A 42-year-old person with alcohol use disorder presents with three months of persistent and progressive draining nodules that started distally and then spread proximally along the right upper extremity. They are an avid gardener and do not regularly wear gloves when pruning their roses.
On examination, the patient has multiple scaly, indurated, and erythematous nodules and keratotic crusted ulcers in a lymphangitic pattern along the right forearm and proximal upper arm.
Tissue culture grew Sporothrix schenckii. In sporotrichosis, also called the “rose gardener’s disease,” skin biopsy may demonstrate non-specific findings of pseudoepitheliomatous hyperplasia and granulomatous inflammation; organisms appear as cigar-shaped yeast forms but are often not seen.
Tissue culture remains the gold standard for diagnosis and is the most sensitive test. Isolated cutaneous involvement is often seen, but disseminated sporotrichosis with visceral, especially pulmonary, involvement tends to occur in middle-aged people assigned male at birth, and with chronic alcohol use.
While Sporothrix schenckii is the most widely recognized cause of nodular lymphangitis, the differential diagnosis for sporotrichosis-like spread includes atypical mycobacteria, especially Mycobacterium marinum, Nocardia, Leishmania, and Francisella tularensis.
Knowledge of this differential may help identify the causative organism to yield the most appropriate diagnosis and treatment plan.
- Figure 1 medical case
- Nodular Lymphangitis (Sporotrichoid Lymphocutaneous Infections). Clues to Differential Diagnosis
- Giordano CN, Kalb RE, Brass C, Lin L, Helm TN. Nodular lymphangitis: Report of a case with presentation of a diagnostic paradigm. Dermatol Online J. 2010 Sep 15;16(9):1. PMID: 20875322.
- Pluss JL, Opal SM. Pulmonary sporotrichosis: review of treatment and outcome. Medicine (Baltimore). 1986 May;65(3):143-53. PMID: 3517551.
- Qin J, Zhang J. Sporotrichosis. N Engl J Med. 2019 Feb 21;380(8):771. doi: 10.1056/NEJMicm1809179. PMID: 30786190.
- Sizar O, Talati R. Sporotrichosis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 [cited 2021 Nov 30]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532255/
- Sporotrichosis | fungal diseases | cdc [Internet]. 2020 [cited 2021 Nov 30]. Available from: https://www.cdc.gov/fungal/diseases/sporotrichosis/index.html
- Tirado-Sánchez A, Bonifaz A. Nodular Lymphangitis (Sporotrichoid Lymphocutaneous Infections). Clues to Differential Diagnosis. J Fungi (Basel). 2018 May 9;4(2):56. doi: 10.3390/jof4020056. PMID: 29747448; PMCID: PMC6023502.
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