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Key Features

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  • Subacute cutaneous ulcers

  • New lesions appearing proximal to existing lesions along a draining lymphatic

  • Absence of systemic symptoms

  • Isolation of Sporothrix schenckii from wound drainage or biopsy

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Clinical Findings

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  • Cutaneous disease is by far the most common manifestation

  • Typically an initial papular lesion slowly becomes nodular and ulcerates

  • Subsequent new lesions develop in a similar fashion proximally along lymphatics draining the primary lesion

  • This sequence of developing painless, chronic ulcers in a linear pattern is strongly suggestive of the diagnosis

  • Solitary lesions may exist and some lesions may develop a verrucous character

  • Systemic symptoms are absent and laboratory evaluations are normal, except for acute-phase reactants

  • The fungus rarely disseminates in immunocompetent hosts

  • Cavitary pneumonia is an uncommon manifestation when patients inhale the spores

  • Disseminated skin lesions and multiorgan disease with extensive pneumonia may develop in immunocompromised patients, especially those with HIV infection

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Diagnosis

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  • Culture

  • Biopsy of skin lesions

    • Demonstrates a suppurative response with granulomas

    • Provides the best source for laboratory isolation

    • Occasionally, the characteristic yeast will be seen

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Treatment

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  • Itraconazole

    • Dosage: 200 mg/d or 5 mg/kg/d for 2–4 weeks after lesions heal, usually 3–6 months

    • Pulmonary or osteoarticular disease, especially in immunocompromised individuals, requires longer therapy

  • Amphotericin B may be required for disseminated disease, CNS disease, and severe pulmonary disease

  • Surgical debridement may be required

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