetes

Clinical isolates
Sporothrix schenckii
 Sporothrix schenckii var. schenckii
 Sporothrix schenckii var. luriei

Sporothrix braziliensis
Sporothrix globosa
Sporothrix cyanescens
Epidemiology and Ecology
Probably the most frequently encountered subcutaneous
mycoses in world
Climatic conditions
High humidity upto 65%
Moderate temperature of 25-280C
However, can withstand cold and grow up to 370C.
Widespread in nature and can be isolated as a saprobe from
dead vegetation, such as thorns, hay, straw, sphagnum moss
and wood
Also found as food contaminants of meat sausages and
mushrooms
Occupational hazard for
Nursery and forestry workers
Farmers
Florists
Gardeners
Veterinary workers
Manual laborers in rural areas etc.
World wide distribution, mainly tropical and
subtropical zones.
North America, Mexico, Latin America, France,
South Africa, Japan and India.
Sporotrichosis in India
The first case reported by L. M. Ghosh
(1932) from West Bengal.
North east India (West Bengal & Assam)
- considered endemic for many years.
Sporadic case reports from rest of India.
1983 onwards, large number of case reports
from North west India i.e. Himachal
Pradesh, Chandigarh. A second endemic
zone recognized. (Chakrabarty et al. 1994, Ghosh et
al. 1999)
Sporotrichosis in India
Opportunistic Infections in AIDS
Sporotrichosis – one of the opportunistic infections
encountered in very small numbers among AIDS
patients (Boloa et al. 1994, Donabedian et al. 1994)
In a review, almost all had < 100 CD4+T cells/µl (Al-
Tawfiq et al. Clin Infect Dis, 1998)
Only about a dozen cases reported till date (Topley &
Wilson, 10th Ed. 2005)
The infection is extremely serious, becomes
disseminated
Dissemination can involve one or more joints or
organ systems including CNS
Pathogenesis and Pathology
S. schenckii produces 2 extracellular
proteinases
Proteinase I : Serine proteinase
Proteinase II : Aspartic proteinase
These enzymes play vital role in fungal
invasion and growth
Detection of antibodies against these
proteinases also contributes to serodiagnosis
of this disease
Asteroid body
Yeast is centrally located and surrounded by
eosinophilic spicules probably derived from
neutrophils of abscess
Can be demonstrated Immunohistochemically
Rays of eosinophilic substance considered to be
antigen-antibody complex
First described by Splendore in 1908
Also known as “Splendore – Hoeppli phenomenon”
Clinical Features
Sporotrichosis is broadly categorized into five clinical
types

1. Lymphocutaneous
2. Fixed Cutaneous
Due to Traumatic injuries
3. Mucocutaneous
4. Disseminated
5. Pulmonary Due to inhalation of conidia
Lymphocutaneous Sporotrichosis
Commonest Type
Implantation of spores in a penetrating wound caused
by Thorn or splinter
Infection of upper and lower extremities
Incubation time: 8-30 days, Avg. 3 wks
Manifestation
 Small, firm, non-tender, mobile cutanoues nodule which
eventually ulcerates to expose ragged necrotic-base forming
sporotrichosis chancre
Involvement of lymphatics that drain primary site of
inoculation and development of characteristic linear
nodulo-ulcerative secondary lesions along lymphatics
Lymphocutaneous sporotrichosis
Fixed Cutaneous Sporotrichosis
Lesions remain localized to inoculation site
Commonly seen in individuals with higher
immunity
Mucocutaneous Sporotrichosis
Lesions develop in mouth, pharynx, vocal cord
or nose
Disseminated Sporotrichosis
Very Rare
May occur by haematogenous spread
Manifested by many widespread skin lesions
Risk Factors : Alcoholism, Diabetes, Extensive use of
Pulmonary Sporotrichosis
Rare
Due to inhalation of conidia
Analogous to Primary pulmonary
tuberculosis, Histoplasmosis or
Coccidioidomycosis
Radiodiagnosis:
Miliary infection mimicking tuberculosis
Laboratory Diagnosis
Specimen Collection
Cutaneous sporotrichosis
 Skin biopsy
 Pus
 Exudates
 Aspirates
Disseminated sporotrichosis
 CSF
 Synovial biopsy
 Joint fluid
 Blood
Pulmonary sporotrichosis
 Bronchial washing
 Lung biopsy
 Sputum
Direct Examination
KOH wet mount
 Small, oval ‘tear drop’ yeast cells of 1-3μm × 3-5μm can be seen
 elongated yeast cells
 Low sensitivity due to paucity of organism in clinical material
Gram stain
 Gram positive
 Irregularly stained
Immunoflorescence
 Sensitivity is higher compared to light microscopy
 Calcoflour white stain proves to be useful
Histopathological Examination
Stains
H/E stain
PAS stain
GMS stain
Microscopy
Histologic examination reveals a central necrotic lesion
with associated infiltration of neutrophils, macrophages
and giant cells
Round, oval or cigar shaped small yeast cells seen
Asteroid body is best seen on histopathological
examination
Histopathology is also very important to
diagnose S. schenckii var. luriei
Three cases have been reported till date
Fungal morphology manifested in host tissue is
significantly different from typical sporotrichosis
These cells each form a single septum that
allows separation of two cells
Two cells can remain temporarily attached giving
the characteristic appearance of spectacles
In culture it is morphologically indistinguishable
from S. schenckii var. schenckii
Fungal Culture
Recovery in culture – most sensitive method of diagnosis
S. schenckii grows well on almost all culture media
Culture plates or slants should be incubated at 25 - 300C for
upto 4 weeks
Off-white to cream coloured moist colonies appear within
few days
In time the colonies become wrinkled and membranous
later turning to brown or black within 10 days to 2 weeks
Some special media e.g. Czapek’s agar, MEA and CMA are
important for sporulation
Slide culture
Hyphae 1- 2 microns.
Conidiophore arise from
undifferentiated hyphae,
tapering at the tip, may
form vesicle with denticles.
Conidia – 1 celled, tear drop
shaped, 2.5 - 5.5µm
Each denticle bears a
conidia, simulating-
Bouquet, Petals of flower
Often thin or thick walled
hyaline to brown, triangular
conidia arise laterally along
side the hyphae.
Confirmation
Demonstration to yeast form – important for
confirmation
Mold to Yeast Conversion
Rich media – BHI, BHI with blood, chocolate agar,
incubated at 35 to 37c
Moist medium, Serial subculture helpful
 Animal Pathogenicity:
Conidial susp injected intra peritonially – Male mice.
Orchitis – 10 days to two weeks.
Typical yeast cells demonstrated.
Biochemical Tests.
assimilation of arabinose, dextrin, raffinose, rhamnose
and starch
Molecular Diagnosis.
Yeast phase
Dull white to brown colonies, may turn
blackish on further incubation.
Surface, dry, wrinkled

Microscopic (Gram stain or Simple stain):

 Oval to elongated ( cigar shaped) yeast cells
(3-5μm).
Immunodiagnosis
In vivo skin test
 Mycelial and yeast phase antigens are used in skin test
 Poor specificity
 Sporotrichin preparation is used
 Prepared from filtrate of 2-3 months mycelial growth in glucose-
yeast-extract-casamino acid liquid medium at RT
 0.1 ml of 1:1000 dilution of Sporotrichin preparation is used
 >5mm diameter of induration and erythema observed after
24-48 hours is taken as Positive
 Not routinely used
 Used for Epidemiological surveys only
Serological Test
Complement fixation test
Latex agglutination test
Immunodiffusion
Western blot

Disadvantages
Requirement of specialized, labile and expensive reagents
Lack of standardization

Molecular Tests
PCR
Treatment
Cutaneous sporotrichosis
Itraconazole (100 – 200 mg/day)– Drug of choice
 Usually takes 3 – 6 months for clinical cure
Saturated solution of Potassium iodide (SSKI)
 Therapy begins as 5 – 10 drops orally thrice a day
 Dose is increased to 25 – 40 drops thrice a day (for children)
 Or 40 – 50 drops thrice daily (for adults)
 Drug to be continued till clinical cure, usually takes 6 months

Local application of heat

 A heat-evolving pad is attached to the lesion for about 2 hours
per day
Terbinafine – effective for plaque sporotrichosis
Ketoconazole – not very effective
Pulmonary sporotrichosis
Amphotericin B
SSKI
Meningitis
Amphotericin B + Fluorocytosine
Therapy of patients with HIV
Itraconazole (400 mg/day)– DOC
Amphotericin B should be used as initial therapy
Lifetime suppressive therapy with itraconazole is needed
due to likelihood of relapse and dissemination
Monitoring of itraconazole is very essential
Thank you…