The difficult management of disseminated Sporothrix brasiliensis in a patient with advanced AIDS
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CASE REPORT
Open Access
The difficult management of disseminated Sporothrix brasiliensis in a patient with advanced AIDS Ariane Gomes Paixão*†, Maria Clara Gutierrez Galhardo†, Rodrigo Almeida-Paes, Estevão Portela Nunes†, Marcelo Luiz Carvalho Gonçalves†, Gisele Larias Chequer† and Cristiane da Cruz Lamas*†
Abstract Sporotrichosis is an infection caused by a dimorphic fungus of the Sporothrix schenckii complex. Host immunity is an important factor in the clinical manifestations of the disease. Deeply immunocompromised individuals, especially those infected with the Human Immunodeficiency Virus (HIV) and T CD4 counts < 350 cells/ul lymphocytes, may present with the systemic form of sporotrichosis. This report describes a case of disseminated sporotrichosis caused by S. brasiliensis in a patient with advanced AIDS. The skin, lungs, bones and central nervous system were affected. Medical treatment involved the administration of amphotericin B, terbinafine, itraconazole and posaconazole. Posaconazole was associated with the best clinical response and clearing of the fungus from the central nervous system. Keywords: Sporotrichosis, AIDS, Amphotericin B, Posaconazole
Introduction Sporotrichosis may be an acute or chronic infection caused by a dimorphic fungus of the Sporothrix schenckii complex [1] generally located in cutaneous and sub-cutaneous tissue, often associated with lymphatic involvement. The fungus can disseminate to bones, lungs and central nervous system, especially in immunosuppressed patients [2-6]. Recent publications have drawn attention to the possibility of dissemination related to fungal virulence factors, as is the case for S. brasiliensis [7]. The disease usually manifests as isolated cases or outbreaks related to specific occupational exposure; however, recently, it has reached epidemic proportions in some parts of Latin America, India [8] and Northeastern China [9]. The clinical, demographic and epidemiologic features vary within regions. The disease affects predominantly tropical and subtropical regions, being the most prevalent subcutaneous mycosis in South America. In Brazil, it is the most common cutaneous mycosis, and, in the Rio de Janeiro metropolitan area, it has been * Correspondence: [email protected]; [email protected] † Equal contributors Fundação Oswaldo Cruz - Fiocruz, Universidade Grande Rio, Rio de Janeiro, RJ, Brazil
considered an epidemic zoonosis since the 1990s [2]. In this area, sporotrichosis occurs mostly via transmission from infected cats to humans, and genotypic analysis has shown that samples isolated from the Rio de Janeiro epidemic have a high genetic similarity. This finding is suggestive of a common niche, as S. brasiliensis is the species most frequently found in the city and in its surroundings [2,7]. Currently, this species is considered the most virulent of the Sporothrix schenckii complex [10]. On the other hand, the immune system of the host is an important factor that contributes to the different forms of the disease [11-14]. HIV co-infection
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