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Sporotrichosis
SPOROTI%ICHOSIS I:{,EPORT OF A CASE
DAVID H. FOGEL, M.D., A~CD DAVID W. MAaTIN, M.D. DUR~IA~, N. C. of the rarity of sporotriehosis in tile South and the few B ECAUSE cases of the disease reported in children, this case is reported in in detail. CASE t~EPORT M. H. (No. A27054)~ a 7-year-old white girl, was admitted to the Duke HospitM on Sept. 12, 1939, complaining of her left thumb which had been sore for two weeks. The family history was irrelevant, except that the mother received anti-syphilitic therapy. Past History.--Negative, except for report of occasional convulsions since the age of 3 years. Repeated Wassermalm tests taken in the last year were reported as negative. Present Illness.--In the latter part of August, 1939j three weeks before admission~ she noticed a ~ ' p i m p l e " on the left thumb, which her aunt pricked. (One week before this~ she had played with a dead rat.) One week later the left thumb swelled and became red and tender, draining small amounts of thick, yellow-green material. On Sept. 1~ 1939, five days after onset~ she noticed " k n o t s " appearing up the forearm and arm. These persisted to the time of admission. There had been no fever and no systemic symptoms. Physical Examination.--The temperature was 3"~.4~ C. (99.3 ~ F.), pulse 100, respiration 20. The patient did not appear ill. There were palpable, nontender, anterior eervieM nodes, and below the right temporomandibular joint there was a nodule of 2 cm., which was nontender an(] freely movable. The tonsils were large and cryptic. On the distal phalanx of the left thumb there was u shallow ulcer of 2 era., covered with a yellow-green crust (F~g. 1). The surrounding tissue was red, tender, and swollen. Extending up the flexor surfaces of the left forearm and upper arm, there were successive nontender, freely movable swellings abou't 2 era. in diameter (F~g. 2). These appeared to be distributed along the lymphatic channels. Accessory Clinical, Data.--The hemoglobin was 14.6 Gm. (94 per cent Sahli) ; red blood cell count, 4,980,000; white blood cell count, 10,450, with 47 per cent polymorphonuclear cells, 13 per cent eosinophiles~ 1 per cent basophiles, and 37 per cent s m a l l lymphocytes. Urine and stool examinations and repeated Wassermann tests were negative. Dark-field preparation of material from the primary lesion revealed no spirochetes. There was no agglutination of Pasteurella tu~arensis antigen with the p a t i e n t ' s serum. Biopsies of the w i m a r y lesion and nodes in the left forearm were made for section and culture. Microscopic sections of the primary lesion on the thumb showed infiltration of the dermis with polymorphonuclear leucocytes and round cells. Microscopic sections of the forearm node showed ~ dense cellular infiltration, the cells being both chronic and acute initmnma~ory in type. No bacteria or fungi could be identified in stained sections. l~rom the Department of Pediatrics of Duke University School of Medicine and Duke Hospital. 193
Fig.
1.--Photograph
showing
primary
ulcer
l~ig.
2.--:Photograph
showing
subcutaneous
on
the
nodules
dorsum
extending
of the
up
the
thumb.
arm.
FOGEL AND !VIARTIN:
SPOROTRICHOSIS
]95
A p o r t i o n of t h e node t a k e n at biopsy was g r o u n d in a m o r t a r with saline, a n d t h r e e s l a n t s of Sabourau,d's m e d i u m were inoculated.'* A f t e r six d a y s a small white growth, which l a t e r t u r n e d black, a p p e a r e d on one o f the slants. T h i s growth w a s identified as Sporotri, ch~rv schen.c]~4 (F~g. 3 ) . T h e r e w a s no g r o w t h on t h e other two slants.
Fig. 3.--A, P h o t o g r a p h of culture t a k e n from s u b c u t a n e o u s nodule; B, Photomicrog r a p h of culture shown in A. Cou~se.--On Sept. 17, 1939, the s i x t h h o s p i t a l day, t h e p a t i e n t was g i v e n satu r a t e d (100 per cent) solution of p o t a s s i u m iodide t h r e e t i m e s daily, s t a r t i n g w i t h a dose of 8 drops a n d i n c r e a s i n g each succeeding dose b y ] drop. Saline compresses were applied to the t h u m b . H e r condition was u n i m p r o v e d f o r t h e n e x t eleven d a y s ; on S e p t e m b e r 28 and succeeding, t h e dose of p o t a s s i u m iodide was i n c r e a s e d b y *Courtesy of Dr. ]Nv. F. Conant and Dr. D. S. 1Y[artin.
196
THE
JOURNAL
OF
PEDIATRICS
5 drops, and on October 4, she was receiving 100 drops throe times daily, a dose which was continued. Three days after ~his dose was reached~ the nodules could be detected only by palpation. The nodules below the right ear had almost disappeared. Silo was discharged on Oct. 7, 1939, an,d instructed to take 100 drops of potassium iodide three times daily. On Oct. 23, 1939, alI of the nodules had disappeared~ and the lesion on the thumb was healed. DISCUSSION
Tularemia was considered as a possible diagnosis, but the afebrilc course, ]ack of systemic reaction, and negative agglutination against P. tularensis made it unlikely. Syphilis was eliminated because of negative dark-field preparations of the chancre and repeated negative Wassermann tests. Low-grade pyogenic infection would not respond so dramatically to iodides. It is of importance to note that diagnosis was not possible in this case by microscopic sections or direct examination of material taken from the primary lesion, but was made only by culture of the biopsy material, with inoculation of several slants.
DAVID H. FOGEL, M.D., A~CD DAVID W. MAaTIN, M.D. DUR~IA~, N. C. of the rarity of sporotriehosis in tile South and the few B ECAUSE cases of the disease reported in children, this case is reported in in detail. CASE t~EPORT M. H. (No. A27054)~ a 7-year-old white girl, was admitted to the Duke HospitM on Sept. 12, 1939, complaining of her left thumb which had been sore for two weeks. The family history was irrelevant, except that the mother received anti-syphilitic therapy. Past History.--Negative, except for report of occasional convulsions since the age of 3 years. Repeated Wassermalm tests taken in the last year were reported as negative. Present Illness.--In the latter part of August, 1939j three weeks before admission~ she noticed a ~ ' p i m p l e " on the left thumb, which her aunt pricked. (One week before this~ she had played with a dead rat.) One week later the left thumb swelled and became red and tender, draining small amounts of thick, yellow-green material. On Sept. 1~ 1939, five days after onset~ she noticed " k n o t s " appearing up the forearm and arm. These persisted to the time of admission. There had been no fever and no systemic symptoms. Physical Examination.--The temperature was 3"~.4~ C. (99.3 ~ F.), pulse 100, respiration 20. The patient did not appear ill. There were palpable, nontender, anterior eervieM nodes, and below the right temporomandibular joint there was a nodule of 2 cm., which was nontender an(] freely movable. The tonsils were large and cryptic. On the distal phalanx of the left thumb there was u shallow ulcer of 2 era., covered with a yellow-green crust (F~g. 1). The surrounding tissue was red, tender, and swollen. Extending up the flexor surfaces of the left forearm and upper arm, there were successive nontender, freely movable swellings abou't 2 era. in diameter (F~g. 2). These appeared to be distributed along the lymphatic channels. Accessory Clinical, Data.--The hemoglobin was 14.6 Gm. (94 per cent Sahli) ; red blood cell count, 4,980,000; white blood cell count, 10,450, with 47 per cent polymorphonuclear cells, 13 per cent eosinophiles~ 1 per cent basophiles, and 37 per cent s m a l l lymphocytes. Urine and stool examinations and repeated Wassermann tests were negative. Dark-field preparation of material from the primary lesion revealed no spirochetes. There was no agglutination of Pasteurella tu~arensis antigen with the p a t i e n t ' s serum. Biopsies of the w i m a r y lesion and nodes in the left forearm were made for section and culture. Microscopic sections of the primary lesion on the thumb showed infiltration of the dermis with polymorphonuclear leucocytes and round cells. Microscopic sections of the forearm node showed ~ dense cellular infiltration, the cells being both chronic and acute initmnma~ory in type. No bacteria or fungi could be identified in stained sections. l~rom the Department of Pediatrics of Duke University School of Medicine and Duke Hospital. 193
Fig.
1.--Photograph
showing
primary
ulcer
l~ig.
2.--:Photograph
showing
subcutaneous
on
the
nodules
dorsum
extending
of the
up
the
thumb.
arm.
FOGEL AND !VIARTIN:
SPOROTRICHOSIS
]95
A p o r t i o n of t h e node t a k e n at biopsy was g r o u n d in a m o r t a r with saline, a n d t h r e e s l a n t s of Sabourau,d's m e d i u m were inoculated.'* A f t e r six d a y s a small white growth, which l a t e r t u r n e d black, a p p e a r e d on one o f the slants. T h i s growth w a s identified as Sporotri, ch~rv schen.c]~4 (F~g. 3 ) . T h e r e w a s no g r o w t h on t h e other two slants.
Fig. 3.--A, P h o t o g r a p h of culture t a k e n from s u b c u t a n e o u s nodule; B, Photomicrog r a p h of culture shown in A. Cou~se.--On Sept. 17, 1939, the s i x t h h o s p i t a l day, t h e p a t i e n t was g i v e n satu r a t e d (100 per cent) solution of p o t a s s i u m iodide t h r e e t i m e s daily, s t a r t i n g w i t h a dose of 8 drops a n d i n c r e a s i n g each succeeding dose b y ] drop. Saline compresses were applied to the t h u m b . H e r condition was u n i m p r o v e d f o r t h e n e x t eleven d a y s ; on S e p t e m b e r 28 and succeeding, t h e dose of p o t a s s i u m iodide was i n c r e a s e d b y *Courtesy of Dr. ]Nv. F. Conant and Dr. D. S. 1Y[artin.
196
THE
JOURNAL
OF
PEDIATRICS
5 drops, and on October 4, she was receiving 100 drops throe times daily, a dose which was continued. Three days after ~his dose was reached~ the nodules could be detected only by palpation. The nodules below the right ear had almost disappeared. Silo was discharged on Oct. 7, 1939, an,d instructed to take 100 drops of potassium iodide three times daily. On Oct. 23, 1939, alI of the nodules had disappeared~ and the lesion on the thumb was healed. DISCUSSION
Tularemia was considered as a possible diagnosis, but the afebrilc course, ]ack of systemic reaction, and negative agglutination against P. tularensis made it unlikely. Syphilis was eliminated because of negative dark-field preparations of the chancre and repeated negative Wassermann tests. Low-grade pyogenic infection would not respond so dramatically to iodides. It is of importance to note that diagnosis was not possible in this case by microscopic sections or direct examination of material taken from the primary lesion, but was made only by culture of the biopsy material, with inoculation of several slants.