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Cryosurgery as adjuvant therapy in cutaneous sporotrichosis

Authors:
Cassio Ferreira at Fundação Oswaldo Cruz
Cassio Ferreira
Maria Clara Gutierrez Galhardo at Fundação Oswaldo Cruz
Maria Clara Gutierrez Galhardo
Antônio Carlos Francescone do Valle
Antônio Carlos Francescone do Valle
Antônio Carlos Francescone do Valle
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181
CLINICAL
IMAGES
Cryosurgery as adjuvant therapy in cutaneous
sporotrichosis
Authors
Cassio Porto Ferreira1
Maria Clara Gutierrez
Galhardo2
Antônio Carlos
Francescone do Valle3
1 MSc, Techonologist;
Dermatologist,
Laboratory of Clinical
Research in Infectious
Dermatology (IPEC/
FIOCRUZ)
2 Post-Doctorate;
Researcher, Laboratory
of Clinical Research in
Infectious Dermatology
(IPEC/FIOCRUZ)
3 PhD; Researcher,
Laboratory of Clinical
Research in Infectious
Dermatology (IPEC/
FIOCRUZ)
Submitted on: 9/29/2010
Approved on: 10/5/2010
Correspondence to:
Cassio Porto Ferreira
Av. Brasil 4365,
Manguinhos
Rio de Janeiro, Brazil
21040-900
Fax: 00.55-21-2209-4110
Phone:
00.55-21-3865-8102
drcassioferreira@yahoo.
com.br
We declare no conict of
interest.
Sporotrichosis is a subacute or chronic dis-
ease that affects animals and humans caused
by the dimorphic fungus Sporothrix schen-
kii.1 An epidemic of sporotrichosis has been
noticed in the city of Rio de Janeiro from
1998 onwards and having the cat as the
main link in the epidemiological chain.2 We
have missed a large proportion of these pa-
tients and adjuvant cryosurgery with liquid
nitrogen3,4 has been performed in patients
that persisted with one or two active lesions
whereas the other healed after 2-3 months
of treatment. This study aims at evaluat-
ing the role of adjuvant treatment in these
patients. Methods: 9 patients (7 women/2
men, mean age 45.8 years-old) with cuta-
neous-lymphatic and fixed sporotrichosis
were selected (Figures 1 and 2). All patients
Figure 1: Sporotrichosis: pre-treatment.
Figure 2: Sporotrichosis: before cryosurgery.
MAR-14 mar-colocada.indd 181 28/03/11 10:01
182
Figure 3: Dimorphic fungus Sporothrix schenckii. (A): mycelium form (250C); (B): yeast form (370C).
had isolated Sporothrix schenckii in culture (Figure 3).
Results: Patients underwent monthly sessions of cryosur-
gery with liquid nitrogen with two cycles of 15 seconds
and halo of 5 mm (Figures 4 and 5) with an average of
2.2 sessions (range 1-4 sessions). Five patients had exclu-
sive use of itraconazole for a mean period of 28.8 weeks
(range 4-56 weeks) and after the introduction of adjuvant
therapy were discharged after a mean period of 12 weeks
(range 4-36 weeks). The patient who made use of potassi-
um iodide was discharged after two adjuvant therapy ses-
sions, totaling 12 weeks of treatment. The three patients
who used itraconazole and terbinane, itraconazole used
primarily by an average of 21.2 weeks and due to lack of
response initiated terbinane, which when combined with
adjuvant therapy were discharged aer a mean period of 16
weeks (range 4-28 weeks). In conclusion, cryosurgery with
liquid nitrogen4 used in patients with slower response to
systemic antifungal agents in a few sessions reduces treat-
ment time and thus reducing cost and side eects.
[Braz J Infect Dis 2011;15(2):181-183]©Elsevier Editora Ltda.
Figure 4: Technique of cryosurgery with liquid nitrogen and halo.
Figure 5: Sporotrichosis: post-treatment.
Cryosurgery in sporotrichosis
MAR-14 mar-colocada.indd 182 28/03/11 10:01
183
Braz J Infect Dis 2011; 15(2):181-183
REFERENCES
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Janeiro, Brazil. Int J Dermatol 2003; 42:677-681.
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3. Moraes AM, Velho PENFV, Magalhães RF. Criocirurgia com
nitrogênio líquido e as dermatoses infecciosas. An Bras Der-
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Ferreira, Galhardo, Valle
MAR-14 mar-colocada.indd 183 28/03/11 10:01
... [16][17][18][19][20] En nuestro caso, puesto que el paciente presentaba una lesión elevada, cumplió el criterio para aplicar ciclos de 60 segundos de congelación y descongelación cada semana. 21 Ferreira y colaboradores (2010) describen nueve casos con esporotricosis linfocutánea y localizada: un paciente tratado con yoduro de potasio, cinco con itraconazol y tres con terbinafina; además, terapia adyuvante de nitrógeno líquido. En cuanto al género, siete fueron mujeres y dos hombres, edad media de 45.8 años. ...
... Todos los esquemas de tratamiento utilizados presentaron mejoría clínica. 21 Bargma y su grupo (1995) describen tres casos de esporotricosis cutánea usando nitrógeno líquido. El primero fue tratado inicialmente con yoduro de potasio 10 gotas, tres veces al día, suspendido por intolerancia gástrica, aplicando criocirugía en 11 sesiones y crema tópica de ketoconazol al 2%, con curación completa a los 24 meses. ...
... 20 La importancia del presente caso radica, en primer lugar, en la sensibilidad de Sporothrix schenckii a las temperaturas bajas del nitrógeno líquido, que puede ser utilizado de forma sola o adyuvante con antimicóticos sistémicos, en ambas con buena respuesta clínica. 3,[20][21][22] BIBLIOGRAFÍA En segundo lugar, el uso de la dermatoscopia como auxiliar del diagnóstico, ya que en ésta infección de origen micótico ha sido poco utilizada. ...
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... Alternatively, terbinafine at 500 mg twice daily may be used for fixed cutaneous and lymphocutaneous forms if ITZ is contraindicated [72]. Additionally, cryosurgery and local heat therapy may be used in conjunction with antifungals to reduce therapy duration, for the treatment of pregnant women, or to treat recalcitrant, hyperkeratotic lesions [73][74][75][76][77]. ...
A One Health Approach to Combatting Sporothrix brasiliensis: Narrative Review of an Emerging Zoonotic Fungal Pathogen in South America
Article
Full-text available
  • Oct 2020
  • J. Fungi
Cat-transmitted sporotrichosis caused by Sporothrix brasiliensis has become a major public health concern and presents a distinct divergence from the traditional epidemiology of sporotrichosis. This emerging fungal pathogen spreads readily among cat populations, and human infections occur exclusively via zoonotic transmission. While sporotrichosis is an implantation mycosis that typically manifests as cutaneous lesions in humans and cats, severe extracutaneous manifestations are more common with S. brasiliensis than other Sporothrix species infections. Rapid diagnosis and appropriate treatment regimens are critical for successful clinical resolution of sporotrichosis in both cats and humans. Species-level identification of Sporothrix is possible with molecular diagnostics and necessary for tracking the geographic expansion of S. brasiliensis and better understanding its epidemiology. Combatting cat-transmitted sporotrichosis requires a One Health approach to successfully implement public health control measures.
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... Areas with reduced blood circulation and low temperatures in the anemic nevus probably play a protective role against dermatophyte infections. Although limited, the available literature data indicate that lower temperatures and in particular cryotherapy, could have a therapeutic effect on fungal infections, in addition to the already established protective one [1][2][3][4][5][6]. ...
View
... Curettage and/or electrocoagulation of these lesions often allows for the suspension of antifungals (Valle and Gutierrez-Galhardo 2012). Another method with excellent results is cryotherapy of the verrucous or ulcerovegetative isolated lesions with liquid nitrogen (Ferreira et al. 2011). Cryotherapy can also be employed in multiple skin lesions associated with AIDS. ...
Therapeutic and Prophylactic Tools for Sporotrichosis: Current Strategies and Future Tendencies
Chapter
  • Nov 2015
Over the past 3 decades, important progress in the therapy of fungal infections has been made. Although several chemotherapeutic agents are relatively effective against the different species of the Sporothrix schenckii complex, even the primary drugs used to treat sporotrichosis are the ergosterol inhibitors: triazole compounds, terbinafine, and amphotericin B. Despite the general effectiveness of these drugs, diverse problems remain, including chronic therapy, toxicity manifestations, and fungal resistance, which limit their use. These problems have stimulated a search for new agents that might be active against a wide range of clinical isolates, that are well absorbed after oral administration, that are widely distributed throughout body tissues, including the central nervous system, and that are relatively nontoxic. This chapter reviews the current therapy strategies for human and animal sporotrichosis and updates the more relevant strategies in study for prophylaxis and treatment.
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Esporotricosis y cromoblastomicosis: revisión de la literatura Sporotrichosis and chromoblastomycosis: literature review
Article
Full-text available
  • Jun 2017
Comparte Resumen Las micosis subcutáneas hacen referencia a infecciones producidas por hongos que se encuentran en la naturaleza, adquiridas por inoculación directa y limitadas a la dermis y tejido celular subcutáneo, pero pueden extenderse hacia la epidermis o hacia planos más profundos llegando a comprometer estructuras óseas, así como diseminarse y producir enfer-medad sistémica. Dentro de las micosis subcutáneas más importantes en nuestro medio y de las cuales se hablarán en este artículo están la esporotricosis y la cromoblastomicosis; mientras que las menos frecuen-tes incluyen micetoma, quistes faeomicóticos, lacaziosis y la zigomicosis subcutánea. Palabras clave: Dermatomicosis, Esporotricosis, Cromoblastomicosis, Micosis subcutáneas. Abstract Subcutaneous mycoses, refer to infections caused by fungi which the eco-logic niche is the nature, they are acquired by direct inoculation, limited to the dermis and subcutaneous tissue, but may extend into the epidermis or deeper levels reaching compromise bone structures and systemic spread and cause disease. Among the most important in our country, and which will discuss in this article, subcutaneous mycoses are sporotrichosis and chromoblastomycosis, mycetoma include less frequent, the faeomycosis, lacaziosis, and subcutaneous zygomycosis. Introducción Las infecciones micóticas incluyen un amplio grupo que van desde en-tidades superficiales hasta infecciones profundas asociadas a planos más profundos, que incluso llegan a comprometer estructuras óseas o diseminarse y producir enfermedad sistémica. Dentro de las micosis sub-cutáneas más importantes en nuestro medio están la esporotricosis y la cromoblastomicosis; las menos frecuentes son micetoma, quistes faeo-micóticos, lacaziosis y zigomicosis subcutánea. Los microrganismos cau-santes se inoculan en la piel luego de un trauma con material vegetal contaminado con el hongo y por esto también han sido llamadas micosis de implantación (1,2).
View
Cat-transmitted sporotrichosis epidemic in Rio de Janeiro, Brazil: Description of a series of cases
Article
  • Feb 2004
Sporotrichosis is the most common subcutaneous mycosis in South America. Classic infection is associated with traumatic inoculation of soil, vegetables, and organic matter contaminated with Sporothrix schenckii. Zoonotic transmission has been described in isolated cases or in small outbreaks. Since 1998, we have been observing an increasing number of cases of sporotrichosis in persons from the city of Rio de Janeiro, Brazil, and surroundings. From 1998 to 2001, 178 cases of culture-proven sporotrichosis had been diagnosed. Female patients predominated, and the median age was 39 years. The most frequent clinical presentation was lymphocutaneous disease. Of the 178 patients, 156 reported domiciliary or professional contact with cats with sporotrichosis, and 97 of these patients had a history of receipt of cat scratch or bite. The patients received itraconazole as first-line treatment. This study suggests that feline transmission of sporotrichosis was associated with a large and long-lasting outbreak of the disease in Rio de Janeiro.
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Successful treatment of cutaneous sporotrichosis with liquid nitrogen: Report of three cases
Article
  • Jul 1995
Sporotrichosis is a not uncommon deep fungal infection that frequently involves the skin. At present, there are several therapeutic modalities available to treat this infection. This report outlines the successful treatment of three cases of sporotrichosis using liquid nitrogen. Cryotherapy may be useful in treating some cases of this disease. Zusammenfassung. Die Sporotrichose ist eine nicht seltene tieflokalisierte Pilzinfektion, häufig in der Haut angesiedelt. Zur Zeit stehen verschiedene therapeutische Modalitäten zur Verfügung, um diese Infektion zu behandeln. Im vorliegenden Bericht wird die erfolgreiche Behandlung von drei Sporotrichose-Situationen mit flüssigem Stickstoff erörtert. Diese Cryotherapie könnte zur Behandlung mancher Sporotrichose-Erkrankungen hilfreich sein.
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Sporotrichosis with widespread cutaneous lesions: Report of 24 cases related to transmission by domestic cats in Rio de Janeiro, Brazil
Article
  • Oct 2003
  • INT J DERMATOL
Sporotrichosis most commonly presents as a localized lymphocutaneous infection following traumatic inoculation of soil, vegetables or organic substrates contaminated with the dimorphic fungus Sporothrix schenckii. Cases of widespread cutaneous lesions are rare. There have been isolated reports of household outbreaks of sporotrichosis involving cats and humans. We report 24 cases of culture-proven sporotrichosis presenting with widespread cutaneous lesions. These 24 cases are part of an epidemic currently occurring in Rio de Janeiro. All patients reported contact with cats with sporotrichosis and 17 reported a history of a scratch or bite. Clinical manifestations included fixed lesions at multiple anatomical sites, and fixed lesions associated with the lymphocutaneous, bilateral lymphocutaneous and mucosal forms of the disease. Two patients were alcoholics and one patient was diabetic, while the remaining patients did not present any immunosuppressing condition. All patients responded to treatment with itraconazole. The domestic cat has played an important role in the transmission of sporotrichosis in Rio de Janeiro and seems to have contributed to this unusual clinical manifestation.
View
Criocirurgia com nitrogênio líquido e as dermatoses infecciosas. An Bras Dermatol
  • Jan 2008
  • 285-298
  • A M Moraes
  • Penfv Velho
  • R F Magalhães
Moraes AM, Velho PENFV, Magalhães RF. Criocirurgia com nitrogênio líquido e as dermatoses infecciosas. An Bras Dermatol. 2008; 83(4):285-98.