216Indian Journal of Medical Microbiology, (2006) 24 (3):216-9 Brief Communication
EMERGENCE OF SPOROTRICHOSIS IN MANIPUR
*KR Devi, MU Devi, TN Singh, KS Devi, SS Sharma, LR Singh, HL Singh, NB Singh Abstract
A retrospective analysis of all cases of sporotrichosis was conducted to examine the pattern and frequency of sporotrichosis cases in Manipur over a period of six year from July 1999 to June 2005. Seventy-three (73) cases of sporotrichosis were detected of which 30 were confirmed by culture and 43 were diagnosed by aspiration cytology only. Most of the patients belonged to the age group of 21 to 40 years (n=23; 31.5%). There were 39 females (53.4%) and 34 males (46.5%). Commonest site of infection was upper limbs (n=39; 53.4%) followed by lower limbs (n=17; 23.2%). Commonest type of infection was lymphocutaneous form (n=46; 63.1%) followed by fixed cutaneous form (n=27; 36.9%). Among these 73 cases, 2 male patients (2.7%) were found to be HIV positive. In our experience, collection of material by aspiration of pus or infected tissue was found to be a better method compared to scraping or exudate. This study revealed Manipur as a new endemic area for sporotrichosis.
Key words: Manipur, sporotrichosis, Sporothrix schenckii
Sporotrichosis is a subacute or chronic infection caused subcutaneous tissues most frequently as a consequence of a by Sporothrix schenckii, a dimorphic fungus found as a traumatic implantation of Sporothrix schenckii onto the skin.4 saprobe from dead or senescent vegetation, such as thorns, Clinically, it may manifest as lymphocutaneous, fixed hay, straw, sphagnum peat moss, wood and also in soil. For cutaneous, mucocutaneous, extracutaneous and disseminated this reason, sporotrichosis is associated with outdoor activities forms and very rarely as pulmonary. The most common form by farmers, florists, leisure gardeners, nursery workers, land of extracutaneous sporotrichosis is osteoarthritis. scapers and green house workers. Disseminated sporotrichosis is rare but with the event of HIV epidemic, the frequency of disseminated sporotrichosis has Sporotrichosis was first described by Schenck in 1898 to increased. This retrospective study was designed to study the be a fungal aetiology at the Johns Hopkins Hospital in frequency of sporotrichosis in Manipur and to find out whether 1 Baltimore. Sporotrichosis is also known as Schenk’s disease Manipur has become a new endemic area for sporotrichosis. or Rose gardener’s disease. Sporotrichosis is worldwide in distribution but more common among people living in Materials and Methods temperate, tropical and sub-tropical regions with high humidity. It occurs in North and South America (Mexico, Brazil, This retrospective study was carried out in the Department Uruguay), South Africa, Australia, Japan but it is rare in of Microbiology and Pathology, Jawaharlal Nehru (JN) Europe. In India, sporotrichosis is known to be endemic in Hospital and Mycology section, Department of Microbiology, the sub-Himalayan regions ranging from Himachal Pradesh in Regional Institute of Medical Sciences (RIMS), Manipur from North-West to Assam and West Bengal in the East. It has also July 1999 to June 2005. These two hospitals were the only been reported sporadically in other states including Punjab, two referral centres in Manipur. All cases diagnosed to be Delhi, Uttar Pradesh, Bihar, Tripura, Meghalaya andhra sporotrichosis were included in the study. Clinical details such Pradesh, Chennai, Karnataka and Kerala.2 Two cases of as age, sex, occupation and other exposure risk, site and sporotrichosis were reported for the first time in Manipur by duration of lesions, history of trauma, mode of spread, Ranjana et al.3 presence of ulceration, personal history and HIV status and any other pertinent data were analysed. Specimens from the The infection is usually limited to the cutaneous and patients had been collected by aspirating the pus, infected tissue or by scraping.
*Corresponding author (email:
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Fungal culture was done using two sets of Sabouraud stained smears. Culture tubes at 25°C showed white mycelial dextrose agar (SDA) with antibiotics (chloramphenicol, 0.05 colonies within the first week. Lactophenol cotton blue (LCB) mg/mL, gentamicin, 0.02 mg/mL and cycloheximide, 0.5 mg/ml) mount (Fig. 3) showed thin, hyaline, delicate mycelia with and two sets of brain heart infusion agar (BHIA) with conidia arising directly from the mycelium and from the antibiotics and cycloheximide. One set of SDA and BHIA was conidiophores giving it a flower like pattern. incubated at 25°C and the other set at 37°C. For the first few cases, animal pathogenecity testing using Results swiss albino mice and yeast conversion testing by repeated subculture on BHIA with blood were conducted. During the study period, 73 cases of human sporotrichosis were recorded. The district wise distribution of sporotrichosis In our experience, collection of material by aspiration of cases in Manipur is shown in figure 1. pus or infected tissue was found to be a better method compared to scraping or exudate as it gives a better PAS stain (Fig. 2) revealed single or budding yeast cells uncontaminated sample which also can be subjected to µ of 3-4 m, round, oval or elongated in shape without a capsule. cytology. Out of 73 cases, 30 cases were culture proven and The yeast cells were not seen well in Gram and Leishman 43 cases were diagnosed by aspiration cytology only. Among these, two male patients (2.7 %) were found to be HIV positive. The characteristic features of these patients are detailed in the table. Most of the patients belonged to the age group of 21 40 years (n = 23; 31.5%); the youngest being a 13 year-old female and the oldest was 83 year-old male. There were 39 females (53.4%) and 34 males (46.5%).The predominant clinical presentation was the lymphocutaneous form (n=46; 63.1%) as shown in figure 4 followed by fixed cutaneous form (n = 27; 36.9 %).
No patient was found to have extracutaneous involvement. Most patients were gardeners, farmers and housewives by occupation. A history of local trauma preceding the development of sporotrichosis could be elucidated from 29
Figure 1: Map showing districtwise distribution of Sporotrichosis cases in Manipur
Figure 3: (A) Culture tube showing the growth of Sporothrix schenckii (multiple white-creamy coarsely tufted colonies) on SDA medium. (B) Photomicrograph of LCB mount showing fungal filaments of Sporothrix schenckii.
Figure 4: (A) Showing multiple, nodular, ulcerative lesions over the Figure 2: Photomicrograph of PAS stain smear showing yeast cell right forearm along the course of lymphatics. (B) showing nodulo-cystic (tissue stage of Sporothrix schenckii) lesions over the right medial aspect of arm and forearm
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Table: Clinical manifestations and sites of involvement in 73 greenhouse workers. Infection takes place when the organism patients with sporotrichosis in Manipur is inoculated directly into the skin - usually on the hand, arm or foot and rarely via inhalation of conidia. The disease can Clinical feature No. (%) of patients be transmitted by bites of insects and animals such as cat, Age (years) dog, armadillo, boar, camel, cattle, chimpanzee, dolphin, 0 - 10 00 donkey, fowl, fox, horse, mule and rat.6 A report from South 11-12 07 (9.5) America relates an infection attributed by the patient to a knife 21-40 23 (31.5) wound sustained while cleaning fish.7 Sporothrix schenckii 41-60 19 (26.1) has been encountered from unexpected substrates such as 61-80 21 (28.7) commercial potting soil,8 as food contaminant of meat 80+ 03 (4.1) sausages,9 culinary mushrooms10 and found growing in a Sex container of intravenous fluid at a medical centre.11 Male 34 (46.5) Female 39 (53.4) It has also been recovered from samples taken for routine HIV status (male) 2 (2.7) microbiological monitoring of various surfaces within an Site of involvement indoor swimming pool complex. Three (4.1%) of our cases Upper extremity 39 (53.4) gave the history of injury sustained by handling and smashing Lower extremity 17 (23.2) of traditionally fermented fish locally called ‘Ngari’. ‘Ngari’ is Face 12 (16.4) composed of traditionally fermented dry fishes of Puntius Buttock 02 (2.7) sophore, Puntius species and Colisa fasiatus. This eating Abdomen 01 (1.3) habits of ‘Ngari’ by the people of Manipur may be an Ear 01 (1.3) alternative source of transmission of the disease in this region. Breast 01 (1.3) Similar case of injury by fish bone has been reported from India 12 Class of lesion by Thomas and co-workers. Another interesting case was Lymphocutaneous 46 (63.1) that of one who gave the history of injury caused by ‘steel Fixed cutaneous 27 (36.9) wool’ while cleaning utensils. H/O trauma 29 (39.7) Disseminated sporotrichosis is rare in the immunocompetent host but may present with widespread patients (39.7%). Three (4.1%) cases gave a history of injury cutaneous, lung, bone, joint and central nervous system with fishbone of locally fermented dry fishes called ‘Ngari’ and involvement in immunocompromised patients. Although one (1.3%) with ‘steel wool’. Most of the lesions were localised sporotrichosis has been an uncommon opportunistic infection on the limbs as follows: upper limbs (n = 39; 53. 4%) and lower in AIDS patients, we came across two male patients (2.7%) limbs (n = 17; 23.2%). There were 12(16.4%) cases located on who were HIV positive. Hence, there is an apprehension that the face, two (2.7%) cases on the buttock and one (1.3%) each the co-infection of HIV and sporotrichosis may increase in case located on the abdomen, ear and breast (Table). Manipur, since Manipur is one of the highly prevalent state of HIV infection in India. Many predisposing conditions of Discussion the host have been pointed out: alcoholism, diabetes mellitus, haematologic malignancies, chronic obstructive pulmonary Sporothrix schenckii occurs worldwide growing disease, long term treatment with corticosteroids, saprophytically as a mould in association with dead or chemotherapy drugs, transplant recipients and patients with decaying plant material. It is still snot clear which climatic AIDS.13 condition exactly helps the growth of Sporothrix schenckii. In a study done in South Africa, it was found that the fungus Sporotrichosis may be mistaken for numerous diseases grew well at 26°C to 27°C and a relative humidity of 92 to 100%. including pyoderma gangrenosum, rosaceae, sarcoma, However, in Mexico the greatest frequency of infection leishmaniasis, tularemia, anthrax, gummatous syphilis, cutaneous coincided with the dry and cooler parts of the year. In a study and lymphatic tuberculosis, leprosy, staphylococcal conducted in Himachal Pradesh (North India), a temperature lymphangitis, erythema nodosum, nocardiosis, yaws, between 15°C and 27°C with high humidity helps its growth.5 histoplasmosis, paracoccidioidomycosis, chromoblastomycosis, In Manipur, the meteorological data shows average sarcoidosis, etc. temperature of 21°C, relative humidity of 75% and rainfall of 1500 mm per year which is favourable to the growth of Lymphocutaneous presentation is the commonest clinical Sporothrix schenckii. form of the disease, where a primary lesion develops at the site of inoculation in immunocompetent hosts with its frequencies Anyone can get the disease but outbreaks have occurred ranging from 46 to 92%, followed by the fixed cutaneous type in nursery workers since it is an occupational disease of (0 to 54%).2 In this study too lymphocutaneous was the farmers, leisure gardeners, florists, land scapers and predominant clinical type (63.1%) followed by fixed cutaneous
www.ijmm.org July 2006 Devi et al – Emergence of Sporotrichosis in Manipur 219 type (36.9%). Among the possible factors determining clinical a fungus possibly related to the sporotricha. Johns Hopk Hosp manifestations of the disease are the size and depth of Rep 1898;9:286-91. implantation of the fungal inoculum, thermotolerence of the 2. Randhawa HS, Chand R, Mussa AY, Khan ZU, Kowshi KT. infecting Sporothrix schenckii strain and immune status of Sporotrichosis in India: First case in a Delhi resident and an 2 the host. There appears to be no relationship of gender update. Indian J Med Microbiol 2003;21:12-6. preponderence to sporotrichosis. Although some reports have suggested that the patients are more likely to be men, others 3. Ranjana Kh, Chakrabarti A, Kulachandra M, Lokendra K, have shown nearly equal ratios and a few have noted a Devendra H. Sporotrichosis in Manipur: Report of two cases. preponderance of female patients.14 In this regard, our study Indian J Dermatol Venereol Leprol 2001;67:86-8. reveals a marginal predominance in females. 4. Kwong-Chung KJ, Bennet JE. Sporotrichosis, In: Kwong-chung Therapy for sporotrichosis in immunocompetent hosts is KJ, Bennet JE (editor) Medical Mycology, Lea & Febiger: Philadelphia; 1992. p.707-29. well established. Itraconazole is the drug of choice for cutaneous, lymphocutaneous and osteoarticular 5. Ghosh A, Chakrabarti A, Sharma VK, Singh K, Singh A. sporotrichosis.15 The recommended dosage of itraconazole is Sporotrichosis in Himachal Pradesh (North India). Trans Roy 100-200 mg daily for 3-6 months. While amphotericin B is Soc Trop Med Hyg 1999;93:41-5. required for severe pulmonary infection and disseminated 6. Kaplan W, Broderson JR, Pacific JN. Spontaneous systemic sporotrichosis. On the other hand, therapy for disseminated sporotrichosis in nine-banded armadillos (Daspus sporotrichosis in HIV infected patients remains unclear and novemcinctus). Sabouraudia 1982;20:289-94. the response to therapy is variable. Al-Tawfiq et al13 revised the treatment of sporotrichosis in AIDS patients pointing 7. Beer-Romero P, Rodriguez-Ochoa G, Angulo R, Cabrera S, amphotericin B as the drug of choice for initial use and Yarzabal L. Sporotrichosis in the Orinoco river basin of suppressive itraconazol therapy for life long to control Venezuela and Colombia. Mycopathologia 1989;105:19-23. infection. This recommendation is in accordance with practice 8. Kenyon EM, Russell LH, Mc Murray DN. Isolation of guidelines for the management of patients with sporotrichosis Sporothrix schenckii from potting soil. Mycopathologia and AIDS for the mycoses study group, Infectious Diseases 1984;87:128. Society of America.15 9. Ahearn DG, Kaplan W. Occurrence of Sporotrichum schenckii Since an opening in the skin is necessary for the on a cold-stored meat product. Am J Epidemiol 1969;80:116 sporotrichosis fungus to enter the body, the best way to 24. prevent the disease is to avoid accidental scrapes and cuts 10. Kazanas N, Jackson G. Sporothrix schenckii isolated from edible on the hands and arms by wearing gloves and long sleeves black fungus mushrooms. J Food Protect 1983;46:714-6. while gardening or handling other materials that may cause minor skin breaks. Washing hands and arms well after working 11. Matlow AG, Goldman CB, Mucklow MG, Kane J. with roses, barberry, sphagnum moss and other potential Contamination of intravenous fluid with Sporothrix schenckii. sources of the fungus may also provide some protection. J infect 1985;10:169-71. In conclusion, this study reveals Manipur as an area where 12. Thomas J, Nair PR, Poothiode U, Bai G. Sporotrichosis. J sporotrichosis is endemic. However, further studies to evaluate Indian Med Assoc 1993;91:210. the frequency of sporotrichosis in Manipur are needed. 13. Al-Tawfiq JA, Wools KK. Disseminated sporotrichosis and Acknowlegements Sporothrix schenckii fungemia as the initial presentation of human immunodeficiency virus infection. Clin Infect Dis The authors are grateful to Dr. Arunaloke Chakrabarti, 1998:26:1403-6. Department of Microbiology, PGIMER, Chandigarh for confirming the first few cases (establishment of dimorphism and animal 14. Conti-Diaz IA. Epidemiology of sporotrichosis in Latin America. pathogenicity testing). Mycopathologia 1989;108:113-6. References 15. Kauffman CA, Hajjeh R. Chapman SW. Practice guidelines for the management of patients with sporotrichosis. Clin Infect Dis 1. Schenck BR. On refractory subcutaneous abscesses caused by 2000;30:684-7.
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