Pulmonary infection with Sporothrix schenckii (S. schenckii) may mimic tuberculosis with an insidious progression of upper lobe predominant fibrocavitation. We describe a young man with severe primary pulmonary sporotrichosis in whom the definitive diagnosis was not established for five years after the onset of symptoms.
A 40 year old carpenter and dry-rot repairman with a five-year history of cough complained of worsening dyspnea on exertion and infrequent night sweats. He produced ½ cup of sputum daily. He had seen numerous physicians. Extensive evaluations for tuberculosis had been negative. Therapeutic attempts with antibiotics had failed. He smoked 2 packs of tobacco daily for 28 years. He drank 6 to10 beers daily. Physical exam was significant for hyperresonance on chest percussion and bronchial breath sounds loudest on the right. Digital clubbing was present. Chest X-ray showed hyperlucent regions in both upper lobes and loss of volume on the right. Thoracic computerized tomography confirmed bilateral bronchiectasis and thick walled irregular cavities. Coarse nodules with a ‘tree and bud’ appearance were seen throughout both lungs. A bronchoalveolar lavage (BAL) specimen was obtained from the right middle lobe. Fungal culture from the BAL grew S. schenckii. Therapy with oral itraconazole was initiated with improvement in symptomsDISCUSSION:S. schenckii is a dimorphic fungus commonly found in soil and plant matter. Lung infection is thought to be caused by inhalation or aspiration of S. schenckii spores.12 An occupational association is suggested as the disease has been reported in florists, construction and agricultural workers, and lumber salesmen. Men appear to be affected more often than women. Most cases present between the ages of 30 and 60.12 Impaired host defense is frequently implicated as an etiological factor. Alcohol abuse is a prominent association. The disease is difficult to recognize and confirm. The differential diagnosis includes other fungal diseases, mycobaterial infection, and malignancy. Tuberculosis is the most frequently suspected diagnosis before confirmation of sporotrichosis.12 Chest imaging often shows cavitary lesions and parenchymal densities with an upper lobe predominance. Noncavitary presentations have been described.3 The optimal therapy is unknown. Amphotericin B has been used to treat cavitary disease, however overall cure rates with the sole use of this agent are poor. Itraconazole is also active against S. schenckii and should be considered.4 The newer antifungal agent voriconazole has not been shown to have enhanced activity against S. schenckii.5 Surgical resection alone has been successful in a limited number of cases. The highest cure rates appear to result from the combined use of antifungals with surgical resection. Intracavitary antifungal treatment may be a consideration in the poor surgical candidate.
Pulmonary infection with S. schenckii is often insidious and the diagnosis is frequently delayed as our case illustrates. Tuberculosis is most often suspected before S. schenckii is identified. In young male patients with upper lobe predominant fibrocavitary lung disease and a history of alcohol abuse, pulmonary sporotrichosis must be considered within the differential diagnosis; especially after a thorough mycobacterial work-up has proven negative. Management recommendations involve the combined use of antifungals with surgical resection.
S.J. Evans, None.