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Clinical Crossroads: Robert C. Moellering Jr A 39-Year-Old Man With a Skin Infection JAMA 2008; 299: 79-87 [Abstract] [Full text] [PDF]

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Sporotrichoid Lymphangitis.

Jihad Bishara   (3 January 2008)

Sporotrichoid Lymphangitis. 3 January 2008
Jihad Bishara, MD Rabin Medical Center; Beilinson Hospital. Petah-Tiqwa, 49100. Israel Send response to journal: Re: Sporotrichoid Lymphangitis. bishara{at}netvision.net.il Jihad Bishara	The described lesion in this patient is compatible with lymphocutaneous syndrome (also termed “nodular lymphangitis” or “sporotrichoid lymphangitis”). This lesion might be caused by a wide variety of fungal, bacterial, mycobacterial, parasitic, and viral pathogens. Of the causative organisms, Sporothrix schenkii, is more frequent in the United States, Leishmania brasiliensis in Central and South America, Francisella tularensis in the Northern Hemisphere, and Pseudomonas pseudomallei in Southeast Asia [1]. A history of a traumatic wound that was contaminated with soil most frequently suggests sporothrichosis, nocardiosis, or infection with rapidly growing mycobacteria. A history of recent contact with fresh or salt water makes infection with M. marinum more likely. Exposure to cats may imply infection with Sporothrix species, Nocardia species, Blastomyces species, rapidly growing mycobacteria, or cowpox virus [2]. Other, less common causes include several fungal pathogens, such as Coccidiodes immitis, Cryptococcus neoformans, Histoplasma capsulatum, Pseudallescheria boydii, Fusarium species, and Scopulariopsis blochii. Among the bacterial pathogens that are less common causes of lymphocutaneous syndrome are Staphylococcus aureus, Group A Streotococcus [3], Mycobacterium chelonae, Mycobacterium kansasii, Mycobacterium tuberculosis, Mycobacterium avium intracellularae, and Mycobacterium fortuitum. Other species of Leishmania (Leishmania tropica, Leishmania major) and viruses (herpes simplex) also induce, less frequently, nodular lymphocutaneous syndrome [2]. In this case, the patient denied history of trauma, exposure to pet and animals, and travel outside the United States in the past few years. However, he is a frequent traveler within the United States, and a regular swimmer. This make the differential diagnosis relatively simpler. Because of his frequent exposure to water Mycobacterium marinum is a highly probable etiologic agent of Mr M's lesion. Other atypical, Mycobacterium species such as M. chelonae, and M. fortuitum might be involved. Herpes simplex transmitted from Mr M's sick young son, causing nodular lymphangitis is another possibility in this case. Finally, endemic fungi in the US, such as Coccidiodes immitis and Histoplasma capsulatum, which might be contracted during his frequent travel within the US, are rare possibilities. The nodular lesions of the lymphocutaneous syndrome can appear clinically indistinguishable, regardless of the microbiologic cause. Accurate diagnosis can usually be made by examination of a punch or wedge biopsy specimen of a subcutaneous nodule. In some cases, in addition to histopathologic examination, culture should be performed for fungi, mycobacteria, viruses, and common bacterial pathogens. Therefore, I would perform a biopsy, and start antibiotic therapy with oral clarithromycin (500 mg bid), until culture and/or pathologic examination results are available. References: 1. Lieberman AA, Grossman ME, Bloomgarden D. Sporotrichoid lymphangitis due to Staphylococcus aureus in a diabetic patient. Clin Infect Dis 1995; 21:433–43. 2. Smego RA, Castiglia M, Asperilla MO. Lymphocutaneous syndrome. Medicine 1999; 78:38–63. 3. Bishara J, Cohen Y, Gabay B, Pavlov R, Samra Z, Pitlik S. Sporotrichoid lymphangitis due to group A Streptococcus. Clin Infect Dis 2001;32:e176–e177.