Disseminated Sporotrichosis as the Initial Presentation of AIDS
- 1. Fundacao Oswaldo Cruz, Instituto Nacional de Infectologia Evandro Chagas, Brazil
CLINICAL IMAGE
A 38-year-old man was admitted to our hospital with 3-month history of fever, asthenia and profound weight loss. In addition, he complained of multiple skin lesions, which started initially as papules and progress to ulcers. He reported a history of cat bite in his arm. Physical examination was notable for numerous skin nodular lesions; the majority of them ulcerated, throughout his body, especially on trunk, back and lower limbs (Figure 1 and 2). Nasal inspection revealed septum ulcer and partial destruction.
Figure 1 Multipleulcero-crusted round lesions on trunk.
Figure 2 Two ulcers in the inner aspect of left lower leg; the largest measure 5x8 cm.
Laboratory exams showed positive reaction to HIV (CD4+ count and viral load were 50 cells/ul and 281.994 copies, respectively). Subsequently, combination antiretroviral therapy was started with Tenofovir, Lamivudine and Efavirenz. A 4-mm abdomen skin’s punch biopsy was obtained and demonstrated diffuse suppurative granulomatous dermatitis with giant cells, epitheliod cells, plasma cells and lymphocytes (Figure 3).
Figure 3 Suppurative granuloma filled with plasma cells, epitheloid cells and lymphocytes (H&E stain, 100x)
PAS and Gomori-Grocott stains revealed rounded and elongated cigar-shaped elliptical yeast structures (Figure 4 and 5).
Figure 4 Numerous rounded and cigar shaped budding yeasts(GomoriGrocott stain, 20x).
Figure 5 Cigar-shapedyeast cell (GomoriGrocott stain, 100x)
Biopsy of nasal septum ulcer grew Sporothrixschenckii on Sabouraud dextrose agar medium, confirming the diagnosis of sporotrichosis.
Amphotericin Bdeoxycholate (2.5 g, total dose) was initiated for 2-weeks, followed by Itraconazol (200 mg/day) for 6 months with clinical improvement. Maintenance therapy with Itraconazol was planned until patient immunological status improved (i.e. CD4> 200 cells/ul).
Sporothrichosis is the mostprevalent mycosis in South America, caused by the dimorphic fungus –Sporothrix complex –which included four distinct species: S. globosa, S. brasiliensis, S. Mexicana and S. schenckii. [1]. Although it is classically described as associated with traumatic inoculation from soil, vegetables and organic matter contaminated with S. species, zoonotic transmission has also been reported [2]. Since 1998, a cat-transmitted Sporothrichosis epidemic has emerged in Rio de Janeiro, Brazil [3]. Remarkably, the majority of HIVinfected patients presented with disseminated form, involving skin, mucosa, bone or meninges [4]. In endemic countries, Sporothrichosis should be considered as an opportunistic infection, requiring the inclusion of this disease in differential diagnosis of skin lesions in AIDS patients.
