Sporotrichosis

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A 71-year-old man with a long history of diabetes mellitus type II, chronic obstructive pulmonary disease, asthmatic bronchitis, and bronchiectasis presented to the VA Clinic in Martinez, Calif, complaining of a severe sore throat, hoarseness, increased coughing, and thick yellow sputum production for the previous 3 months. The patient had been undergoing chronic corticosteroid treatment with systemic prednisone as well as fluticasone propionate by inhalation aerosol. Chest x-ray showed bilateral focal patchy areas of infiltrate at the bases of both lungs, which was interpreted to be consistent with pneumonitis. No masses were seen. Esophagogastroduodenoscopy and laryngoscopy demonstrated an ulcerating epiglottis and generalized inflammation of the larynx and hypopharynx. Vocal cord biopsy showed acute and chronic inflammation with granulomas (Figure, A, hematoxylin-eosin, original magnification X40) with small, 24-micron-diameter budding yeast within multinucleated giant cells (Figure, A insets, Gomori methenamine silver [top] and hematoxylineosin, [bottom], arrow indicates yeast forms, original magnification X 1000). Bronchoscopy revealed patchy inflammation of the larynx, the entire trachea, and the right upper lobe bronchus. Transbronchial biopsies of the right upper and lower lobes of the lung revealed suppurative and granulomatous inflammation with a few small, elongated, cigar-shaped yeast consistent with Sporothrix schenckii (Figure, B, hematoxylin-eosin, original magnification X400; insets, arrow indicates single and budding yeast forms, Gomori methenamine silver, original magnification X 1000), similar to those present in the vocal cord biopsy. The patient was treated with itraconazole. Cultures of sputum, endobronchial biopsy, bronchial wash, and bronchial alveolar lavage performed upon Sabouraud dextrose with chloramphenicol and Mycobiotic agar rapidly produced the typical biphasic forms of S schenckii: pigmented mycelia with flowerlike bouquets of microcandida at 25 deg C (Figure, C, scotch-tape preparation stained with methylene blue, original magnification x 1000) with conversion, upon brain-heart-infusion agar, to cigar-shaped yeast forms at 37 deg C (Figure, C, inset, scotch-tape preparation stained with methylene blue, original magnification x 1000). Fungal cultures of blood were not productive. The patient responded, with improvement in speech and breathing, decreased sputum production, and weight gain.

Sporothrix schenckii is a dimorphic fungal pathogen with a worldwide distribution that most often causes infection of the skin of the arms with possible lymph node involvement. Systemic or pulmonary involvement is rare. Risk factors for systemic or pulmonary disease include immunosuppression as well as chronic disease or debilitation. Primary pulmonary sporotrichosis can demonstrate chest x-ray appearances of lung nodules, cavities, or patchy infiltrates, as in our case.1,2 We could find only one previous case of laryngeal sporotrichosis. Agger and Seage reported vocal cord sporotrichosis in a healthy female who had worked in a sphagnum moss-packing plant and developed cough and hoarseness. Direct laryngoscopic examination and biopsy revealed noncaseating granulomas of the vocal cords caused by S schenckii. Our patient had a different presentation, with multiple risk factors for sporotrichosis, including diabetes mellitus type II, chronic obstructive pulmonary disease, and steroid therapy, and the localization of sporotrichosis to the upper and lower respiratory tract without systemic spread indicates that the inhaled, aerosolized corticosteroid (fluticasone propionate) may have enhanced the growth of sporothrix in the larynx and lung airways. Sporotrichosis needs to be considered in any undiagnosed granulomatous lesions with clinical laryngitis, tracheitis, and bronchitis, especially in the setting of steroid use with other risk factors. Small yeast forms similar to those of S schenckii can be produced by several other pathogenic fungi. Cryptococcus neoformans can be excluded through capsular stains (Alcian Blue) or through specific staining of the yeast wall by the Fontanna-Masson stain. Histoplasma capsulatum or Penicillium marneffi can grow small budding yeast that are similar in size, but single, elongated yeast forms are most suggestive of S schenckii. Candida albicans often has pseudohyphae in addition to yeast forms. Yeast forms of S schenckii may be rare in tissue, particularly in those immunocompetent patients who are not undergoing steroid treatment.

We thank Carol Fleming, MT, VA microbiologist, for her technical assistance.

References

1. England DM, Hochholzer L. Sporothrix infection of the lung without cutaneous disease: primary pulmonary sporotrichosis. Arch Pathol Lab Med. 1987; 111:298-300.

2. England DM, Hochholzer L. Primary pulmonary sporotrichosis: report of eight cases with clinicopathologic review. Ami Surg Pathol. 1985;9:193-204.

3. Agger WA, Seager GM. Granulomas of the vocal cords caused by Sporothrix schenckii. Laryngoscope. 1985;95:595-596.

C. Heidi Zhou, MD; Alfredo Asuncion, MD; Gordon L. Love, MD

Accepted for publication January 21, 2003.

From the University of California-Davis, School of Medicine, Sacramento, Calif (Dr Zhou) and the Department of Pathology, Veterans Affairs Northern California Health Care System and the University of California-Davis, School of Medicine, Sacramento, Calif (Drs Asuncion and Love).

Reprints: Gordon L. Love, MD, Chief of Pathology, Laboratory (113), VA Outpatient Clinic, 150 Muir Rd, Martinez, CA 94553 (e-mail: GLi 09@post.com).

Copyright College of American Pathologists Jul 2003
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