Diagnosis at first sight
Hand and arm injuries of torpid evolution after a puncture wound in a male fond of hiking
Lesiones en mano y brazo de curso tórpido tras herida punzante en un varón aficionado al senderismo
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"autores" => array:4 [ 0 => array:4 [ "nombre" => "Francisco Javier" "apellidos" => "Rodríguez-Gómez" "email" => array:1 [ 0 => "med007369@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Juan Antonio" "apellidos" => "Pérez Cáceres" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Francisco Javier" "apellidos" => "Martínez-Marcos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Dolores" "apellidos" => "Merino Muñoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Gestión de Enfermedades Infecciosas, Hospital Juan Ramón Jiménez, Huelva, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Infanta Elena, Huelva, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesiones en mano y brazo de curso tórpido tras herida punzante en un varón aficionado al senderismo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 717 "Ancho" => 955 "Tamanyo" => 67687 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pigmented colonies of <span class="elsevierStyleItalic">Sporothrix schenckii</span> in their filamentous form after 15 days of growth at room temperature (Sabouraud-chloramphenicol agar).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 52-year-old man was seen due to an eight-week history of nodular skin lesions, which appeared after being pricked with a ‘spike’ at the base of the fourth finger of his right hand while hiking through scrubland. Days later, his finger swelled and painful beaded lesions appeared on the back of his hand, extending proximally to the ipsilateral forearm and arm. Throughout this time, the patient sought medical attention on multiple occasions, both with his GP and at A&E, and was diagnosed with both soft tissue infection and phlebitis. He received local treatments, ciprofloxacin 500 mg/12 h/per os (7 days) and amoxicillin-clavulanic acid 500 mg/125 mg/12 h/per os (7 days), with no improvement. He did not exhibit fever or any other symptoms. From an epidemiological standpoint, he denied handling meat or fish, maintaining aquariums or contact with animals. The physical examination was normal except for the lesions shown in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The complete blood count and clinical chemistry, including transaminases and coagulation, revealed no abnormal findings. Syphilis, HBV, HCV and HIV serology tests were negative. The plain X-ray of the patient’s chest and right hand revealed no abnormalities. With a diagnosis of nodular lymphangitis secondary to sporotrichosis, two punch skin biopsies were performed, which were processed for microbiological and histological study.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical course</span><p id="par0015" class="elsevierStylePara elsevierViewall">Empirical treatment with itraconazole 200 mg/day/per os was started. The fungal culture isolated <span class="elsevierStyleItalic">Sporothrix schenckii</span> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Auramine staining and mycobacterial culture were negative. The histological study identified a dense mixed inflammatory infiltrate in the superficial and reticular dermis with necrosis. PAS staining was negative and no microorganisms were found in the infiltrate. Three months after starting treatment, the patient's lesions had completely resolved. He completed the six-month regimen with no evidence of clinical or blood toxicity.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Final considerations</span><p id="par0020" class="elsevierStylePara elsevierViewall">Sporotrichosis is a subacute or chronic granulomatous fungal infection caused by fungi of the species <span class="elsevierStyleItalic">Sporothrix schenckii</span>. These fungi are thermally dimorphic, expressing their filamentous form in nature at temperatures below 37 °C and their yeast-like form in the tissue and at temperatures of 37 °C<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. They are found all over the world in soil, plants, decomposing vegetables and several species of animal, particularly cats<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>. The infection is predominantly acquired by cutaneous inoculation with the contaminated medium, or following bites or scratches by infected cats, while infection by inhalation is rare<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>. The clinical perspective takes into consideration the cutaneous, lymphocutaneous, osteoarticular, pulmonary and disseminated forms, with lymphocutaneous sporotrichosis (lymphangitic form) being the classic and most common infection<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a>. Differential diagnosis with other nodular lymphangitis-causing infections is therefore warranted: <span class="elsevierStyleItalic">Nocardia brasiliensis</span> infection, <span class="elsevierStyleItalic">Mycobacterium marinum</span> infection, <span class="elsevierStyleItalic">Leishmania brasiliensis</span> infection and tularaemia<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–7</span></a>. The epidemiological context, incubation period and certain clinical characteristics are key to a successful differential diagnosis<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–7</span></a>. A traumatic wound while gardening, caused by splinters or contaminated with earth or soil, should lead clinicians to suspect sporotrichosis or nocardiosis, while an injury in contact with water should point to <span class="elsevierStyleItalic">M. marinum</span> infection<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. For hunters who develop a painful ulcer with regional lymphadenopathy and systemic symptoms days after contact with infected animals, tularaemia should be considered<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a>. Purulent exudate is typical of nocardiosis<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,7</span></a>. A definitive diagnosis is made by isolating and identifying the causative microorganism in aspirate culture or tissue biopsy<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,8</span></a>. If <span class="elsevierStyleItalic">Sporothrix schenckii</span> is suspected, its isolation in Sabouraud agar incubated at 25 °C is recommended. Growth of the filamentous form should be observed in 5–7 days. Thermal dimorphism, with the conversion of the fungus into its yeast form, is required for definitive identification. This is achieved in enrichment cultures such as brain heart infusion (BHI) agar or blood agar incubated at 37 °C<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,8</span></a>. The treatment of choice for cutaneous forms and nodular lymphangitis caused by sporotrichosis consists of itraconazole 200 mg/day/per os, to be maintained for 2–4 weeks after lesion resolution, typically for a total of 3–6 months<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>. In conclusion, several infectious agents must be considered in the aetiology of nodular lymphangitis in order to clinically diagnose the infection. Early and precise culture-based microbiological diagnosis could prevent the incorrect use of antimicrobials and disease progression.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical course" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Final considerations" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodríguez-Gómez FJ, Pérez Cáceres JA, Martínez-Marcos FJ, Merino Muñoz D. Lesiones en mano y brazo de curso tórpido tras herida punzante en un varón aficionado al senderismo. Enferm Infecc Microbiol Clin. 2021;39:516–517.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1344 "Ancho" => 1005 "Tamanyo" => 269740 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lesions on the fourth finger of the right hand eight weeks after puncture.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1277 "Ancho" => 955 "Tamanyo" => 227052 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Nodular lymphangitis caused by <span class="elsevierStyleItalic">Sporothrix schenckii</span>.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 717 "Ancho" => 955 "Tamanyo" => 67687 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pigmented colonies of <span class="elsevierStyleItalic">Sporothrix schenckii</span> in their filamentous form after 15 days of growth at room temperature (Sabouraud-chloramphenicol agar).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Sporothrix schenckii</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 1 | 7 |
| 2024 October | 33 | 10 | 43 |
| 2024 September | 61 | 20 | 81 |
| 2024 August | 49 | 15 | 64 |
| 2024 July | 36 | 6 | 42 |
| 2024 June | 33 | 7 | 40 |
| 2024 May | 16 | 19 | 35 |
| 2024 April | 19 | 9 | 28 |
| 2024 March | 31 | 5 | 36 |
| 2024 February | 43 | 3 | 46 |
| 2024 January | 49 | 4 | 53 |
| 2023 December | 38 | 4 | 42 |
| 2023 November | 36 | 6 | 42 |
| 2023 October | 70 | 12 | 82 |
| 2023 September | 22 | 1 | 23 |
| 2023 August | 26 | 3 | 29 |
| 2023 July | 39 | 4 | 43 |
| 2023 June | 46 | 5 | 51 |
| 2023 May | 67 | 2 | 69 |
| 2023 April | 55 | 3 | 58 |
| 2023 March | 48 | 5 | 53 |
| 2023 February | 49 | 3 | 52 |
| 2023 January | 49 | 6 | 55 |
| 2022 December | 45 | 19 | 64 |
| 2022 November | 41 | 7 | 48 |
| 2022 October | 29 | 7 | 36 |
| 2022 September | 36 | 20 | 56 |
| 2022 August | 22 | 8 | 30 |
| 2022 July | 17 | 9 | 26 |
| 2022 June | 17 | 4 | 21 |
| 2021 December | 9 | 0 | 9 |
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