A Girl and Cat with Sporotrichosis
We report a pediatric case of sporotrichosis with zoonotic transmission of Sporothrix schenckii from a feline to an otherwise healthy 2-year-old girl.
Sporotrichosis typically presents as a subcutaneous mycosis secondary to the dimorphic fungus, Sporothrix schenckii. The classic clinical presentation involves a site of inoculation and evidence of lymphocutaneous spread, typically in the setting of an individual with a history of a thorn prick. There is persistent local infection at the site of inoculation evolving to ulceration. In many cases, proximal lymphatic spread with subcutaneous nodules and overlying erythema may be noted.
Sporotrichosis commonly manifests as a localized cutaneous infection occurring in immunologically normal hosts. This entity occurs in persons with frequent exposure to plant material such as rose bushes, hence commonly being referred to as “rose gardener’s disease.” Sporotrichosis is more prevalent in warmer moist climates. Pulmonary and disseminated infections are less common, though can be devastating. Animal to human transmission is reported but is rare. This infection more commonly affects adults but can be seen in all ages. There have been increasing reports of S schenckii transmission by infected cats, particularly in the Rio de Janeiro region of Brazil. S schenckii tend to be present in large numbers within the nonhealing ulcers of these animals.1
Figure 1A. Edematous ulcerative plaque with overlying pustules on the right wrist.
A 2-year-old girl from central Texas presented to our pediatric dermatology clinic with a 1-month history of a nonhealing wound on the right wrist. She had been treated with a 2-week course of cephalexin and clindamycin without improvement. She was also receiving frequent wound care treatments without improvement. Of note, the patient lived in a rural area with exposure to a variety of outdoor animals. Interestingly, the patient’s mother mentioned that the family had an outdoor cat that had multiple nonhealing ulcers on the face and body for months. The cat was routinely in close contact with the patient, but there was no known history of a cat bite or scratch. The patient was also noted to be helping her mother in their garden over the preceding months but had no known thorn injury. The child’s mother also noted that they had a fish and turtle pond that the child frequently played near. The patient had no history of out of state or international travel. The patient had no history of recurrent infections or immunosuppression.
Figure 1B. Multiple firm erythematous nodules distributed in a linear fashion along the right upper arm.
Upon initial evaluation, physical examination revealed a well-appearing toddler in no acute distress. The patient was afebrile. Examination of the right hand and wrist revealed a rather well-demarcated, erythematous, ulcerative pink plaque with scattered pustules and 2 firm, erythematous, subcutaneous nodules in a linear distribution along the upper right arm (Figures 1A and B). The plaque was tender to palpation. There was no epitrochlear, axillary, or cervical lymphadenopathy noted. The patient did not display any hepatosplenomegaly. There were no other cutaneous findings. Review of systems was otherwise negative. Two punch biopsies from the ulcerated plaque were performed for routine histology and bacterial, fungal, and atypical mycobacterial tissue cultures. Out of concern for an atypical mycobacterial infection, the patient was initially empirically started on oral clarithromycin 15 mg/kg per day divided twice daily. Cat-scratch disease was also considered in the initial clinical differential. Infectious serology workup revealed negative screening for Blastomyces, Histoplasma, Coccidioides, and Cryptococcus. Upon clinic follow up, after approximately 1 week after starting the oral clarithromycin, the ulcerative plaque continued to enlarge and become increasingly painful. New sporotrichoid nodules continued to migrate up the right forearm and upper arm as well.
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