Sporotrichosis in Manipur: Report of two cases

KH Ranjana¹ , A Chakrabarti² , M Kulachandra³ , K Lokendra³ , H Devendra³

¹ Department of Microbiology, J.N. Hospital, Imphal, Manipur, India
² Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh -160012, India
³ Department of Dermatology, J.N. Hospital, Imphal, Manipur, India

Correspondence Address:
A Chakrabarti
Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh -160012
India

Introduction

Sporotrichosis, caused by the dimorphic fungus Sporothrix schenckii, is a chronic pyogenic granulomatous infection. Clinically it may manifest as lymphocutaneous, fixed cutaneous, mucocuta-neous, extracutaneous and disseminated form or very rarely as primary pulmonary.[1] Trauma to the skin by thorns and splinters, cuts from sedge barbs, handling of soil, sphagnum moss and grasses allow entry of the organism to subcutaneous tissue. Rarely it has also been reported following animal and insect bites.[1] From India cases of sporotrichosis were mainly reported from Himachal Pradesh, Punjab, West Bengal and Assam and a few cases from South India.[2],[3],[4],[5],[6] This paper describes for the first time cases from Manipur, a neighboring state of Assam.

Case Reports

Case 1A 67-year-old woman attended Dermatol-ogy OPD at J.N. Hospital, Imphal with multiple raised ulcerated lesions of right forearm, not responding to various courses of antibiotics in the last one year. It was a single painless papule to start with, that increased in size with ulceration and discharge of pus. Later it started spreading to other adjacent areas presumably along the lymphatics. She couldn′t recollect any history of injury or scratches. Suspecting it to be cutaneous tuberculosis, she was given antituberculous regime for seven months, without any clinical improvement. After ten months of onset, a pathologist conducted histopathological examination and suspecting it to be cutaneous blastomycosis, she was treated with itraconazole. She had been taking the medicine irregularly. After 7 months, pus was collected for microbiological examination. S.schenckii was isolated from pus. She was treated with saturated solution of potassium iodide (5 drops 3 times daily increased by 1 drop/ dose/day till 40 drops 3 times daily for 6 weeks), and she was clinically cured of the disease after about 1 month.

Case 2A 70-year- old woman, presented with mul-tiple raised ulcerated lesions spreading in an ascend-ing manner from the dorsum of right hand towards the forearm and arm in one month. She gave a history of injury with fishbone of Ngari, name of the fermented fish consumed by the local people. The injury was at the base of the little finger and was followed by pain, induration and ulcertion after about 10 days. She noticed the same type of le-sion on the medial aspect of wrist, then forearm and arm. Inspite of various courses of antibiotics, there was no relief. Pus from the lesions was col-lected for microbiological examination. S. schenckii was isolated from pus. She was treated with saturated solution of potassium iodide (5 drops 3 times daily increased by 1 drop/dose/day till 40 drops 3 times daily for 6 weeks) and the lesion completely healed after 1 month.

Mycological investigation

Pus collected from the lesion was subjected to direct examination of 10% KOH wet mount, Gram and periodic-acid-schiff stained smear. Pus was cultured on two sets of Sabouraud′s dextrose agar with chloramphencicol 09.05 mg/ml and cylohexamide-0.5 mg/ml (SDA) and two sets of brain heart infusion agar with chloramphenicol 0.05 mg/ml and cylohexamide 0.5 mg/ml (BHIA). One set each of SDA and BHIA was incubated at 30°C and the other set was incubated at 25°C which showed off-white mycelial colonies after about 5-6 days. Lactophenol cotton blue mount showed thin hyaline delicate mycelia with conidia. On slide typical morphology of saprophytic form of S. schencki was confirmed with conidia arising directly from the mycelium and from small stems giving a flower-like pattern.

To confirm dimorphism, the mycelial form was subcultured on BHI with defbrinated sheep′s′ blood and incubated at 37° C. Yeast conversion was possible after 5-7 repeated subcultures.

Animal pathogenicity test

About 1 ml saline suspension of each growth was inoculated intraperitoneally into two outbred Swiss albino mice. After about 14-15 days orchitis was observed. Pus from the testes was examined for cigar-shaped bodies and by culture for isolation of S schenckii.

Discussion

Sporotrichosis was once considered a rare disease in India and had been reported only from Assam and Bengal.[2],[3] But with the increase in awareness more endemic foci are recorded from this country.[4],.[6],[7] In Manipur, though adjacent to the state of Assam, clinicians were not aware of this entity. Therefore, though the disease was reported from Assam since 1950s,[2] these two cases were diagnosed for the first time from Manipur. It is likely that sporotrichosis is widely prevalent in this country and population based exploratory study and greater awareness may help us to know exact prevalence of this disease in India.

During evaluation of the geo-climatic conditions in which sporotrichosis is prevalent in In-dia it was found that the disease is common in villages of north India that have lower average temperature (15.5-23.6°C) and higher rainfall (3364mm).[7] In Manipur, the meteorological data shows average temperature of 21°C and rainfall of 1550 mm/year [Table - 1]. It is still not clear which climatic condition helps in growth of S schetckii in the environment. In South Africa, it was found that the fungus grew well at 26-27°C and a relative humidity of 92-100%. However, in Mexico greatest frequency of infection coincided with the dry and cooler parts of the year.[8] Thus it is still not clear which climate condition exactly helps the growth of S. scheckii.

Sporotrichosis is usually initiated by outdoor activities where thorn prick or cut or blunt injury helps in implantation of the organism in subcutaneous tissue. Florists, gardners, forestry workers, miners and laboratory personnel have been typically considered most at risk for developing sporotrichosis.[9].[10] However, infection has also been associated with insect stings, fish handling and the bites of birds, dogs, horses, reptiles and rats, even though clinical symptoms may not be present in those animals.[1],[10],[11] Our second patient gave history of injury by fish bone of fermentation fish (Ngari). Similar case of injury by fishbone of fresh unfrozen fish initiating sporotrichosis was reported from India.[5] People of Manipur have the habit of eating fermented fish (Ngari) and this may be an important source for transmission of the disease in this region. Extensive epidemiological study is being proposed to probe such a hypothesis.

Cutaneous spotrichosis may clinically re-semble cutaneous leishmaniasis, tuberculosis, chromoblastomycosis, blastomycosis and even chronic staphylococcal skin lesions.[1] In our first case, one pathologist thought it to be a case of cutane-ous blastomycosis. The patient received antituberculosis therapy initially suspecting it to be a case of cutaneous tuberculosis. Thus, the overlap in clinical presentation necessitates that accurate diagnosis of cutaneous sporotrichosis be based upon isolating the fungus from clinical specimens.

The therapy of cutaneous sporotrichosis still largely relies on saturated solution of potassium iodide though it is difficult to administer and is frequently associated with side effects. Itraconazole has been used in a few cases with response rate of> 90%.[12],[13] Our first patient took itraconazole irregularly for 7 months without any improvement. However, it cannot be called a case of treatment failure. We need to evaluate itraconazole in more number of patients before substituting it for potassium iodide therapy.

Acknowledgement

The authors are grateful to the Medical Superintendent, J.N.Hospital, Imphal for permission to publish the paper.

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