Sporotrichosis in Renal Transplant Patients

Two Case Reports and a Review of the Literature

Mazhar Hussein Amirali; Jacques Liebenberg; Sheylyn Pillay; Johan Nel


J Med Case Reports. 2020;14(79) 

In This Article

Case 1

A forty-three-year-old mixed ancestry male patient known to our division with end-stage kidney disease (ESKD) due to crescentic glomerulonephritis underwent a living related renal transplantation in 2009, with a current baseline creatinine of 118 μmol/L (64–104 μmol/L) and an estimated glomerular filtration rate (eGFR) of 58 mL/min/1,73 m2 (> 60 mL/min/1,73 m2). His immunosuppression regime consists of cyclosporine 150 mg twice daily, azathioprine 50 mg once daily, and prednisone 10 mg once daily. Other comorbidities include systemic hypertension, well controlled on amlodipine 5 mg once daily, and gastritis, well controlled with omeprazole 20 mg once daily. He presented in December 2018 with concerns of a non-healing ulcer on his left arm (Figure 1c) for the past year which was nonresponsive to conservative therapy with daily saline dressings and empiric courses of antibiotics, including Amoxicillin. He had a history of being employed as a general worker in construction performing manual labour where he reports to have sustained injuries to his fingers and hands on multiple occasions. He has been working in the clothing factory for the past 6 years, he does not smoke or consume alcohol and does not give a history of gardening or other similar hobbies. The family and environmental history were unremarkable. Three years post-transplantation he presented with a non-healing ulcer of his left thumb which had developed from a nodule on the same digit. He received treatment in the form of surgical debridement and daily saline dressings which assisted with ulcer healing. He also reported features in keeping with nodular lymphangitis which resolved spontaneously prior to his current presentation. On physical examination he was clinically well, with a blood pressure of 116/71 mmHg, pulse rate of 72 beats/min and temperature of 36.0 °C. He had a 2 X 3 cm ulcer on the posteromedial aspect of his left arm which had a granulated base with some purulent discharge; his systemic examination was otherwise unremarkable. With concerns of malignancy post-transplantation, skin biopsies were performed. These revealed necrotizing granulomatosis with no malignant features. A repeat biopsy in March 2019 isolated Sporothrix schenkii on fungal culture and polymerase chain reaction (PCR) sequencing and he was subsequently initiated on oral itraconazole 400 mg once daily for four weeks followed by 200 mg once daily as life-long prophylaxis. His wound healed within 2 weeks of commencing treatment, he has been well since, and follows up regularly at our transplant clinic for review.

Figure 1.

a Sporothrix schenkii growth on Saboraud Dextrose agar – 28 °C. b Sporothrix schenkii – typical "cigar" shaped budding yeast cells – 37 °C (Gram stain from cerebrospinal fluid (CSF), X 100 magnification). a and b: CSF specimen obtained from case 2. c Left arm 2 X 3 cm non-healing ulcer with a granulated base and some purulent discharge (case 1)