39 year old man with multiple ulcerating nodules on the leg and genitalia. Possible diagnoses were discussed.

The patient is a 39-year-old healthy oil palm worker who presented with 7-month history of reddish nodules on the left foot which subsequently spread to the left knee and then to the penis. It was not very itchy but painful recently. It appeared to spread proximally along the lymphatics. About 2 weeks ago, he noticed a painful swelling over the left groin. It was associated with night sweats, chill, loss of appetite and weight loss. He admitted there was an injury to his left foot from oil palm prick. There was no family history of tuberculosis.

Laboratory Data

Blood counts and biochemistry normal

HIV screen negative

Chest X Ray showed a soft oval shadow over the right lung apex suspicious of a granuloma

X Ray of left knee was normal

Section shows necrotic tissue admixed with sheets of neutrophils. No granuloma. Langerhan giant cells or caseation necrosis was seen. No fungal colonies

Lymphocutaneous/ Disseminated Sporotrichosis vs Tuberculosis

This is an unusual case of a patient with multiple painful nodules on the left leg, left knee and penis. It appeared that the spread is proximal and along lymphatic distribution. With a history of injury, sporotricosis is a very likely diagnosis. However, the histology of the lesion was inconclusive. There was no granuloma seen but this could be a sampling error.

Findings from the chest radiograph of a soft oval shadow over the right lung apex suspicious of a granuloma complicates the clinical picture. Usually such lesions are considered tuberculous in origin unless proven otherwise. However, there have been reports of pulmonary sporotricosis where the apical lesion results from foreign body giant cell reaction ( CHEST March 2009 vol. 135 no. 3 872-875)

This patient would require a repeat skin biopsy with culture (fungi/AFB) and chest referral (for bronchoscopy studies) . PCR studies for AFB would be helpful.

1. Do you think this is more likely lymphocutaneous/ disseminated sporotricosis than tuberculosis?
2. What would you treat with in this patient - amphotericin B 3-5 mg /kg/day followed by oral itraconazole 200mg bd for several months?

sporotricosis,tuberculosis, itraconazole, amphotericin B

Azar Maluki MD, Asst. Prof. Dermatology, Kufa College of Medicine, Kufa, Iraq on July 28, 2011

Generally, tuberculosis appears to be more reasonable diagnosis than sporotrichosis in this collection of signs and symptoms. Definitely PCR and culture studies would be beneficial and meanwhile it might be more helpful starting an anti tuberculosis therapy trial and monitoring the response.

Felix Boon-Bin Yap MD, Dermatologist, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia on July 28, 2011

Excellent case. As mentioned, biopsy for tissue culture and PCR is of utmost importance. It is worthwhile doing a CT Chest, sputum AFB and Mantoux test. The other differential diagnoses would be atypical mycobacterial infection (with sporotrichoid spread) and chromoblastomycosis (less likely).

As sporotrichosis is the provisional diagnosis, it is advisable to give a trial of oral Itraconazole 200 mg BD. Although the clinical picture looks like sporotrichosis, the HPE is more suggestive of TB.

Need to consider Non Tuberculoud Mycobacterium infection. Secondly, if this is sporotrichosis or NTM infection, the issue of immunosuppression needs to be considered. Disseminated sporotrichosis (lung and skin) usually occurs in the immunosuppressed.

Thamir Kubaisi MD, Assistant Prof, Anbar, Iraq on July 30, 2011

Clinical diagnosis goes more towards sporotrichosis but should prove by laboratory results. The recent lymph node enlargement and tenderness may be due to secondary bacterial infections that need antibiotic cover. I have not seen a patient with sporotricosis before. Nice to know the follow up of the patient.

Sunil Dogra MD, Associate Prof, Dept of Dermatology, PGIMER, Chandigarh, India on July 30, 2011

This seems to be sporotichoid distribution of an infectious etiology. Lesions are more inflammatory in nature for cutaneous tuberculosis and relatively short history for Cut TB to spread from foot to groin.

I will consider - sporotrichosis, Chromoblastomycosis and cat scratch disease. Rarely malignant tumors like melanoma and SCC can also present in sporotrichoid pattern but morphology and course do not suggest that in present case.

Repeat biopsies (nodules) and FNAC (Lymph node) along with cultures will be required. Chest findings should be explored further to find their relevance.

Abdullah Mancy MD, Al-Ramadi Teaching Hospital, Ramadi, Iraq on August 2, 2011

The history and clinical picture are typical for lymphangitic sporotrichosis, so it is important to exclude other lymphangitic infections like atypical mycobacteria. Culture can prove sporotrichotic infection. Inguinal lymph node enlargment could be due to secondary bacterial infection although tuberculosis can cause lymphadenopathy but it is associated with ulceration at distant site not arranged along lymphatics.

Carlos Garcia MD, Associate Professor. University of Oklahoma, Oklahoma City, Oklahoma, USA on August 2, 2011

Excellent case illustrating a common diagnostic dilemma. The clinical features suggest an infectious etiology. The inconclusive histology and the evolution/ progression favor sporotrichosis. Yet, the lymphadenopathy, systemic symptoms, and lung lesion are more suggestive of tuberculosis. Other differential diagnoses would include histoplasmosis, blastomycosis, and atypical mycobacteria. Personally, and taking everything into consideration, I would favor tuberculosis.

Samuel Moschella MD, Professor of Dermatology, Harvard Medical School; Physician, Lahey Clinic, Burlington, MA, USA on August 4, 2011

If you can get a sporotrichin skin test it would be helpful. The process appears to be infectious and the path picture with strong neutrophilic response without granuloma formation suggests bacteria and since you difficulty in demonstrating the organism you think of mycobacterium tuberculosis. Do not forget disseminated Sweet's disease.