Ganguly, Nivedita

McWilliams, Heather

The University of Kansas: Journals@KU

Rose Handler’s Knee: A Case of Osteoarticular Sporotrichosis Heather McWilliams DO¹, Nivedita Ganguly MD² ¹Department of Internal Medicine, ² Division of Infectious Diseases, University of Kansas Medical Center, Kansas City, KS   BACKGROUND Sporotrichosis, also known as “Rose Handler’s Disease”, is caused by the dimorphic fungus Sporothrix schenckii. It is found throughout the world in decaying vegetation, wood, sphagnum moss and soil. Typically, healthy adults acquire this disease by direct inoculation of skin during outdoor activities. Most commonly it presents as subacute or chronic lymphocutaneous lesions of the extremities. Hematogenous dissemination may result in unusual presentations including pulmonary, meningeal and osteoarticular disease. Extracutaneous manifestations are uncommon and most often reported in immunocompromised hosts in association with alcoholism, diabetes, COPD and AIDS.  CASE PRESENTATION  A 45 year old alcoholic male presented with worsening right knee pain, swelling and intermittent purulent drainage for several months.  He had experienced a minor soft tissue injury of his right knee involving a chainsaw five years prior and an injury during a basketball game three years prior. In the past one year, he had multiple I&D procedures with negative cultures. He received multiple courses of oral and intravenous antibiotic regimens without improvement. His most recent I&D procedure was performed with placement of an antibiotic cement spacer with no improvement. Extensive bony destruction, purulence and a clear sinus tract were noted during this surgery. Finally, intraoperative tissue and bone cultures grew Sporothrix schenckii after a thirty day incubation period. Therapy was started with liposomal Amphotericin B, followed by oral Itraconazole  with a plan to treat for at least one year in anticipation of knee replacement due to extensive bony destruction.  DISCUSSION  Osteoarticular sporotrichosis causing septic arthritis and osteomyelitis is not a common presentation. It often involves a single joint such as the knee, elbow, ankle or wrist. A high index of suspicion should remain for Sporothrix schenckii when there is a history of injury involving possible soil inoculation, negative bacterial cultures and antibiotic treatment failure. Generally the outcome of osteoarticular sporotrichosis is poor due to delay in diagnosis and initiation of antifungal therapy.  Diagnosis is often delayed by several months. This disease is difficult to treat with a high recurrence rate and poor outcome even after prolonged antifungal therapy.  DIAGNOSTIC TESTS Culture is the gold standard for diagnosis of Sporothrix Schenckii. Material from cutaneous lesions, sputum, synovial fluid, CSF or biopsy should be obtained depending on location of infection. A majority of cases will show growth within eight days, however, some cases may take up to four weeks.  TREATMENT First line treatment is Itraconazole 200mg orally twice daily for a minimum of twelve months.  Amphotericin B is indicated for more severe cases. Ketoconazole and fluconazole have not been shown to be effective.  Surgical debridement alone for osteoarticular sporotrichosis is not effective but often needed in addition to antifungal treatment.        REFERENCES Kauffman CA, Bustamante B, Chapman SW, Pappas PG. Clinical Practice Guidelines for the Management of Sporotrichosis: 2007 Update by the Infectious Diseases Society of America. Clin Infect Dis 2007; 45:1255-1265. Araujo TD, Marques AC, Kerdel F. Review Sporotrichosis. International Journal of Dermatology 2001;40:737-742. Campos-Macias P, Arenas R, Vega-Memije ME, Kawasaki, M. Journal of Dermatology 2006;33:295-299. Kaufman, C. Clinical features and diagnosis of sporothricosis.  Basic Biology and Epidemiology of Sporotrichosis. UptoDate. Long SS, Pickering LK, Prober CG, et al. Principles and Practices of Pediatric Infectious Disease. 3rd ed. Philadelphia, Pennsylvania: Elsevier Inc.; 2008 1193-1194.            Colonies of Sporothrix schenckii from surgical specimen of this patient  Lactophenol cotton blue stain from the above colony: Sporothrix schenchiii           

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Rose Handler’s Knee: A Case of Osteoarticular Sporotrichosis

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Rose Handler’s Knee: A Case of Osteoarticular Sporotrichosis

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