A Case of Cutaneous Disseminated Type of Sporotrichosis Resistant to Itraconazole and Terbinafine

Kim, Dong Seok; Kim, Jong Woo; Kim, Sang Won

Abstract

Sporotrichosis, a deep fungal infection caused by Sporothrix schenckii, is mainly treated with potassium iodide (Kl) and other antifungal agents, and recently there were reports of cases treated with itraconazole or terbinafine. A 56-year-old female patient presented with multiple painless firm nodules covered with crusts measured 1.0x1.5 cm and 1.0x3.0 cm on the right side of neck and an erythematous plaque with ulceration measured 2.0x2.0 cm on the right cheek for 20 days. Eight months before visit, she noted two subcutaneous nodules on the right side of neck. Excisional biopsy and treatment for tuberculous lymphadenitis were done. There had been no clinical response for 2 months, but new painless nodules and plaque with ulceration were developed on the opposite side of previous lesions. Biopsy showed a granulomatous change with polymorphic infiltrates, yeast cells and asteroid body. Routine laboratory findings and chest X-ray were not contributory. No evidence of tuberculosis was found in the examination with sputum and tissue.4 dark brown to black, moist and wrinkled colony on the Sabouraud's dextrose agar and septate, branched mycelia and clustered conidia on slide culture were shown to be consistent with Sporothrix schenckii. Cutaneous disseminated type of sporotricosis was diagnosed. The treatment was started with 500 mg of terbinafine daily which was known to be fungicidal, but there was no improvement clinically and mycologically for 2 months except initial transient stopping of progression. The regimen was subsequently changed to intraconazole 200 mg daily for 3 months, but new lesions were developed. So she was treated with saturated solution of potassium iodide. Five drops were given three times a day, and the dose was increased by 5 drops each day to a dose of 30 drops three times a day. Nodular lesions markedly decreased in size in two weeks, but serial tissue cultures were positive. After 3 months of administration, tissue culture was negative. No evidence of clinical relapse was noted after 3 years of follow-up.