|Year : 2003 | Volume
| Issue : 1 | Page : 12-16
Sporotrichosis in India: First case in a Delhi resident and an update
HS Randhawa, R Chand, AY Mussa, ZU Khan, T Kowshik
Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi-110 007, India
Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi-110 007, India
PURPOSE: To report the first case of sporotrichosis in a Delhi resident without history of travel to any known endemic area, and to present an update of the disease with special reference to India. METHODS: OThe case was tentatively diagnosed by clinical features, and confirmed by culture and histopathologic examination of a biopsy specimen. The update on the disease is based upon literature review (1932-2001). RESULTS: A 40-year-old female hospital employee developed lymphocutaneous lesions, involving her right middle finger, wrist and forearm following accidental pricking with a hypodermic syringe needle. A definitive diagnosis of sporotrichosis was established by culture of S. schenckii, verification of its dimorphic character, morphology in histopathologic sections and a positive pathogenicity test (intratesticular inoculation) in male white mice. The patient was successfully treated with saturated solution of potassium iodide. Of 205 cases compiled from literature, 91 (44%) came from West Bengal, 56 (28%) from Himachal Pradesh and 45 from Assam whereas the remaining 13 (6.3%) occurred sporadically in other states, including Bihar, Punjab and Karnataka. CONCLUSIONS: The available literature does not provide a true index of regional distribution of sporotrichosis in India. More correctly, it seems to reflect the distribution of groups of investigators with a special interest or expertise in sporotrichosis and S. schenckii. Further studies are likely to reveal new endemic areas for sporotrichosis.
|How to cite this article:|
Randhawa H S, Chand R, Mussa A Y, Khan Z U, Kowshik T. Sporotrichosis in India: First case in a Delhi resident and an update. Indian J Med Microbiol 2003;21:12-6
|How to cite this URL:|
Randhawa H S, Chand R, Mussa A Y, Khan Z U, Kowshik T. Sporotrichosis in India: First case in a Delhi resident and an update. Indian J Med Microbiol [serial online] 2003 [cited 2013 May 18];21:12-6. Available from: http://www.ijmm.org/text.asp?2003/21/1/12/8308
Sporotrichosis is generally a chronic mycotic infection characterized by nodular and ulcerative lesions of cutaneous, subcutaneous or lymphatic tissues. Osteoarticular and visceral sporotrichosis occurs mostly in patients who are immunocompromised and have underlying alcoholism. It has a worldwide distribution but more common in temperate and tropical zones with high temperature and humidity. The etiologic agent is a dimorphic fungus, Sporothrix schenckii, that occurs as a saprobe on a variety of dead or decaying plant materials. The infection is acquired by traumatic implantation of the fungus from the environment. In India, sporotrichosis is known to be endemic in the sub-Himalayan region, i.e., in Assam and West Bengal in the north-east and Himachal Pradesh in north-west. It has not been reported so far in the residents of Delhi area and the adjoining plains of Uttar Pradesh, Haryana and Rajasthan states. We are, therefore, prompted to report the following case of sporotrichosis in a resident of Delhi.
| ~ Case Report|| |
A 40-year old female, resident of Delhi since birth and an employee of ESI Hospital, Basai Darapur, Delhi, gave a clinical history of accidentally pricking the middle phalanx of the middle finger of her right hand while handling a hypodermic syringe needle about one year earlier. The injury was initially treated in private clinics with antiseptic dressing and oral antibacterial antibiotics. That gave her some relief from pain and led to partial healing of the wound. After a few weeks, the patient observed some oozing from the site of the injury for which she was again put on antibacterial antibiotic therapy but there was no relief. About 7-8 months later, a sinus with oozing of some serosanguinous exudate appeared dorsally at the base of proximal phalanx of the same finger. This was followed by another lesion without oozing that appeared a few weeks later on the right forearm just above the wrist. Treatment in the form of antibacterial antibiotics and some antituberculous drugs reportedly failed to provide any relief.
At the time of examination in the Skin Outpatient Clinic of the ESI Hospital, the patient presented with discharging lesions occurring linearly along the dorsum of the right middle finger, wrist and the forearm [Figure - 1]. Biopsy material taken from a lesion on the wrist was examined in the Medical Mycology Laboratory of VP Chest Institute, Delhi. Periodic acid Schiff (PAS) stained sections of the specimen revealed a few spherical to oval, cigar-shaped, budding yeast-like cells suggestive of Sporothrix schenckii [Figure - 2]. The identification of S. schenckii was subsequently confirmed by isolation of the fungus in culture on Sabouraud glucose agar [Figure:3], verification of its pathogenicity by intratesticular inoculation of male white mice and its conversion to the yeast form in a subculture on BHI agar at 37oC.
The patient was successfully treated with a saturated solution of potassium iodide (KI). Thirty grams of KI dissolved in 21 mL of sterile distilled water at room temperature yielded 30 mL of saturated solution. Initial dose of KI was 5 drops (1 mL) of the saturated solution mixed in milk administered thrice daily. This was gradually increased by 3 to 5 drops each dose each day (minimum increase 1.5 mL per day) as tolerated until a dose of 40 drops thrice daily was reached. The treatment was stopped after 6 weeks when the lesions had healed completely. There was no relapse of the disease during a follow up period of over 5 years.
| ~ Discussion|| |
The case of sporotrichosis described here is noteworthy in that the patient had been a resident of Delhi since birth. She probably acquired the infection locally following an accidental prick with a used hypodermic syringe needle while collecting the discarded materials from a dustbin in an OPD room of the ESI Hospital. Enquiries from the hospital revealed that none of its laboratories was maintaining or handling cultures of S. schenckii. The likelihood of the syringe needle having been contaminated with the fungus from a culture in the hospital is, therefore, excluded. We do not believe that the prick injury due to the needle was an infective event. It only provided a suitable site to the infective fungus from an undetermined environmental source. The patient gave no history of having travelled to any of the known endemic areas of sporotrichosis in India. However, the possibility of her exposure to the fungus by coming into contact with fomites originating from an endemic area cannot be ruled out.
An overview of the regional distribution of sporotrichosis cases reported since 1932 from India [Table - 1] indicates that the disease is endemic in Assam, West Bengal, Himachal Pradesh and probably in the hilly areas of Uttar Pradesh as well as other northern States.4-20 Of the 205 cases reported todate, 91 (44.3%) originated from West Bengal, 56 (27.3%) from Himachal Pradesh and 45 (21.9%) from Assam. The remaining 13 cases (6.3%) occurred sporadically and were reported from Punjab, Chandigarh, Uttar Pradesh, Bihar, Tripura, Meghalya and Karnataka. It is noteworthy that all of the large series of sporotrichosis cases reported from Assam, West Bengal and Himachal Pradesh were by certain groups of investigators who had developed a special interest or gained expertise in the diagnosis of this disease. We believe that the available literature on sporotrichosis does not provide a true index of regional distribution of the disease in India. More correctly, it seems to reflect regional distribution of the afore-mentioned teams of investigators who were actively working on sporotrichosis. Considering the vastness of the country and its climatic diversity, further studies are likely to reveal new endemic areas for sporotrichosis.
It is well known that S. schenckii occurs saprobically in soil, on decaying wood, Sphagnum moss, hay or other vegetable matter. The fungus has, however, not yet been reported from environmental sources in India. Epidemiologic data from some countries indicate that S. schenckii proliferates and survives better in climates with a temperature range of 15oC to 27oC and high humidity., It is probably for this reason that sporotrichosis has been rarely reported from areas with dry and hot climate although microniches favouring growth of S. schenckii may exist even in such areas. In this context, attention may be called to a sporotrichin skin test survey conducted by Chakravarty et al. in the urban and rural inhabitants of Delhi and Mathura district of Uttar Pradesh. It was reported that cutaneous sporotrichin hypersensitivity occurred in 22.4% (201 out of 897 individuals) of the urban population and 37.2% (101 out of 273 individuals) of the rural population, indicating thereby considerable environmental exposure of the population to S. schenckii in this region. In a more recent sporotrichin skin test survey in some endemic areas of Himachal Pradesh, Ghosh et al reported that prevalence of cutaneous hypersensitivity to sporotrichin was significantly higher (22.9% to 40%) in the case villages than in the control areas (6.5% to 7.5%).
Sporotrichosis has a global distribution with a preponderance of cases reported from North and South America, South Africa and Japan.,,,,,,, The disease involves all age groups but a higher proportion of the cases occurs in the adults barring one study from Peru23, in which 60% of the patients belonged to the younger age group (15 years). Recently 10 cases of sporotrichosis were reported in prepubertal girls by Burch et al. There is no uniform pattern of gender distribution in the cases. Reports from Latin America and South Africa, showed that males were more frequently affected, whereas reports from Japan indicated greater involvement of females.26 However, these apparent differences in distribution of the disease by gender may actually be related to occupational activities leading to exposure to the fungus rather than to their age, gender or geographic location.
Lymphocutaneous presentation is the commonest reported clinical form of the disease in immunocompetent hosts with its frequency ranging from 46% to 92%, followed by the fixed cutaneous type (frequency range: 0% to 54%). A history of trauma preceding the infection is present in a majority of the patients. Disseminated visceral, osteoarticular, meningeal and pulmonary forms of the disease are uncommon and are usually seen in patients with underlying risk factors. The underlying mechanism of why some persons develop lymphocutaneous sporotrichosis while others develop the fixed cutaneous lesion is not clearly understood. Among the possible factors determining clinical manifestations of the disease are the size and depth of implantation of the fungal inoculum, thermotolerance of the infecting S. schenckii strain and immune status of the host., There is a solitary case of pulmonary sporotrichosis reported so far in India.18 It was diagnosed post mortem and the etiologic agent was S. schenckii var. luriei. Cases of pulmonary sporotrichosis are likely to be missed for want of a pathognomonic clinical syndrome and due to inadequate awareness about this clinical entity.
Culture of S. schenckii from clinical material is necessary for a definitive diagnosis of sporotrichosis. In a study of 238 cases from Peru, it was reported that cultures became positive within 8 days in 211 (89%) cases and within 29 days for the remaining 27 (22%) cases. Fluorescent antibody test, although specific, is rarely available for the diagnosis of sporotrichosis.18 Currently, no rapid diagnostic test is available for sporotrichosis. Direct microscopic or histopathologic examination of tissue stained with the conventional hematoxylin and eosin stain lacks sensitivity. Serologic diagnostic tests have not been adequately evaluated. Recently, Loureiro et al have isolated an antigenic fraction of the cell wall of S. schenckii that showed 100% reactivity with 35 sera from patients with sporotrichosis in enzyme-linked immunosorbent test.
Until recently the standard therapy for lymphocutaneous and cutaneous sporotrichosis was saturated solution of potassium iodide concentration. Initial dosage is 5 drops (1 mL) in milk, juice or water three times a day, to be increased by 5 drops per dose each week until the maximum dosage of 40-50 drops three times a day is reached. The recommended duration of therapy is generally 3-6 months. However, side effects such as metallic taste, salivary gland swelling, nausea, rash and fever are common. Currently, itraconazole has become the drug of choice for lymphocutaneous sporotrichosis., The recommended dosage is 100-200 mg daily, to be administered for 3-6 months. If a patient does not tolerate itraconazle, fluconazole can be used as a second-line treatment but it has a lower success rate than that with the former azole. In pregnant women with fixed cutaneous sporotrichosis, who cannot safely take any antifungal therapy, local hyperthermia may be an effective treatment but it requires weeks of daily applications.
| ~ Acknowledgements|| |
Acknowledgement is made to the University Grant Commission, New Delhi, for the award of a Senior Fellowship to AYM, to the Indian National Science Academy, New Delhi for the award of an Hony. Sr. Scientist position to HSR and Mrs Silvey Mathew for technical assistance. Appreciation is expressed to Dr. A Thammayya, formerly Mycologist, Calcutta School of Tropical Medicine, Kolkata, for allowing us to include his unpublished data.
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