Clinical Challenge: Bright Plaques, Papules on the

Thumb

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ARTICLE:

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A patient, aged 34 years, presented for evaluation of a rash on his dorsal proximal right thumb
and right wrist. The rash was first noted three weeks ago on the thumb. The patient applied
clobetasol spray, but the rash became more red and diffuse.
Upon further questioning, the patient revealed that he was a salesman who enjoyed gardening in
his free time.
Physical examination revealed bright erythematous plaques and papules of the right thumb and
wrist. The patient was afebrile and his axillary lymph nodes were nonpalpable.
A culture was obtained and the patient was started on itraconazole pending culture. When the
patient was seen 10 days later, the erythema and the elevation of the plaque and papules had
diminished.
papules had diminished.

QUESTION
My diagnosis is:

Sporotrichosis

Staphylococcal infection

Leprosy

Candidiasis

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CLINICAL QUIZ
SUBMIT

RESULTS
My diagnosis is:
Sporotrichosis 73% 4144
Staphylococcal infection 10% 546
Leprosy 1% 42
Candidiasis 17% 954
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Based on the clinical appearance and patient history, the presumptive diagnosis was
Sporotrichosis. Upon further questioning the patient recalled a rose thorn penetration at the initial
site when gardening. The culture results confirmed Sporotrichosis.
Cutaneous Sporotrichosis is an infection caused by the fungal organism Sporothrix
schenckii. This infection usually results from direct fungal inoculation through trauma with a
thorn or splinter but zoonotic cases do occur from a bite or a scratch of cats, dogs, rodents,
parrots, horses, or armadillos.1,2

The fungus is predominantly found on decaying vegetation, soil, thorns, animal claws, and
sphagnum moss. Consequently, patients with a higher risk of Sporotrichosis are gardeners,
florists, veterinarians, and farmers due to higher exposure to plants, soil, and animals.3
Sporotrichosis first manifests with symptoms approximately 3 weeks after onset of infection.
Classic disease is characterized by initial symptoms of small, painless erythematous papules at
the site of inoculation, commonly on the arm or hand.1
The organism will then spread through the lymphatic system, forming papules and nodules along
the lymphatic tracts. The lesions will then undergo necrosis, forming ulcerations, crusting, or
drainage.
3

Disseminated cutaneous and extracutaneous types of Sporotrichosis are rare and usually manifest
in immunocompromised individuals.2,3,4 These result from hematogenous spread of the organism
throughout the body, and may eventuate in stiffness and pain in the large joints, brain abscesses,
meningitis, or pulmonary disease.2
The gold standard for diagnosis of Sporotrichosis is culture. Sporotrix schenckii has a dimorphic
quality that exists as a mold at 25C and a yeast at 37C.3,4 A positive culture on Sabouraud
dextrose agar will grow best at 25C and will demonstrate white, smooth, or verrucous colonies
with aerial mycelium that turn brown to black.3
Microscopy of the fungus is characterized by thin branching hyphae with conidia.3,4 A biopsy can
be done, but may not be diagnostic due to the small number of organisms present.3 A biopsy of
an initial lesion will show a non-specific inflammatory dermal infiltrate with epidermal changes,
such as hyperplasia and hyperkeratosis. A biopsy at 28 days after infection often demonstrates
granulomas comprised of lymphocytes and lesser amounts of neutrophils and fungal organisms.1
The drug of choice for cutaneous and lymphocutaneous Sporotrichosis is itraconazole.5,6
Alternatively, fluconazole can be used if itraconazole is untolerable, but it is less effective.5
Potassium iodide was the drug of choice before the advent of azoles and is still considered a
viable treatment option.6
In rare cases, such as pregnancy, daily treatments with local hyperthermia using a device that
generates heat at 42-43C has proven efficacy.5
Sporotrichosis is a treatable cutaneous infection that can be diagnosed early given clinical
suspicion and proper history. Clinicians should consider this infection in their differential when
patients present with papules on the hands or arms with a history of outdoor exposure, especially
gardening.
Megha D. Patel, is a student at the Commonwealth Medical College, Scranton, Pennsylvania.
Stephen Schleicher, MD, is an associate professor of Medicine at the Commonwealth Medical
College and an Adjunct Assistant Professor of Dermatology at the University of Pennsylvania
Medical College. He practices dermatology in Hazleton, Pennsylvania.

References
1. Fernandex-Flores A, Saeb-Lima M, Arenas-Guzman R.Am J
Dermatopathol. 2014; 36(7): 531-553.
2. Morris-Jones R. Sporotrichosis. Clinical and Experimental Dermatology. 2002;
27:427-431.
3. Trent J, Kirsner R. Adv Skin Wound Care. 2003; 16:122-129.
4. Mahajan VK, Sharma NL, Shanker V, Gupta P, Mardi K. Indian J Dermatol
Venerol Leprol. 2010; doi: 10.4103/0378-6323.62974.
5. Kauffman CA, Hajjeh R, Chapman SW. Clinical Infectious Disease. 2000; 30:
684-687.

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