Sporotrichosis — DTM&H MCQ

Correct answer: C — Oral itraconazole for 3-6 months

The correct answer is C, oral itraconazole for 3 to 6 months. The clinical picture, a sporotrichoid pattern of nodular lymphangitis following a gardening injury, with a dimorphic fungus forming cigar shaped yeasts at 37C, is classic for lymphocutaneous sporotrichosis caused by Sporothrix schenckii. Itraconazole 200 mg daily is first line for cutaneous and lymphocutaneous disease, continued until 2 to 4 weeks after all lesions resolve, typically totalling 3 to 6 months, because the organism responds reliably to sustained triazole exposure and relapse occurs if treatment is stopped early. This regimen has response rates exceeding 90 percent in published series, making it the standard of care over alternative antifungals. Why the other options are wrong: A. IV amphotericin B for 2 weeks: reserved for severe, disseminated, osteoarticular or meningeal sporotrichosis, or disease in immunocompromised hosts; it is unnecessarily toxic and invasive for localised lymphocutaneous infection. D. Oral fluconazole for 2 weeks: fluconazole has significantly lower efficacy against Sporothrix than itraconazole and is only used when itraconazole is not tolerated, plus two weeks is far too short a course. B. Topical ketoconazole cream: topical antifungals do not penetrate the dermis and lymphatics where Sporothrix resides, so they cannot clear lymphocutaneous disease. E. Surgical excision of all nodules: excision does not address the deeper lymphatic spread and residual fungal foci, and lesions typically recur without systemic antifungal therapy. Key point: Sporotrichoid nodular lymphangitis with cigar shaped yeasts at 37C is sporotrichosis, and it requires prolonged oral itraconazole (3 to 6 months), not short courses, topical treatment, or surgery alone.

Reference: Kauffman CA, Bustamante B, Chapman SW, Pappas PG. Practice Guidelines for the Management of Patients with Sporotrichosis. Clinical Infectious Diseases (Infectious Diseases Society of America guideline, referenced in Manson's Tropical Diseases and used in UK DTMH teaching), https://academic.oup.com/cid/article/30/4/684/421539