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cutaneous leishmaniasis and syphilis Extensive coalescent ulcerations may eventually result in destruction of the epiglottis, vocal cords, and uvula Extension to the lips and face may occur Eating and drinking are extremely painful Skin lesions may occur, usually on the face Variable in appearance, they may have a necrotic central crater with a hard hyperkeratotic border Lymph node enlargement may follow mucocutaneous lesions, eventually ulcerating and forming draining sinuses; in some patients, it is the presenting symptom Hepatosplenomegaly may be present as well Cough, sometimes with sputum, indicates pulmonary involvement, but the symptoms and signs are often mild, even though radiographic findings indicate severe parenchymatous changes in the lungs The extensive ulceration of the upper gastrointestinal tract may prevent caloric intake and result in cachexia Laboratory findings are nonspecific Serology by immunodiffusion is positive in 98% of cases Complement fixation titers correlate with progressive disease and fall with effective therapy The fungus is found in clinical specimens as a spherical cell that may have many buds arising from it If direct examination does not reveal the organism, biopsy with Gomori staining may be helpful Itraconazole, 100 200 mg orally daily, is the treatment of choice and generally results in a clinical response within 1 month and effective control after 2 6 months
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Menezes VM et al Drugs for treating paracoccidioidomycosis Cochrane Database Syst Rev 2006 Apr 19;(2):CD004967 [PMID: 16625617]
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except for simple aspiration of secondary nodules Joint involvement may require arthrodesis The prognosis is good for lymphocutaneous sporotrichosis; pulmonary, joint, and disseminated disease respond less favorably
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da Rosa AC et al Epidemiology of sporotrichosis: a study of 304 cases in Brazil J Am Acad Dermatol 2005 Mar;52(3 Pt 1): 451 9 [PMID: 15761423]
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Penicillium marneffei is a dimorphic fungus, endemic in southeast Asia, that causes systemic infection in both healthy and immunocompromised hosts There have been reports of travelers with advanced AIDS returning from southeast Asia with disseminated infection Clinical manifestations include fever, generalized umbilicated papular rash, lymphadenopathy, cough, and diarrhea Diagnosis is made by identification of the organism on smears or histopathologic specimens or by culture, where the fungus produces a characteristic red pigment The best sites for isolation of the fungus include the skin, blood, bone marrow, respiratory tract, and lymph nodes Antigen and antibody tests have been developed in endemic regions Patients with mild to moderate infection can be treated with itraconazole, 400 mg divided into two doses daily by mouth for 8 weeks Amphotericin B, 05 07 mg/kg/d, is the drug of choice for severe disease and should be continued until patients have had a satisfactory clinical response, at which time they can be switched to itraconazole Because the relapse rate after successful treatment is 30%, maintenance therapy with itraconazole, 200 400 mg daily, is indicated indefinitely
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Vanittanakom N et al Penicillium marneffei infection and recent advances in the epidemiology and molecular biology aspects Clin Microbiol Rev 2006 Jan;19(1):95 110 [PMID: 16418525]
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Sporotrichosis is a chronic fungal infection caused by Sporothrix schenckii It is worldwide in distribution; most patients have had contact with soil, sphagnum moss, or decaying wood Infection takes place when the organism is inoculated into the skin usually on the hand, arm, or foot, especially during gardening The most common form of sporotrichosis begins with a hard, nontender subcutaneous nodule This later becomes adherent to the overlying skin and ulcerates Within a few days to weeks, similar nodules develop along the lymphatics draining this area, and these may ulcerate as well The lymphatic vessels become indurated and are easily palpable Disseminated sporotrichosis is rare in the immunocompetent person but may present with widespread cutaneous, lung, bone, joint, and central nervous system involvement in immunocompromised patients, especially those with AIDS and alcohol abuse Cultures are needed to establish diagnosis Antibody tests may be useful for diagnosis of disseminated disease, especially meningitis Itraconazole, 200 400 mg orally daily for several months, is now the treatment of choice for localized disease and some milder cases of disseminated disease Terbinafine, 500 mg twice daily, also appears to have good efficacy in lymphocutaneous disease Amphotericin B intravenously, 1 2 g (see Additional Reading at the end of the chapter), is used for severe systemic infection Surgery is usually contraindicated
Chromoblastomycosis is a chronic, principally tropical cutaneous infection usually affecting young men who are agricultural workers and caused by several species of closely related black molds; Cladophialophora carrionii and Fonsecaea pedrosoi are the most common etiologic agents Lesions usually follow puncture wounds and are slowly progressive, occurring most frequently on a lower extremity The lesion begins as a papule or ulcer Over months to years, papules enlarge to become vegetating, papillomatous, verrucous elevated nodules Satellite lesions may appear along the lymphatics There may be secondary bacterial infection Elephantiasis may result The fungus is seen as brown, thick-walled, spherical, sometimes septate cells in potassium hydroxide preparations of pus or skin scrapings, which are quite sensitive for diagnosis The type of reproduction found in culture determines the species Itraconazole, 200 400 mg/d orally for 6 18 months, achieves a response rate of 65% Response rates may be
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