Sporotrichosis is a subacute or chronic subcutaneous mycosis caused by a dimorphic and geophilic fungus, Sporothrix spp, which can infect humans and other mammals1,2. Infection occurs through trauma to the skin through contaminated wood, soil and decomposing plants, as well as abrasions or bites from contaminated animals, particularly domestic cats, which are primarily responsible for the current increase of cases in humans in the Brazilian territory1,3,4.
Sporotrichosis has a global distribution, although it is more common in regions with a tropical and subtropical climate, such as Central America, South America, and Africa2. In Brazil, epidemics have been reported in recent decades in the State of Rio de Janeiro4.
Sporotrichosis is classified into the following four clinical forms: localized cutaneous, cutaneolymphatic, disseminated cutaneous, and extracutaneous. The most common form in humans is the cutaneolymphatic form, followed by the localized cutaneous form2,5,6.
Disseminated sporotrichosis is an uncommon form of presentation, found in approximately 4% of cases and is usually related to diseases (immunosuppressive disease such as human immunodeficiency virus (HIV) infection and hepatitis C, diabetes mellitus and alcoholism) and treatment measures (chemotherapy treatment for neoplasia, transplantation, and corticosteroid treatment)7.
Cell culture, is the gold standard diagnostic test. However, anatomopathological examination may strongly suggest the diagnosis by showing granulomatous inflammation, epithelial hyperplasia, and histiocytic plasma cell infiltration. Asteroid corpuscles can still be found2,8.
The recommended treatment for the disseminated cutaneous form is amphotericin B and, after initial disease control, maintenance with itraconazole. In endemic areas, the saturated solution of potassium iodide is considered an excellent option due to its cost-effectiveness2.
We report a case of disseminated cutaneous sporotrichosis with an exuberant clinical condition in a patient with alcoholism.
A 47-year-old male patient, who worked as a farmer, presented with a soft, unattached and painless nodule in the left leg that had been present for 1 year. The appearance of similar disseminated cutaneous lesions occurred subsequently after the first lesion, with progressive growth, and drainage of purulent secretion as well as a weight loss of 13kg in the 3 months prior to his visit were noted. The patient had a 30-year history of alcoholism but no other medical conditions. On physical examination, the patient had cutaneous softened nodules and subcutaneous masses, some with superficial ulceration and drainage of a purulent secretion in the upper and lower limbs, trunk, abdomen, scalp, and cervical region (Figure 1, Figure 2 and Figure 3). Skin biopsy and mycological examination showed a positive culture for Sporothrix spp. Chest radiography and abdominal ultrasound results were normal, except for the presence of visceral involvement. The laboratory tests (hemogram, kidney function, liver function and thyroid function) did not show any abnormal results, and the serology test results [hepatitis B, hepatitis C, Venereal Disease Research Laboratory (VDRL) and HIV] were negative. The patient was then diagnosed with disseminated cutaneous sporotrichosis and treatment with saturated potassium iodide (20 drops three times a day) was started for 5 months, which resulted in complete resolution of the lesions. Upon 5-year follow-up, the patient reported continued alcoholism.
We present an unusual case of disseminated cutaneous sporotrichosis without systemic involvement in a patient with alcoholism who lived in an endemic area of this disease. In this case, the likely contributing factor of the spread of the fungus was the alcoholism. Our report corroborates the association previously reported by other authors7,9,10,11 between alcoholism and the spread of sporotrichosis.
We believe that the alcoholism and the lack of access to dermatological services delayed the time to diagnoses and treatment and therefore contributed to this unusual form of sporotrichosis. We know that chronic alcohol consumption suppresses innate and adaptive immune systems, yet activates chronic inflammation. Ethanol is a known inhibitor of nuclear factor kappa B (NF-kB) activation and its consumption is associated with decreased circulating levels of tumor necrosis factor (TNF) and interleukin-1 beta (IL-1 β); however, the methods through which ethanol exerts its immunosuppressive effects are still unclear.
The patient was treated with a saturated solution of potassium iodide, which had a satisfactory therapeutic response. This resulted in a complete resolution of symptoms, demonstrating the favorable cost-benefit ratio of this therapeutic option.