Editor's note: This case is reprinted from the "Spot the Rash " department of Infectious Diseases in Children, a sister SLACK Incorporated publication.
A 4-year-old boy presented with a history of crusting and drainage of the surface of the nose for several weeks (see image above). His parents said the lesion initially looked like a mosquito bite and then progressed to its appearance at the time of presentation.
Previously, a simple wound culture for bacteria was negative. He had been treated with antibiotics and prednisone, with little or no improvement. The lesion has continued to spread slowly.
The boy lives on a farm in Indiana. His family owns a few livestock, chickens, and two cats. The child's physician sent fresh tissue from a biopsy for culture and grew Sporothrix schenckii.
S. schenckii is a dimorphic fungus that grows as an oval or cigar-shaped yeast at 98.6 degrees E It can be found in soil, hay, straw, thorny plants (especially roses), sphagnum moss, and decaying vegetation.
Cutaneous sporotrichosis is the most common manifestation of an infection with S. schenckii. Inoculation occurs in the presence of a minor break in the skin. After 1 to 12 weeks, a painless nodule, typically red or violaceous, appears at the site of the inoculation. More nodules develop, and these tend to open, ulcerate, and drain. Pulmonary and disseminated forms of sporotrichosis can be seen in immunocompromised patients. The differential diagnosis for this condition should include herpes, mycetoma, blastomycosis, chromoblastomycosis, mycobacterium infections, and discoid lupus.
This patient was treated for 3 months with saturated solution of potassium iodide. He healed, but with scarring (Figure 2). Itraconazole is approved for treatment of cutaneous and lymphocutaneous sporotrichosis in adults; however, the 2003 Red Book states: "Although there are no controlled trials to document the efficacy of itraconazole in pediatrie patients, most experts consider itraconazole the preferred treatment."1 Immunocompromised patients with disseminated sporotrichosis often require treatment with amphotericin B.
Figure. A photograph taken following treatment show scarring on the nose of the patient resulting from sporotrichosis infection.
Recommendations for preventing infection include wearing gloves and long sleeves when working with materials where the fungus can be found.
1. Rckering LK, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Evanston, IL: American Academy of Pediatrics; 2004.