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Infectious Diseases I


Monday, October 25, 2004

4:15 PM - 5:45 PM

Primary Pulmonary Sporotrichosis: A Case Report

Atul Mehta, MD, Marie M. Budev, DO*, Justin Ranes, MD and Rabin Shrestha, MD

Cleveland Clinic Foundatoin, Cleveland, OH

INTRODUCTION: Pulmonary sporotrichosis is an uncommon pulmonary infection caused by the thermally dimorphic fungus Sporothrix schenckii. We report a case of "primary" pulmonary sporotrichosis diagnosed by bronchoalveolar lavage (BAL). The patient had no dermatologic manifestations.

CASE PRESENTATION: A 55 year old housewife was referred for evaluation of worsening left lower lobe alveolar infiltrates. She complained of low grade fever, frequent sweats, nasal congestion, ongoing cough, and shortness of breath of six months duration. Her past medical history was significant for asthma, hypothyroidism, nephrolithiasis, and inflammatory bowel disease. She quit smoking eight years previously and only consumed alcohol occasionally. She had traveled to Europe, China and Caribbean in the past year. She reported a hobby of building English hay racks with wet moss and planting flowers in them. Her examination was normal except for wheezing in the left lower lung field. There were no skin lesions or lymphadenopathy. A CT scan revealed patchy alveolar infiltrates in the right lung with bronchiectatic changes and new nodules in the left lower lobe and lingula. (figure 1 .) Her basic laboratory studies were normal and a PPD was negative. She underwent bronchoscopy where transbronchial biopsy and BAL were performed. Culture of the BAL specimen grew a mould identified as Sporothrix schenckii (figure 2 ).



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DISCUSSIONS: Sporotrichosis is caused by the thermally dimorphic fungus Sporothrix schenckii, the yeast form of which infects human tissues. S. schenckii is found worldwide in decaying vegetation such as rotting wood, sphagnum moss, rose thorns and rich humus soil. Sporotrichosis is an occupational illness of gardeners, forestry workers and others who receive minor trauma from contaminated thorns, branches and wood splinters. Infections occur sporadically and are associated with trauma during outdoor work.1 The lymphocutaneous form of sporotrichosis is the most common, but pulmonary, osteoarticular, meningeal and disseminated forms have been described.2 The pulmonary form can occur as primary infection when S. schenckii conidia, aerosolized from soil or decaying vegetation, are inhaled.3 Pulmonary sporotrichosis usually presents as chronic cavitary fibronodular disease involving the upper lobes. The diagnosis is usually made accidentally when Sporothrix is cultured from the sputum of a patient suspected of having tuberculosis or chronic cavitary histoplasmosis.4 The clinical syndrome mimics tuberculosis with cough, dyspnea, low grade fever, night sweats, and weight loss. Radiologically, pulmonary sporotrichosis may present as cavitary disease or tracheo-bronchial lymphadenopathy.5 Diagnosis is usually achieved by sputum culture or bronchoscopic biopsy revealing granulomatous pneumonia. Itraconazole is the recommended therapy for patients with non-life-threatening pulmonary sporotrichosis, while amphotericin B is indicated for life-threatening or extensive pulmonary lesions. Surgical removal of the infected tissue along with antibiotic therapy appears to be the most effective treatment.5

CONCLUSION: Pulmonary sporotrichosis is an unusual infection which may mimic tuberculosis or histoplasmosis. Diagnosis is achieved either by culture of the organism or by transbronchial biopsy. Consideration to the diagnosis of pulmonary sporothichosis should be given in patients with cavitary parenchymal disease or unexplained intrathoracic lymphadenopathy, particularly those with a history of environmental exposure.

DISCLOSURE: M.M. Budev, None.

REFERENCES

  1. Dixon DM, Salkin IF, Duncan RA, et al. Isolation and characterization of Sporothrix schenckii from clinical and environmental sources associated with the largest U.S. epidemic of sporotrichosis. J Clin Microbiol1991; 29 :1106 –1113
  2. Davies SF. An overview of pulmonary fungal infections. Clin Chest Med1987; 8 :495 –512
  3. Conti Diaz IA. Epidemiology of sporotrichosis in Latin America. Mycopathologia1989; 108 :113 –116
  4. Jay SJ, Platt MR, Reynolds RC. Primary pulmonary sporotrichosis. Am Rev Respir Dis1977; 115 :1051 –1056
  5. Breeling JL, Weinstein L. Pulmonary sporotrichosis treated with itraconazole. Chest1993; 103 :313 –314





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Copyright © 2004 by the American College of Chest Physicians.