Medical Mycology,2015,53,3–14 doi: 10.1093/mmy/myu062 Advance Access Publication Date: 19 December 2014 Review Article Review Article Global epidemiology of sporotrichosis 1, 2 Arunaloke Chakrabarti ∗,AlexandroBonifaz , Maria Clara Gutierrez-Galhardo3,TakashiMochizuki4 and Shanshan Li5 1Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Downloaded from Chandigarh, India, 2Department of Mycology & Service of Dermatology, General Hospital of Mexico, Mexico´ city, Mexico, 3Laboratorio´ de Dermatologia Infecciosa, Instituto de Pesquisa Cl´ınica Evandro Chagas, Fundac¸aOswaldoCruz,RiodeJaneiro,Brazil,˜ 4Department of Dermatology, Kanazawa Medical University, Uchinada, Kahoku, Ishikawa, Japan and 5Department of Dermatology and Venereology, First Hospital of Jilin University, Changchun, Jilin, China http://mmy.oxfordjournals.org/ *To whom correspondence should be addressed. Arunaloke Chakrabarti, Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India. Tel: 91 172 2755155; + Fax: 91 172 2744401; E-mail: [email protected] + Received 23 April 2014; Revised 11 July 2014; Accepted 18 August 2014 Abstract Sporotrichosis is an endemic mycosis caused by the dimorphic fungus Sporothrix at University of Manchester on January 19, 2015 schenckii sensu lato. It has gained importance in recent years due to its worldwide preva- lence, recognition of multiple cryptic species within the originally described species, and its distinctive ecology, distribution, and epidemiology across the globe. In this review, we describe the current knowledge of the taxonomy, ecology, prevalence, molecular epi- demiology, and outbreaks due to S. schenckii sensu lato. Despite its omnipresence in the environment, this fungus has remarkably diverse modes of infection and distribution patterns across the world. We have delved into the nuances of how sporotrichosis is intimately linked to different forms of human activities, habitats, lifestyles, and environ- mental and zoonotic interactions. The purpose of this review is to stimulate discussion about the peculiarities of this unique fungal pathogen and increase the awareness of clin- icians and microbiologists, especially in regions of high endemicity, to its emergence and evolving presentations and to kindle further research into understanding the unorthodox mechanisms by which this fungus afflicts different human populations. Key words: sporotrichosis, epidemiology, taxonomy, Sporothrix,zoonoses. Introduction infections involving the lymphatics, fascia, muscles, carti- lage, and bones. Although sporotrichosis causes consider- Sporotrichosis, an endemic disease caused by the dimor- able morbidity, it is only rarely associated with mortality. phic fungus Sporothrix schenckii sensu lato, is prevalent The etiological agents thrive in soil and decaying vegeta- worldwide in tropical and subtropical areas. Patients with tion such as dead wood, sphagnum moss, cornstalks, and this infection usually present with “implantation mycoses” hay. Humans usually acquire the infection through trau- that is caused by transcutaneous trauma through which the matic inoculation of the fungus during outdoor activities fungal conidia enter the host. Such infections may progress such as farming, gardening, animal husbandry, and similar into chronic cutaneous, subcutaneous, and/or even deeper C ⃝ The Author 2014. Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology. 3 All rights reserved. For permissions, please e-mail: [email protected] 4 Medical Mycology, 2015, Vol. 53, No. 1 occupations [1]. Among dimorphic fungal diseases, enigma. Smith, a mycologist, identified the fungus isolated sporotrichosis stands out for the following distinctive char- by Schenck as “Sporotricha”[2], and Howard confirmed its acteristics: despite being an endemic fungal disease, its en- dimorphic nature in 1961 [3]. In 1962 Carmichael distin- demicity is widespread; the etiological agents are widely dis- guished it from the basidiomycetous fungal group and clas- tributed in the environment; it is the only infection caused sified it under Sporotrichum by identifying the septum and by a dimorphic agent in which the pulmonary system is not woronin body characteristic of this group [4]. The fungus the major route of infection; its ecology, epidemiology, and was eventually named Sporothrix schenckii, and Guarro clinical features vary across different geographical regions; et al. classified the fungus under division Ascomycota, class and it is the only dimorphic fungal disease that seems to Pyrenomycetes,orderOphistomatales,familyOphistom- have substantial zoonotic transmission. ataceae [5]. While no sexual stage has yet been identified, Sporotrichosis has emerged as a major fungal infection molecular analysis of the 18s region of ribosomal DNA sug- over the last two decades due to changes emerging in epi- gests that Ophiostoma stenoceras may represent its sexual demiology, distribution, taxonomic evolution, and multiple form [6]. However, further examination of phenotypic and outbreaks. Here, we present a treatise on the present status genotypic characteristics refuted such a possibility, though Downloaded from and global epidemiology of sporotrichosis. a sexual stage within the genus Ophiostoma was not ruled out [7]. In 1979 Kwon-Chung first reported the heterogeneity Etiological agent and taxonomy of Sporothrix schenckii sensu lato strains. She noted that Ever since its isolation by Benjamin Schenck in 1898, the the isolates from lymphocutaneous and fixed cutaneous http://mmy.oxfordjournals.org/ taxonomic position of Sporothrix species has remained an (Fig. 1a, b) forms of disease differed in their growth at at University of Manchester on January 19, 2015 Figure 1. Different clinical presentations of sporotrichosis. (a) Lymphocutaneous sporotrichosis, (b) fixed cutaneous sporotrichosis, (c) ulcerating lesions in a patient who slept with her cat, (d) oro-labial sporotrichosis in a patient who kissed her cat. Chakrabarti et al. 5 Downloaded from http://mmy.oxfordjournals.org/ Figure 2. Global distribution of Sporothrix brasiliensis, S. globosa, S. schenckii clade IIa, and S. schenckii clade IIb. (Adapted from Zhou et al., 2013) 37◦C and virulence in animal models [8]. However, this China described two clades for S. globosa [18]. Simi- heterogeneity was better established by subsequent mito- larly, S. schenckii sensu stricto has wide geographical dis- chondrial and ribosomal DNA analyses. Restriction frag- tribution and has been isolated from the Americas (Ar- ment length polymorphism (RFLP) of different gene tar- gentina, Bolivia, Brazil, Columbia, Guatemala, Mexico, gets [9,10], random amplified polymorphic DNA (RAPD) Peru, the United States, Venezuela), Europe (France, Italy, at University of Manchester on January 19, 2015 analysis, DNA sequencing of internal transcribed spacer the United Kingdom), Africa (South Africa), and Asia (ITS) regions of ribosomal DNA [11,12], amplified frag- (Japan). Sporothrix schenckii sensu stricto is also classi- ment length polymorphism (AFLP) [13], polymerase chain fied into two clades, wherein clade IIa represents a ho- reaction (PCR) of DNA topoisomerase II gene [14], and mogenous clade that includes isolates from South America M13 PCR fingerprinting of S. schenckii isolates corrobo- (Argentina, Bolivia, Columbia, Peru) and North American rated the heterogeneity noted earlier [15]. Based on phy- isolates. Clade IIb isolates, on the other hand, are geograph- logeny of DNA and rDNA types, isolates were clustered ically restricted to South America, particularly Peru and Ar- into the following two groups: group A comprising most gentina. Isolates from Asia and Africa have not been eval- of the isolates from the United States and Latin Amer- uated [19]. Sporothrix brasiliensis is an emerging species ica and group B comprising Asian isolates [9]. However, restricted to Brazil and is highly pathogenic to humans and Marimon et al. [16,17]describedsixspeciesbasedon animals [20]. Sporothrix luriei has been described from sequence analysis of three protein-encoding loci (chitin three human infections in Africa [21], Italy [22], and In- synthase, ß-tubulin, and calmodulin) and phenotypic char- dia [23] and a canine infection in Brazil [24]. Sporothrix acteristics (morphology of conidia; growth at 30◦C, 35◦C, mexicana has been recovered from the environment in Aus- and 37◦C; and assimilation of sucrose, raffinose, and tralia, Mexico, and Portugal and has been reported to cause ribitol). Three were clinically relevant cryptic species un- occasional human infections [20]. Recently, a study of 124 der S. schenckii (S. brasiliensis, S. globosa, S. luriei) and isolates identified as Sporothrix (n 99) and Ophiostoma = two environmental fungi (S. mexicana and S. albicans), (n 25) species [25] elucidated the global distribution pat- = with the original S. schenckii now known as S. schenckii tern of clinically important Sporothrix species (Fig. 2). sensu stricto. Sporothrix species differ in their geograph- ical distribution. Sporothrix globosa is distributed world- wide and has been recovered from clinical specimens in Ecology Europe (the United Kingdom, Spain, Italy), the United Though S. schenckii is omnipresent in the environment in States, South America (Mexico, Guatemala, Columbia), soil, dead wood, mosses, hay, and cornstalks, its ecology and Asia (India, China, Japan). A recent study