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

Literature Review

Sporothrix schenkii (SS) is a thermally dimorphic fungus – capable of existing as a saprophytic mold at environmental temperatures (25–30 °C) and a yeast at body temperature (37 °C) – belonging to the genus Sporothrix. SS is the primary pathogen responsible for sporotrichosis and spores of the mold are usually found in soil, damp or decaying wood and roses, and hence sometimes referred to as rose gardener's disease. The fungus is usually inoculated through the skin and most frequently (95%) involves the cutaneous and subcutaneous tissues and lymphatics in immunocompetent patients. Persons at risk for disseminated SS are usually immunocompromised, and include, diabetics, those with chronic alcoholism, Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) and solid organ transplant patients. Zoonotic transmission from infected cats has been reported in Brazil and other South American countries where the disease is endemic.[1] The cutaneous form begins with a papule at the site of inoculation which may ulcerate or remain nodular with surrounding erythema. Drainage fluid may be odourless and non-purulent or pyogenic in nature, pain is usually mild with absent systemic symptoms. Similar lesions occur along the lymphatic drainage proximal to the index lesion, termed "Sporotrichoid" spread or nodular lymphangitis. Differential diagnoses include non-tuberculous mycobacterial infection, Nocardia and Leishmania.[2,3] The disseminated form can involve various organ systems; including, pulmonary, osteoarticular, eyes (uveitis), and heart (endocarditis).[1] Gullberg et al.[4] reported a recurring case of disseminated sporotrichosis in a renal transplant patient, involving joints, skin, and the central nervous system. This required three treatment cycles with systemic AMB-d. In the second cycle, intra-articular AMB-d was administered and in the third one, intrathecally. Immunosuppression was tapered to prevent further relapses. Agarwal et al.[5] reported a case of pyelonephritis due to SS in a renal transplant patient with a history of multiple renal calculi and recurrent urinary tract infections, the patient died in an accident before appropriate treatment could be initiated. Caroti et al.[6] reported SS infection in a renal transplant patient who initially presented with erythematous papulonodular lesion following trauma to the leg which responded to treatment with fluconazole. He presented again seven years later with acute osteomyelitis and gangrene in the same foot with ulcers. Biopsy of the ulcer revealed SS infection, MMF was discontinued and the patient responded well to fluconazole with regression of the lesions. Gewehr et al.[7] report two cases of sporotrichosis in renal transplant patients, the first patient had a prior history of trauma, presented with papular lesions on the hand and ear, while the second patient had no history of trauma, presented with generalized weakness, joint pain and disseminated nodular and ulcerated lesions involving the upper and lower extremities and the trunk. Both these patients were treated with itraconazole and amphotericin B. Table 4 summarizes cases of sporotrichosis in renal transplant patients reported in the literature to date.