Volume 27 Number 3 September 1992

Brief communications

463

Successful treatment of disseminated cutaneous sporotrichosis with ketoconazole Stanley 1. Cullen, MD, Arthur A. Mauceri, MD, and Nelson Warner, MD Gainesville, Florida Sporotrichosis is usually acquired by the traumatic implantation of the dimorphic fungus Sporo~ thrix schenckii into the skin. The infection may be limited to the site of inoculation but usually appears in the lymphocutaneous form extending along the regional lymphatics. We report a severe case of disseminated cutaneous sporotrichosis (DCS) that re~ sponded dramatically to treatment with ora) ketoconazole. CASE REPORT

A 71-year-old man had a 3-month history of fever and malaise associated with progressive painful abscesses of the skin. Examination revealed an acutely ill, debilitated, febrile person. The skin lesions were located on the face, anterior trunk, and extremities (Fig. 1) and ranged from intact nodules to necrotic ulcerations with crusting. Initial laboratory studies revealed the following values: hematocrit, 31%; hemoglobin, 10.3 gmjdl; white blood cell count, 12,8oojmm3 with neutrophilia. The erythrocyte sedimentation rate (Wintrobe) was 58 mm/hr. Urinaly~ sis was within normal limits. An elevated alkaline phosphatase level of 269 U (normal 30 to 40 U) was noted. Serum protein electrophoresis and immunoglobulin analysis were consistent with an infection or inflammatory disorder. Serum complement C3 and C4 and an antinuclear antibody test were negative. Gram's stain of the aspirate of the lesions demonstrated many white blood cells and yeastlike structures. Cultures grew Sporothrix schenckii.

Histopathologic findings of two skin biopsy specimens were similar and demonstrated chronic granulomatous dermal inflammation with small budding yeasts present. Treatment with oral ketoconazole, 200 mg daily for 10 days, resulted in considerable clinical improvement. Lesional pain, an initial striking symptom, completely subsided and individual skin lesions showed early signs of healing. Because of a few persistent skin lesions, the dose of ketoconazole was increased for a short interval to 600 mg daily and then reduced to a 400 mg daily dose. The patient tolerated treatment well and his lesions healed Reprint requests: Stanley 1. Cullen, MD, 6628 NW 9th Blvd., Gainesville, FL 32605. 16/54/37193

Fig. 1. Nodular ulcerative lesions of anterior trunk. Fig. 2. Hyperpigmented hypertrophic and atrophic residuallesions of anterior trunk. with both hypertrophic and atrophic hyperpigrnented scars (Fig. 2). DISCUSSION

Sporotrichosis is usually divided into the cutaneous and extracutaneous forms. I Cutaneous sporotrichosis is subclassified into the following three forms: lymphocutaneous, fixed cutaneous, and disseminated cutaneous (DeS). Our patient meets the criteria established for the diagnosis of DeS. The disseminated cutaneous variety of the disease is rare. 2 Everett 3 found only I of 117 patients with sporotrichosis had this variant. Smith et al. 2 reported

Journal of thc American Academy of Dermatology

464 Brief communications three patients who had extensive cutaneous involvement without detectable systemic involvement. Most patients with sporotrichosis have a purely cutaneous disorder; as many as 95% of the patients in some series 3 have the disease limited to the skin. Only a few cases 1,4-7 of cutaneous sporotrichosis have been treated with ketoconazole and most of these were ofthe lymphocutaneous type. Our results indicate that DeS may also respond well to ketoconazole therapy.

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REFERENCES

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1. Belknap BS. Sporotrichosis. Dermatol Clin 1989;7: 193-202. 2. Smith PW, Loomis OW, Luckasen JL, et al. Disseminated

3. 4.

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cutaneous sporotrichosis: three illustrative cases. Arch Dermato11981;117:143-4. Everett MA. Atypical sporotrichosis. J Okla State Moo Assoc 1963;56:483-5. Reshad H, Pegum JS, Keir MIS, et al. Cutaneous lymphatic sporotrichosis treated with ketoconazole: report of an infection acquired in the United Kingdom. Clin Exp Dermatol 1984;9:599-603. Dismukes WE, Stamm AM, Graybill JR, et al. Treatment of systemic mycoses with ketoconazole: emphasis on toxicity and clinical response in 52 patients. Ann Intern Moo 1983;98:13-20. Calhoun DL, Waskin H, White MP, et al. Treatment of systemic sporotrichosis with ketoconazole. Rev Infect Dis 1991;13:47-51. Difonzo EM, Palleschi GM, Vannini P, et al. Therapeutic experience with ketoconazole. Drug Exp Clin Res 1986; 12:397-403.

Amelanotic melanoma presenting as inflammatory plaques Jaime A. Tschen, MD,a Dawn Bhasin Fordice, MD,b Max Reddick, MD,c and John Stehlin, MDa Houston, Texas Amelanotic malignant melanomas comprise approximately 2% of all melanomas and are the variety most often cited as simulating other tumors. I -3 Seven macular amelanotic melanomas have been reported. 4 We report four additional cases with similar features. CASE REPORTS

Case 1. A 53-year-old woman had an erythematous, scaling 3 X 4 em plaque on her right forearm for several months (Fig. I). She was treated with betamethasone dipropionate cream. Seven months later the lesion had enlarged. Two punch biopsy specimens showed superficial spreading amelanotic melanoma. A wide excision was performed. She remains free of tumor after 18 months. Case 2. A 52-year-old man noticed a plaque on the left side of the upper part ofthe neck that slowly enlarged to 1.0 X 1.2 em. A biopsy specimen revealed a nonpigmented superficial spreading malignant melanoma. The entire lesion was excised and the patient remains tumor free after 18 months. Case 3. A 64-year-old woman had a 5 X 3 cm erythematous irregular plaque on her right calf (Fig. 2). Shereported a small pigmented lesion at that site that was treated with liquid nitrogen 14 years earlier. The lesion From 81. Joseph Hospital"; Department of Ophthalmology, Baylor College of Medicineb; private practice. c Reprint requests: Jaime A. Tschen, MD, 81. Joseph Dermatopathology, 1919 LaBranch, Houston, TX 77002.

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1 Fig. 1. Case 1. Erythematous scaly plaque with pale irregular borders on proximal forearm. recurred as an erythematous plaque that slowly enlarged. A punch biopsy specimen showed a superficial spreading amelanotic melanoma that was later completely excised. The patient is well 1 year after treatment. Case 4. An 81-year-old man had a small nodule within an erythematous patch of 4 months' duration (Fig. 3). A biopsy specimen of the nodule showed an amelanotic melanoma that extended into the base of the biopsy (at least 2.6 mm thick). Excision of the erythematous scaly macule showed lentigo maligna with an invasive component in the deep papillary dermis. Material and methods. Specimens from the four patients were processed for routine histology, histochemistry, silver staining of nucleolar organizer regions (Ag-

Successful treatment of disseminated cutaneous sporotrichosis with ketoconazole.

Volume 27 Number 3 September 1992 Brief communications 463 Successful treatment of disseminated cutaneous sporotrichosis with ketoconazole Stanley...
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