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病例漫谈12:播散性皮肤孢子丝菌病 [复制链接]


Disseminated cutaneous sporotrichosis

         A 53-year-old man with hepatitis C presented with joint aches and a subcutaneous nodule on the chest. 8 weeks after incision and drainage, he developed several nodules on the head, trunk, legs, and arms.


        On admission, physical examination showed more than 80 rubbery cutaneous and subcutaneous nodules of 1–10 cm in diameter. Nodules were polymorphic, ranging from subtly erythematous to violaceous, suppurative, and centrally ulcerated (figure, A). On day 7 of admission, subcutaneous nodules emerged on the forearm in a linear pattern. Cutaneous histopathological abnormalities showed a mixed granulomatous and pyogenic infiltrate with isolated round yeast cells. One organism was flanked by a spiked crystallised border and concentric layers of neutrophils, histiocytes, and plasma cells characteristic of an asteroid body (figure, B). Skin culture showed dark colonies with conidia in rosettes at right angles with hyphae, thus confirming sporotrichosis.

       入院时,体格检查显示80多块类橡胶皮肤以及直径为1~10 cm的皮下结节。结节表现为多种形态,从淡红斑到紫色,化脓皮疹,甚至中央溃疡(图A)。在入院的第7天,前臂出现呈线性排列的皮下结节。皮肤组织病理显示为混合型肉芽肿以及伴随有孤立的圆形酵母细胞化脓性浸润。一个细胞的边缘为尖刺结晶结构,同心绕以中性粒细胞,组织细胞和浆细胞浸润的典形星状体结构。皮肤培养为暗色菌落生长,镜下见直角分枝菌丝长有梅花状排列的分生孢子。因此,确诊为孢子丝菌病。

      The patient had a social history of exposure to blackberry bush thorns in relation to alcohol use. MRI showed lytic lesions with development in the ankle and elbow that were compatible with osteomyelitis as confirmed by bone biopsy. Treatment started with itraconazole 200 mg twice daily, resulting in cessation of nodule formation. Nodules diminished in size by week 4 of treatment, mostly resolving with post inflammatory hyperpigmentation within 3 months. Joint aches improved within 2 months. At 1 year follow up, the patient had maintained resolution of skin lesions in the absence of new lesions, and will likely continue lifelong suppressive treatment with itraconazole.

       患者曾经受到黑莓刺的刺伤,并用酒精擦洗过。MRI显示脚踝和肘部有发展性的溶骨性病变,这符合骨活检确诊的骨髓炎。口服伊曲康唑200 mg(每天两次)开始治疗后无新生结节。治疗4周后,结节减小。通常3个月内,炎症后色素沉着消退。随访一年左右,患者皮损消退,无新发皮损,可能通过服用伊曲康唑继续终身抑制治疗。

       Sporothrix schenkii has a paucity of organisms on microscopy and might not be immediately diagnosed, particularly with no recognisable sporotrichoid pattern. Although disseminated cutaneous sporotrichosis is rare, most often occurring in immunocompromised patients, it can afflict immunocompetent patients and should be in the differential diagnosis of disseminated nodular lesions. Although skin culture is the gold standard for diagnosis, cutaneous histopathology can be valuable to accelerate diagnosis and prompt treatment.



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