|Year : 2006 | Volume
| Issue : 3 | Page : 216-219
Emergence of sporotrichosis in Manipur
KR Devi1, MU Devi1, TN Singh1, KS Devi1, SS Sharma2, LR Singh3, HL Singh1, NB Singh1
1 Department of Microbiology,Regional Institute of Medical Sciences, Manipur - 795 004, India
2 Department of Microbiology and Pathology, Jawaharlal Nehru Hospital, Imphal - 795 004, Manipur, India
3 Department of Pathology, Regional Institute of Medical Sciences, Manipur - 795 004, India
K R Devi
Department of Microbiology,Regional Institute of Medical Sciences, Manipur - 795 004
A retrospective analysis of all cases of sporotrichosis was conducted to examine the pattern and frequency of sporotrichosis cases in Manipur over a period of six year from July 1999 to June 2005. Seventy-three (73) cases of sporotrichosis were detected of which 30 were confirmed by culture and 43 were diagnosed by aspiration cytology only. Most of the patients belonged to the age group of 21 to 40 years (n=23; 31.5%). There were 39 females (53.4%) and 34 males (46.5%). Commonest site of infection was upper limbs (n=39; 53.4%) followed by lower limbs (n=17; 23.2%). Commonest type of infection was lymphocutaneous form (n=46; 63.1%) followed by fixed cutaneous form (n=27; 36.9%). Among these 73 cases, 2 male patients (2.7%) were found to be HIV positive. In our experience, collection of material by aspiration of pus or infected tissue was found to be a better method compared to scraping or exudate. This study revealed Manipur as a new endemic area for sporotrichosis.
Keywords: Manipur, sporotrichosis, Sporothrix schenckii
|How to cite this article:|
Devi K R, Devi M U, Singh T N, Devi K S, Sharma S S, Singh L R, Singh H L, Singh N B. Emergence of sporotrichosis in Manipur. Indian J Med Microbiol 2006;24:216-9
|How to cite this URL:|
Devi K R, Devi M U, Singh T N, Devi K S, Sharma S S, Singh L R, Singh H L, Singh N B. Emergence of sporotrichosis in Manipur. Indian J Med Microbiol [serial online] 2006 [cited 2013 May 19];24:216-9. Available from: http://www.ijmm.org/text.asp?2006/24/3/216/26998
Sporotrichosis is a subacute or chronic infection caused by Sporothrix schenckii , a dimorphic fungus found as a saprobe from dead or senescent vegetation, such as thorns, hay, straw, sphagnum peat moss, wood and also in soil. For this reason, sporotrichosis is associated with outdoor activities by farmers, florists, leisure gardeners, nursery workers, land scapers and green house workers.
Sporotrichosis was first described by Schenck in 1898 to be a fungal aetiology at the Johns Hopkins Hospital in Baltimore. Sporotrichosis is also known as Schenk's disease or Rose gardener's disease. Sporotrichosis is worldwide in distribution but more common among people living in temperate, tropical and sub-tropical regions with high humidity. It occurs in North and South America (Mexico, Brazil, Uruguay), South Africa, Australia, Japan but it is rare in Europe. In India, sporotrichosis is known to be endemic in the sub-Himalayan regions ranging from Himachal Pradesh in North-West to Assam and West Bengal in the East. It has also been reported sporadically in other states including Punjab, Delhi, Uttar Pradesh, Bihar, Tripura, Meghalaya andhra Pradesh, Chennai, Karnataka and Kerala. Two cases of sporotrichosis were reported for the first time in Manipur by Ranjana et al .
The infection is usually limited to the cutaneous and subcutaneous tissues most frequently as a consequence of a traumatic implantation of Sporothrix schenckii onto the skin. Clinically, it may manifest as lymphocutaneous, fixed cutaneous, mucocutaneous, extracutaneous and disseminated forms and very rarely as pulmonary. The most common form of extracutaneous sporotrichosis is osteoarthritis. Disseminated sporotrichosis is rare but with the event of HIV epidemic, the frequency of disseminated sporotrichosis has increased. This retrospective study was designed to study the frequency of sporotrichosis in Manipur and to find out whether Manipur has become a new endemic area for sporotrichosis.
| ~ Materials and Methods|| |
This retrospective study was carried out in the Department of Microbiology and Pathology, Jawaharlal Nehru (JN) Hospital and Mycology section, Department of Microbiology, Regional Institute of Medical Sciences (RIMS), Manipur from July 1999 to June 2005. These two hospitals were the only two referral centres in Manipur. All cases diagnosed to be sporotrichosis were included in the study. Clinical details such as age, sex, occupation and other exposure risk, site and duration of lesions, history of trauma, mode of spread, presence of ulceration, personal history and HIV status and any other pertinent data were analysed. Specimens from the patients had been collected by aspirating the pus, infected tissue or by scraping.
Fine needle aspiration cytology was done by preparing a smear and staining with Leishman/Giemsa stain. Whenever the lesion was clinically suspected to be of fungal aetiology either clinically or when there were features of microabscess formation with predominent polymorphonuclear cells, giant cells and necrotic tissues, Periodic-acid-Schiff stain (PAS) was done.
Fungal culture was done using two sets of Sabouraud dextrose agar (SDA) with antibiotics (chloramphenicol, 0.05 mg/mL, gentamicin, 0.02 mg/mL and cycloheximide, 0.5 mg/ml) and two sets of brain heart infusion agar (BHIA) with antibiotics and cycloheximide. One set of SDA and BHIA was incubated at 25°C and the other set at 37°C.
| ~ Results|| |
During the study period, 73 cases of human sporotrichosis were recorded. The district wise distribution of sporotrichosis cases in Manipur is shown in [Figure - 1].
PAS stain [Figure - 2] revealed single or budding yeast cells of 3-4 mm, round, oval or elongated in shape without a capsule. The yeast cells were not seen well in Gram and Leishman stained smears. Culture tubes at 25°C showed white mycelial colonies within the first week. Lactophenol cotton blue (LCB) mount [Figure - 3] showed thin, hyaline, delicate mycelia with conidia arising directly from the mycelium and from the conidiophores giving it a flower like pattern.
For the first few cases, animal pathogenecity testing using swiss albino mice and yeast conversion testing by repeated subculture on BHIA with blood were conducted.
In our experience, collection of material by aspiration of pus or infected tissue was found to be a better method compared to scraping or exudate as it gives a better uncontaminated sample which also can be subjected to cytology. Out of 73 cases, 30 cases were culture proven and 43 cases were diagnosed by aspiration cytology only. Among these, two male patients (2.7 %) were found to be HIV positive. The characteristic features of these patients are detailed in the table. Most of the patients belonged to the age group of 21-40 years (n = 23; 31.5%); the youngest being a 13 year-old female and the oldest was 83 year-old male. There were 39 females (53.4%) and 34 males (46.5%).The predominant clinical presentation was the lymphocutaneous form (n=46; 63.1%) as shown in [Figure - 4] followed by fixed cutaneous form (n = 27; 36.9 %).
No patient was found to have extracutaneous involvement. Most patients were gardeners, farmers and housewives by occupation. A history of local trauma preceding the development of sporotrichosis could be elucidated from 29 patients (39.7%). Three (4.1%) cases gave a history of injury with fishbone of locally fermented dry fishes called 'Ngari' and one (1.3%) with 'steel wool'. Most of the lesions were localised on the limbs as follows: upper limbs (n = 39; 53. 4%) and lower limbs (n = 17; 23.2%). There were 12(16.4%) cases located on the face, two (2.7%) cases on the buttock and one (1.3%) each case located on the abdomen, ear and breast [Table - 1].
| ~ Discussion|| |
Sporothrix schenckii occurs worldwide growing saprophytically as a mould in association with dead or decaying plant material. It is still snot clear which climatic condition exactly helps the growth of Sporothrix schenckii . In a study done in South Africa, it was found that the fungus grew well at 26°C to 27°C and a relative humidity of 92 to 100%. However, in Mexico the greatest frequency of infection coincided with the dry and cooler parts of the year. In a study conducted in Himachal Pradesh (North India), a temperature between 15°C and 27°C with high humidity helps its growth. In Manipur, the meteorological data shows average temperature of 21°C, relative humidity of 75% and rainfall of 1500 mm per year which is favourable to the growth of Sporothrix schenckii .
Anyone can get the disease but outbreaks have occurred in nursery workers since it is an occupational disease of farmers, leisure gardeners, florists, land scapers and greenhouse workers. Infection takes place when the organism is inoculated directly into the skin - usually on the hand, arm or foot and rarely via inhalation of conidia. The disease can be transmitted by bites of insects and animals such as cat, dog, armadillo, boar, camel, cattle, chimpanzee, dolphin, donkey, fowl, fox, horse, mule and rat. A report from South America relates an infection attributed by the patient to a knife wound sustained while cleaning fish. Sporothrix schenckii has been encountered from unexpected substrates such as commercial potting soil, as food contaminant of meat sausages, culinary mushrooms and found growing in a container of intravenous fluid at a medical centre.
It has also been recovered from samples taken for routine microbiological monitoring of various surfaces within an indoor swimming pool complex. Three (4.1%) of our cases gave the history of injury sustained by handling and smashing of traditionally fermented fish locally called 'Ngari'. 'Ngari' is composed of traditionally fermented dry fishes of Puntius sophore , Puntius species and Colisa fasiatus. This eating habits of 'Ngari' by the people of Manipur may be an alternative source of transmission of the disease in this region. Similar case of injury by fish bone has been reported from India by Thomas and co-workers. Another interesting case was that of one who gave the history of injury caused by 'steel wool' while cleaning utensils.
Disseminated sporotrichosis is rare in the immunocompetent host but may present with widespread cutaneous, lung, bone, joint and central nervous system involvement in immunocompromised patients. Although sporotrichosis has been an uncommon opportunistic infection in AIDS patients, we came across two male patients (2.7%) who were HIV positive. Hence, there is an apprehension that the co-infection of HIV and sporotrichosis may increase in Manipur, since Manipur is one of the highly prevalent state of HIV infection in India. Many predisposing conditions of the host have been pointed out: alcoholism, diabetes mellitus, haematologic malignancies, chronic obstructive pulmonary disease, long term treatment with corticosteroids, chemotherapy drugs, transplant recipients and patients with AIDS.
Sporotrichosis may be mistaken for numerous diseases including pyoderma gangrenosum, rosaceae, sarcoma, leishmaniasis, tularemia, anthrax, gummatous syphilis, cutaneous and lymphatic tuberculosis, leprosy, staphylococcal lymphangitis, erythema nodosum, nocardiosis, yaws, histoplasmosis, paracoccidioidomycosis, chromoblastomycosis, sarcoidosis, etc.
Lymphocutaneous presentation is the commonest clinical form of the disease, where a primary lesion develops at the site of inoculation in immunocompetent hosts with its frequencies ranging from 46 to 92%, followed by the fixed cutaneous type (0 to 54%). In this study too lymphocutaneous was the predominant clinical type (63.1%) followed by fixed cutaneous type (36.9%). Among the possible factors determining clinical manifestations of the disease are the size and depth of implantation of the fungal inoculum, thermotolerence of the infecting Sporothrix schenckii strain and immune status of the host. There appears to be no relationship of gender preponderence to sporotrichosis. Although some reports have suggested that the patients are more likely to be men, others have shown nearly equal ratios and a few have noted a preponderance of female patients. In this regard, our study reveals a marginal predominance in females.
Therapy for sporotrichosis in immunocompetent hosts is well established. Itraconazole is the drug of choice for cutaneous, lymphocutaneous and osteoarticular sporotrichosis. The recommended dosage of itraconazole is 100-200 mg daily for 3-6 months. While amphotericin B is required for severe pulmonary infection and disseminated sporotrichosis. On the other hand, therapy for disseminated sporotrichosis in HIV infected patients remains unclear and the response to therapy is variable. Al-Tawfiq et al revised the treatment of sporotrichosis in AIDS patients pointing amphotericin B as the drug of choice for initial use and suppressive itraconazol therapy for life long to control infection. This recommendation is in accordance with practice guidelines for the management of patients with sporotrichosis and AIDS for the mycoses study group, Infectious Diseases Society of America.
Since an opening in the skin is necessary for the sporotrichosis fungus to enter the body, the best way to prevent the disease is to avoid accidental scrapes and cuts on the hands and arms by wearing gloves and long sleeves while gardening or handling other materials that may cause minor skin breaks. Washing hands and arms well after working with roses, barberry, sphagnum moss and other potential sources of the fungus may also provide some protection.
In conclusion, this study reveals Manipur as an area where sporotrichosis is endemic. However, further studies to evaluate the frequency of sporotrichosis in Manipur are needed.
| ~ Acknowlegements|| |
The authors are grateful to Dr. Arunaloke Chakrabarti, Department of Microbiology, PGIMER, Chandigarh for confirming the first few cases (establishment of dimorphism and animal pathogenicity testing).
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
[Table - 1]
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