The Journal of Dermatology Vol. 6: 321-323,1979
LYMPHOCUTANEOUS SPOROTRICHOSIS CAUSED BY ACCIDENTAL INOCULATION HIROSHI ISHIZAKI, MASAYASU IKEDA
AND
YUKIO KURATA
ABSTRACT
An inoculation accident resulting in the lymphocutaneous form of sporotrichosis in a 27 -year-old dermatologist is described. The initial symptom was a nodule which appeared 12 days after inoculation at the inoculation site on the right third finger. Subsequent lesions appeared like stepping stones by way of the lymphatics on the dorsa of the hand and forearms, followed finally by involvement of the right supraclavicular lymph nodes. The patient was successfully treated with potassium iodide.
CASE REPORT
A 27-year-old healthy male, one of the authors, suffered a small cut by glass on the dorsa of the DIP joint of the right third finger on July 15, 1966. The cut was immediately covered with a bandage. A few hours later, the bandage was contaminated by two drops of a suspension of the live yeast form Sporothrix schenckii (ATCC 10268, 5xl0 5 cells /rnmt) while injecting S. schenckii into mice. Upon completing the mouse injections approximately ten minutes later, the cut was thoroughly washed with running tap water and a new bandage was applied. The cut healed within the next four days. On July 27 (twelve days after inoculation), a tender, intracutaneous nodule of half rice grain size developed at the site of the cut, followed by pustular change on the surface one week later. The nodule gradually enlarged to rice grain size and became ulcerated. The surrounding area was erythematous, and a small amount of purulent discharge drained from the nodule (Fig. 1). On August 5, a tender cord was seen to extend from the primary lesion to the MP joint along the lymphatics of the inner side of the third finger. The cord became prominent. On August 9, two tender nodules of rice grain size appeared on the dorsa of the right hand, The right Received April 17, 1979; accepted for publication May 21,1979. Department of Dermatology (Director: Prof. R. Fukushiro), Kanazawa University School of Medicine, Kanazawa 920,japan.
supraclavicular lymph nodes were swollen and tender, but the cubital lymph node was not palpable. On August 11, a new nodule developed on the right hand and forearm close to the cubital joint. Culture of the purulent discharge from the primary lesion revealed S. schenckii in pure culture on Sabouraud's glucose agar. The sporotrichin skin test was positive. Routine laboratory data were within normal limits. Biopsy specimens taken from the primary lesion showed typical histopathological findings of sporotrichosis (Fig. 2). PAS staining revealed yeast form fungi (Fig. 3). Direct immunofluorescent study by use of rabbit anti-So schenckii (ATCC 10268) serum prepared according to the method of Yoshizumi (1) also disclosed S. schenckii
Fig. 1. Lesion on the accident.
theI'ighil:liifdlffi~;2;'daYS after
322
ISHIZAKI ET AL
Fig. 2. Histology of sporotrichosis, showing tuberculoid granuloma type lesion.
Fig. 4. Direct fluorescent antibody staining. The arrows indicate S. schenckii.
trichin skin test. DISCUSSION
Fig. 3. PAS s~aining. The arrow indicates S. schenckii.
organisms in the tissue sections (Fig. 4). On August 13, administration of potassium iodide (1.5 g/day) was started orally, and the dosage was increased stepwise to a level of 3 g per day, which was continued for 42 days. Two days after the initiation of iodide therapy, tenderness of the nodules decreased. On August 17, swelling of the supraclavicular lymph nodes began to resolve without tenderness. On August 20, the primary lesion became dried and crusted, and the surrounding erythema was hardly visible. On August 23, all the lesions except the primary lesion were non-palpable. On September 11, the primary lesion healed clinically, leaving a residual scar. The total dose of potassium iodide was 123.5g. Relapse has not occurred, and up to the present, the patient some 13 years later has retained a positive sporo-
As the case reported here was the first case in the Hokuriku district (middle of Japan, facing the Sea of Japan) and the authors had never previously seen sporotrichotic patients, immediate therapy was withheld and the clinical course of the infection was observed daily. In this case, a highly concentrated suspension of live S. schenckii contaminated the bandage on the cut. The first symptom of sporotrichosis was the appearance of a small, tender, intracutaneous nodule twelve days after the accident, followed by subsequent lesions developing proximally like stepping stones by way of the lymphatics, finally involving the right supraclavicular lymph nodes. Our case followed the typical clinical course of lymphocutaneous sporotrichosis. Shibuya (2) inoculated S. schenckii (isolated from a patient) into his skin, and clinical and pathological findings were reported. In his case, a reddish papule developed six days after inoculation. The occurrence of sporotrichosis in summer is extremely rare compared with that seen in other seasons in Japan (3-5). This may be explainable on the basis of the fact that S. schen-
323
SELF·INOCULATED SPOROTRICHOSIS
ckii is susceptible to heat and resistant to cold. Therefore, cold seasons are favourable for S. schenckii. In this present case, however, the inoculation was done accidentally in summer, suggesting that this disease can be caused by virulent S. schenckii regardless of the season. For these reasons, it is speculated that the incidence of sporotrichosis may depend on the natural environment that S. schenckii lives in rather than on the conditions of potential hosts. For prevention of accidental sporotrichosis, Thompson and Kaplan (6) state that instruments contaminated by S. schenckii must be handled carefully. The number of cells that is introduced spontaneously by accidental trauma is about 1-100 cells (7). In our case, the number of cells inoculated may have been extraordinarily high, and repeated washing with running tap water some ten minutes later obviously . did not completely remove the organisms from the wound. This indicates that the organisms may have been already incorporated into the tissue. Resection of such a contaminated wound might therefore be the most appropriate immediate procedure. Fortunately, as a biohazard for laboratory workers, cutaneous sporotrichosis is relatively easily treated. Our case responded remarkably well to treatment with potassium iodide.
In suspected cases of accidental sporotrichosis at the early stage, spotrichin skin testing is recommended for screening, and the conversion to a positive reaction is highly suggestive of sporotrichosis, in cases occurring in nonendemic areas. In addition, fluorescent antibody staining of tissue sections or of purulent discharge is helpful for rapid diagnosis. REFERENCES 1) Yoshizumi, M.: Experimental studies on fluorescent antibody technique of Sporotrichum schenckii, The Dermatology and Urology, 28: 556-567, 1966. (in japanese) 2) Shibuya, H.: Clinical observations and human experiments on sporotrichosis and the mechanism of efficacy of potassium iodide for this disease, Jap. J. Dermatol., 69: 1791-1809, 1959. (in japanese) 3) Urabe, H .. Nagashima, T. and Shiromizu, G.: Sporotrichosis in the Kyushu district, Rinsho derma (Tokyo), 7: 539-553, 1965. (in japanese) 4) Nakajima, H., Katakura, H., Yanagida, H. and Uchiyama, M.: Statistic observation on twenty-three cases of sporotrichosis, Dermatologica et Urologica, 20: 1137-1142, 1966. (in japanese) 5) Igarashi, T.: Supplementary clinical findings in sporotrichosis, The Kitakanto MedicalJournal, 21: 57-80, 1971. (in japanese) 6) Thompson, D.W. and Kaplan, W.: Laboratoryacquired sporotrichosis, Sabouraudia, 15: 167170. 1977. 7) Mariat , F.: The epidemiology of sporotrichosis. In Systemic Mycosis. Wolstenholme, G.E.W. and Porter. R. (eds), Churchill, London, pp. 144-159, 1968.
LYMPHOCUTANEOUS SPOROTRICHOSIS CAUSED BY ACCIDENTAL INOCULATION HIROSHI ISHIZAKI, MASAYASU IKEDA
AND
YUKIO KURATA
ABSTRACT
An inoculation accident resulting in the lymphocutaneous form of sporotrichosis in a 27 -year-old dermatologist is described. The initial symptom was a nodule which appeared 12 days after inoculation at the inoculation site on the right third finger. Subsequent lesions appeared like stepping stones by way of the lymphatics on the dorsa of the hand and forearms, followed finally by involvement of the right supraclavicular lymph nodes. The patient was successfully treated with potassium iodide.
CASE REPORT
A 27-year-old healthy male, one of the authors, suffered a small cut by glass on the dorsa of the DIP joint of the right third finger on July 15, 1966. The cut was immediately covered with a bandage. A few hours later, the bandage was contaminated by two drops of a suspension of the live yeast form Sporothrix schenckii (ATCC 10268, 5xl0 5 cells /rnmt) while injecting S. schenckii into mice. Upon completing the mouse injections approximately ten minutes later, the cut was thoroughly washed with running tap water and a new bandage was applied. The cut healed within the next four days. On July 27 (twelve days after inoculation), a tender, intracutaneous nodule of half rice grain size developed at the site of the cut, followed by pustular change on the surface one week later. The nodule gradually enlarged to rice grain size and became ulcerated. The surrounding area was erythematous, and a small amount of purulent discharge drained from the nodule (Fig. 1). On August 5, a tender cord was seen to extend from the primary lesion to the MP joint along the lymphatics of the inner side of the third finger. The cord became prominent. On August 9, two tender nodules of rice grain size appeared on the dorsa of the right hand, The right Received April 17, 1979; accepted for publication May 21,1979. Department of Dermatology (Director: Prof. R. Fukushiro), Kanazawa University School of Medicine, Kanazawa 920,japan.
supraclavicular lymph nodes were swollen and tender, but the cubital lymph node was not palpable. On August 11, a new nodule developed on the right hand and forearm close to the cubital joint. Culture of the purulent discharge from the primary lesion revealed S. schenckii in pure culture on Sabouraud's glucose agar. The sporotrichin skin test was positive. Routine laboratory data were within normal limits. Biopsy specimens taken from the primary lesion showed typical histopathological findings of sporotrichosis (Fig. 2). PAS staining revealed yeast form fungi (Fig. 3). Direct immunofluorescent study by use of rabbit anti-So schenckii (ATCC 10268) serum prepared according to the method of Yoshizumi (1) also disclosed S. schenckii
Fig. 1. Lesion on the accident.
theI'ighil:liifdlffi~;2;'daYS after
322
ISHIZAKI ET AL
Fig. 2. Histology of sporotrichosis, showing tuberculoid granuloma type lesion.
Fig. 4. Direct fluorescent antibody staining. The arrows indicate S. schenckii.
trichin skin test. DISCUSSION
Fig. 3. PAS s~aining. The arrow indicates S. schenckii.
organisms in the tissue sections (Fig. 4). On August 13, administration of potassium iodide (1.5 g/day) was started orally, and the dosage was increased stepwise to a level of 3 g per day, which was continued for 42 days. Two days after the initiation of iodide therapy, tenderness of the nodules decreased. On August 17, swelling of the supraclavicular lymph nodes began to resolve without tenderness. On August 20, the primary lesion became dried and crusted, and the surrounding erythema was hardly visible. On August 23, all the lesions except the primary lesion were non-palpable. On September 11, the primary lesion healed clinically, leaving a residual scar. The total dose of potassium iodide was 123.5g. Relapse has not occurred, and up to the present, the patient some 13 years later has retained a positive sporo-
As the case reported here was the first case in the Hokuriku district (middle of Japan, facing the Sea of Japan) and the authors had never previously seen sporotrichotic patients, immediate therapy was withheld and the clinical course of the infection was observed daily. In this case, a highly concentrated suspension of live S. schenckii contaminated the bandage on the cut. The first symptom of sporotrichosis was the appearance of a small, tender, intracutaneous nodule twelve days after the accident, followed by subsequent lesions developing proximally like stepping stones by way of the lymphatics, finally involving the right supraclavicular lymph nodes. Our case followed the typical clinical course of lymphocutaneous sporotrichosis. Shibuya (2) inoculated S. schenckii (isolated from a patient) into his skin, and clinical and pathological findings were reported. In his case, a reddish papule developed six days after inoculation. The occurrence of sporotrichosis in summer is extremely rare compared with that seen in other seasons in Japan (3-5). This may be explainable on the basis of the fact that S. schen-
323
SELF·INOCULATED SPOROTRICHOSIS
ckii is susceptible to heat and resistant to cold. Therefore, cold seasons are favourable for S. schenckii. In this present case, however, the inoculation was done accidentally in summer, suggesting that this disease can be caused by virulent S. schenckii regardless of the season. For these reasons, it is speculated that the incidence of sporotrichosis may depend on the natural environment that S. schenckii lives in rather than on the conditions of potential hosts. For prevention of accidental sporotrichosis, Thompson and Kaplan (6) state that instruments contaminated by S. schenckii must be handled carefully. The number of cells that is introduced spontaneously by accidental trauma is about 1-100 cells (7). In our case, the number of cells inoculated may have been extraordinarily high, and repeated washing with running tap water some ten minutes later obviously . did not completely remove the organisms from the wound. This indicates that the organisms may have been already incorporated into the tissue. Resection of such a contaminated wound might therefore be the most appropriate immediate procedure. Fortunately, as a biohazard for laboratory workers, cutaneous sporotrichosis is relatively easily treated. Our case responded remarkably well to treatment with potassium iodide.
In suspected cases of accidental sporotrichosis at the early stage, spotrichin skin testing is recommended for screening, and the conversion to a positive reaction is highly suggestive of sporotrichosis, in cases occurring in nonendemic areas. In addition, fluorescent antibody staining of tissue sections or of purulent discharge is helpful for rapid diagnosis. REFERENCES 1) Yoshizumi, M.: Experimental studies on fluorescent antibody technique of Sporotrichum schenckii, The Dermatology and Urology, 28: 556-567, 1966. (in japanese) 2) Shibuya, H.: Clinical observations and human experiments on sporotrichosis and the mechanism of efficacy of potassium iodide for this disease, Jap. J. Dermatol., 69: 1791-1809, 1959. (in japanese) 3) Urabe, H .. Nagashima, T. and Shiromizu, G.: Sporotrichosis in the Kyushu district, Rinsho derma (Tokyo), 7: 539-553, 1965. (in japanese) 4) Nakajima, H., Katakura, H., Yanagida, H. and Uchiyama, M.: Statistic observation on twenty-three cases of sporotrichosis, Dermatologica et Urologica, 20: 1137-1142, 1966. (in japanese) 5) Igarashi, T.: Supplementary clinical findings in sporotrichosis, The Kitakanto MedicalJournal, 21: 57-80, 1971. (in japanese) 6) Thompson, D.W. and Kaplan, W.: Laboratoryacquired sporotrichosis, Sabouraudia, 15: 167170. 1977. 7) Mariat , F.: The epidemiology of sporotrichosis. In Systemic Mycosis. Wolstenholme, G.E.W. and Porter. R. (eds), Churchill, London, pp. 144-159, 1968.
