Research Article | Open Access
Sporotrichosis: Epidemiological, clinical and mycological study of 53 cases in Guatemala
Sánchez-Cárdenas CD1, Porras-López C2, Morales-Ezquivel O3, Frías-De-León MG4, Juárez-Durán ER1, Arenas R1 and Martínez-Herrera E4*
2Maestría en Microbiología de la Enfermedades Infecciosas, Universidad de San Carlos de Guatemala
3Departamento de Microbiología, Universidad de San Carlos de Guatemala
4Unidad de Investigación, Hospital Regional de Alta Especialidad de Ixtapaluca, Estado de México, México
*Corresponding author: Erick Martínez-Herrera
Hospital Regional de Alta, Especialidad de Ixtapaluca, Estado de México, México, E-mail:firstname.lastname@example.org
Received: July 7th, 2017; Accepted: August 20th, 2017; Published: August 24th, 2017
Life Sci Press. 2018; 2(1): 66-69. doi: 10.28964/LifesciPress-2-110
Ⓒ 2018 Copyright by Martínez-Herrera E. Creative Commons Attribution 4.0 International License (CC BY 4.0).
Introduction: Sporotrichosis is a granulomatous subcutaneous mycosis, with a worldwide distribution and endemic in some areas of Latin America.
Methodology: Observational, descriptive, retrospective and cross-sectional study in patients with diagnosis of sporotrichosis ina private Dermatological Center andat the University of San Carlos from 2007 to 2016. Sociodemographic, clinical, mycological and therapeuticcharacteristics were collected. We excluded the files of patients with incomplete data. Descriptive statistics of the variables were performed.
Results: 53 cases of sporotrichosis were identified. Most were men (61%) with a median age of 44.1 years. 70% were rural workers, mainly related to farm activities (43.4%). The most common clinical presentation was lymphocutaneous, affecting upper limbs in arms and hands (62.2%). The most common treatment was potassium iodide (62.3%). Terbinafine and itraconazole were also used among other treatments. All patients were cured.
Conclusion: Sporotrichosis in this study in Guatemala predominated in rural areas in males, as well as lymphocutaneous variety in upper extremities.
KEYWORDS:Sporotrichosis, Sporothrixschenckii complex,lymphocutaneous,potassium iodide.
Sporotrichosis is a subcutaneous, subacute or chronic granulomatous mycosis with a worldwide distribution,and endemic in some areas of Latin America(1-3). Mainly observed in tropical or subtropical climate (3,4),such as Peru (5), Brazil (6), Mexico (7), Colombia (8), Uruguay, Costa Rica and Guatemala(9).
It is caused by dimorphic fungi of the Sporothrix schenckii complex, more often Sporothrix schenckii sensu stricto(4,10).
The clinical forms of this fungal infection are variable and depends on the immune status of the host, the fungal load and the site of inoculum. The most common presentation is lymphocutaneous affecting limbs, followed by the fixed cutaneous, and in a lower percentage disseminatedand extracutaneous forms (4,11).
The aim of this study was to describe the sociodemographic, clinical and mycological characteristics of patients with sporotrichosis in Guatemala.
Observational, descriptive, retrospective and cross-sectional study in patients with a diagnosis of sporotrichosisin a private Dermatological Center and at the University of San Carlos from 2007 and 2016.
Files of patients with confirmed diagnosis of sporotrichosis were collected in order to identify sociodemographic, clinical, mycological and therapeutic features.
For identification of the causal agent, exudate or a fragment of affected tissue were obtained and processed by maceration andculture was performed in Sabouraud agar with antibiotics (Mycosel-agarBeckton-Dickinson, MD). The sample was taken in order to observe it on the microscope with Lacto-phenol cotton blue for the morphological identification of the fungus (Figures 1 and 2).
Files of patients whose data were incomplete were excluded. Descriptive statistics of the variables were performed, which are presented in frequency and medians with ranges.
53 cases of sporotrichosis were identified,33 (61%) weremales and 21 (39%) females, with a median age of 44.1 years (8 months- 85 years).
The median duration of the infection was 8.3 months (0.5 months – 15 years).
Sociodemographic, clinical and mycological characteristics are describedin Table 1 (Figures 3 to 6).
33 (62.3%) were treated with potassium iodide, 15 (28.3%) with terbinafine and 5 (9.4%) with Itraconazole. 100% of patients had complete remission of clinical manifestations.
Sporotrichosis is a fungal infection that affects men and women of any age. This varies according to the region, the type of activity and associated risk factors. In Latin American countries such as Colombia and Brazil, this disease is more common in men over 40 years dedicated to rural activities such as agriculture or other associated activities (12,13).
In our study, the mostaffected patients were males (61%) and the median age was 44.1 years, according to literature reports.
The infection is acquired by traumatic inoculation from soil, plants or organic matter and transmission from animals is rare(1). It is also associated to people living in rural areas (farmers, gardeners) and veterinaries (14).
Most of our cases (70%) were patients from rural areas, 43.4% farmers, which corresponds to socio-demographic and risk factors.
Usually, the infection is limited to the skin, subcutaneous tissue and lymphatics, eventually infection can spread to other organs, rarely the inhalation of conidia can cause systemic infection(13). It is characterized by nodular lesions, non-painful, sometimes ulcerated or verrucous(15).
Diagnosis is usually suspected by clinical, epidemiological correlation and confirmed by laboratory data.Samples can be obtained from of affected tissue,or sputum, urine, blood, cerebrospinal and synovial fluid(13).The culture of the fungusin Sabouraud dextrose agar, is the standard diagnostic for detecting infection.Currentlyother auxiliary diagnostic tools can be used, such as histopathology, fluorescence, serology and molecular biology(13,15).
Ameidaet al. (6), studied 50 patients with sporotrichosis, 34 women and 16 men, with a median age of 47 years. Lesions were found in upper limbs (62%), lower limbs (12%), face (2%), trunk (2%) and more than one segment (22%). Most cases were identified in patients in rural zones. Regarding clinical forms, 30% had mixed cutaneous forms, 48% lymphocutaneous, 12%disseminated cutaneous forms and 10% disseminated forms including internal organs.
In our study, 39% of patients with sporotrichosis were women; however, men were most affected. The median age, clinical, topographical variety, and the prevalence of patientsof rural area, corresponds to whatAmeida et al.(6) foundmost of our patients were treated with potassium iodide and only 9.4% received itraconazole. All patients had clinical remission.
In our study, most cases occurred in male farmers living on rural areas, with involvement of upper limbs and lymphocutaneousaffection. Mata-Essayag et al. (16) described the follow-up of 133 patients with sporotrichosis for 46 years in Venezuela. 41.35% from urban areas and 34.6% from rural environments. 66.15% were under 30 years and 71.4% were males, students 37.6%, 29.3% farmers and 6.8% housewives. Like our cases, the most common clinical presentation was lymphocutaneous (63.15%), followed by mixed (36.09%). 54.9% affected the upper limbs, 15.8% lower limbs, face and neck in 13.5%, trunk 1.5%, 12% were disseminated and 1 case with corneal condition. Direct examination was conducted on 123 cases, and 57. 9% were positive, with the presence of asteroid bodies. S. schenckii was isolated in 130 cases (97.7%).
Oyarce et al. (17), describedin Peru, a similar study to ours in Guatemala. From 1991-2014, 128 patients were identified but only 94 cases were included. The average age was 36 years, 78% above 15 years, 71% males. 30% farmers, 25% students, 13% buildersand 14% housewives. Lymphocutaneous form was the most common (47%), followed by the fixed cutaneous(39%), 12%disseminated, 1% extracutaneous and 1% unclassifiable. 59% affected upper limbs,22% lower limbs and 19% head and neck(17).
Potassium iodide was the first choice in the majority of cases, it is believed to act by destroying granulomas through the increased proteolysis. However, itraconazole is currently the treatment choice all over the world; the dose may vary from 100-200 mg/d orally for cutaneous and lymphocutaneous forms. The dose of 400 mg/d is administered in cases with poor response to the initial dose or osteoarticular, pulmonary forms and also immunocompromised patients previously treated with amphotericin B(13).
Ameida et al. (6) studied 50 patients with sporotrichosis, 4 patients cured spontaneously, the other cases were treated with itraconazole with good response. In the study of Mata-Essayag et al. (16) 76.6% of patients with sporotrichosis were treated with potassium iodide, 12% itraconazole, 11.2% other treatments (fluconazole, terbinafine) with good response to all therapies.
Most of our patients were treated with potassium iodide,15 with terbinafine and just 5 with itraconazole. All had clinical remission.
Sporotrichosis cases in Guatemala are found most often in male farmers in rural areas. The topography and clinical variety corresponds to that reported by other authors. This is important because of the limited information available about the characteristics of this fungal infection.
CONFLICTS OF INTEREST
We declare have no conflict of interest.
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