Sporotrichosis or Rose Gardener’s Disease: Types, Transmission, Symptoms, Treatment, Risk Factors, Diagnosis

What is Sporotrichosis Disease or Rose Gardener’s Disease ?

The fungal infection caused by the Sporothrix Schenckii fungi is known as Sporotrichosis. Infection is observed in almost all the countries in the world. Sporothrix Schenckii fungus lives throughout the world in soil, water and on plant. The fungus Sporothrix Schenckii is also considered as a mold or yeast. The Sporothrix Schenckii fungi mold is frequently found on rose thorns, hay, sphagnum moss, twigs and soil The fungus when grows over plant is known sphagnum moss and hay. The skin infection is the most common disease caused by fungus Sporothrix Schenckii. Systemic infection is rare. Systemic disease affects lungs, skeletal system (joint and bone), brain and meninges.

Sporotrichosis is also known as Rose Gardener’s disease since disease is frequently observed in hand or arms of gardener. Sporotrichosis is observed with individuals working in tree nurseries, garden centers, working as a gardener in domestic garden and transporting contaminated plant.

What is Sporotrichosis Disease or Rose Gardener’s Disease ?

Types of Sporotrichosis Disease or Rose Gardener’s Disease :-

Cutaneous Infection- Cutaneous or skin fungal infection is the most common disease caused by Sporotrichosis Disease (Sporothrix Schenckii fungi). The infection does responds to treatment if initiated earlier. Most of the lesions are observed over fingers, hands and arms.

Lymph Node and Lymphatic Infection- Sporotrichosis Disease (Sporothrix Schenckii fungi) is transmitted from skin or cutaneous lesion to lymphatic vessels that are originating at the area of infected skin. The particles of fungi and spores then transmitted through the lymph channels to lymph node. Occasionally the lymphatic spread widens as fungi particles or spores passes from one lymph node to adjacent lymph node or distant lymph node via lymphatic channels. Most of the lymphatic spread of fungal infection is observed after fungal infection of skin and lung.

Lung Infection- Sporotrichosis Disease (Sporothrix Schenckii fungi) infection of lung is rare. Inhalation of spores or fungal particles leads to lung infection. Occasionally the lung infection may occur when fungi are transmitted to lung from skin through blood stream.

Skeletal Infection- Systemic infection of Sporothrix Schenckii fungi results in spread of fungi through lymphatic and blood vessels. The spores and fungal particles when lodge in bone or joint initiates infection within bones and joints. Skeletal spread of Sporothrix Schenckii fungi is very rare and less frequent than lung infection.

Meningitis- The covering of brain is known as meninges. Rarely particles or spores of Sporothrix Schenckii fungi may lodge into meninges and cause infection or disease known as meningitis. Meningitis is difficult to treat. Meningitis caused by Sporothrix Schenckii fungi is very rare.

Brain Infection- The brain infection caused by Sporotrichosis or Rose Gardener’s Disease results in growth of mold within brain tissue. The fungal growth is in the beginning microscopic and later may grow larger in size over 1 cm. The brain infection is very rare.

Transmission of Sporotrichosis or Rose Gardener’s Disease :-

  1. Skin- The spores or particles of Sporothrix Schenckii fungi is transmitted within the skin following direct contact with the source. The source of Sporothrix Schenckii fungi spores and particle is soil, infected plant, tree and rose thorn. Sporotrichosis Disease or Rose Gardener’s Disease is observed in individuals not using gloves or skin protective cloths while working in garden or cutting trees or bushes. The fungi and spores penetrates through lacerated, cut or injured skin into the deeper skin tissue. Sporothrix Schenckii fungi infection of skin is also observed in individual hosting pet animal. The scratch and bites of animal transmits spores or fungi from contaminated nail or paws to human skin. The published report suggests Sporotrichosis outbreaks have occurred among forestry workers.
  2. Lungs- The Sporotrichosis or Rose Gardener’s Disease resulting in lung disease is rare but occasionally observed. The mold particles and spores may transmit into mouth and then throat as well as bronchi and trachea (respiratory passage). Fungus particles or spores when inhaled causes lung infection.
  3. Skeletal System- This is extremely rare type of systemic Sporothrix Schenckii fungi infection. Particles of fungus from lungs or skin passes into blood stream and then carried to bones and joint. The microscopic fungus particles may stay inactive in bones and joint for several weeks or months. The fungus particle triggers infection when immunity or resistance goes down in affected individuals. Low immunity results in inability of white blood cells to stop spread of fungal infection.
  4. Brain and Meninges- Transmission of spores or particles of Sporothrix Schenckii fungi from blood to brain or meninges causes transmission of infection. The Sporothrix Schenckii fungi infection of brain and meninges is extremely rare like skeletal infection and often seen in immunosuppressed individual suffering with HIV or medicated for kidney or liver transplant. The brain fungal infection may cause a growth of fungus as a ball of mold resulting pressure symptoms of i persistent headache, nausea and vomiting. The fungus spreads to brain and meninges through blood.

Risk Factors for Sporotrichosis or Rose Gardener’s Disease –

The following risk factors influences the systemic spread of Sporotrichosis or Rose Gardener’s Disease. Sporotrichosis is not contagious and does not spread from person to person.

Corticosteroid Treatment- Higher dosage of corticosteroid is prescribed for treatment of auto-immune disease, cancer therapy and following organ transplant like kidney, heart and liver transplant. Higher dosage and prolong corticosteroid therapy suppresses immunity resulting in inactive or less active white blood cells. The lack of resistance caused by inactive white blood cells results in rapid multiplication and growth of microscopic fungal particles.

Chemotherapy- Chemotherapy is prescribed for patient suffering with cancer. Chemotherapy decreases immunity and makes white blood cells weak to fight the infection cause by fungi, bacteria and viruses.

Immunosuppressing Diseases- The white blood cells prevents the spread of bacteria, fungus and viruses in human body. Few diseases cause weakness in white blood cells that results in low resistance or immunity to fight the invasion of bacteria, fungus and viruses. Weakened immune systems is observed in patient suffering with diseases like HIV and AIDS. The other diseases which decreases immunity are diabetes, chronic obstructive pulmonary disease (COPD) and alcoholism.

Symptoms and Signs of Sporotrichosis or Rose Gardener’s Disease

Symptoms of Cutaneous (Skin) Sporotrichosis-

The initial lesion observed in skin following skin infection is rash and skin discoloration. The symptom appears after 2 to 12 weeks following penetration of fungi into superficial layer of the skin or lung.

  1. Pain- Most skin lesions are painless unless ulcer is form as in advanced stages. The infected nodule or ulcer is often painful.
  2. Itching- The initial lesion is rarely causes itching. Itching is a common symptom once nodule is form or ulcer is developed.
  3. Discoloration- Skin rash become red and purple. Aggressive itching causes purple discoloration of the skin. The color of skin turns dark and brown once nodule or ulcer develops.
  4. Nodule Formation- Small painless or minor painful bump or nodule is observed following initial skin lesion. The nodules are more often observed over finger, hand or arm. The nodule looks red to purple. The nodule if not promptly treated grows in size and forms ulcer.
  5. Ulcer Formation- The nodule and skin lesion eventually forms an ulcer if ignored and treatment is delayed. The healing of ulcer become very slow and lesion become painful. If ignore ulcer may remain for prolong period of time. The open sore (ulcer) often drains clear serous fluid.

Enlarged and Tender Lymph Node-

More than 50% of individuals suffering from Sporotrichosis or Rose Gardener’s Disease shows lymphatic spread of infection after ulcer is formed. The lymph node and lymphatic vessels become tender and painful.

The tender group of lymph nodes over elbow and shoulder joint may be the only sign observed in individual suffering with systemic Sporotrichosis. The persistent cutaneous infection caused by Sporothrix Schenckii fungi may expand into adjacent lymph node located over elbow and shoulder joint. Enlarged lymph node are felt during palpation.

Rarely isolated infection of lymph vessels and node is observed in patients with Sporotrichosis or Rose Gardener’s Disease. Systemic Sporotrichosis infection may spread through lymph vessels and nodes.

Symptoms of Pulmonary (Lung) Sporotrichosis-

Pulmonary (lung) disease is less common than cutaneous disease. The initial lung infection caused by Sporotrichosis (Sporothrix Schenckii fungi) if not treated promptly may progress to formation of nodule and cavities within lung tissue. The cavities within lung when observed on X-Ray and CT scan is often misdiagnosed as tuberculosis. The Sporotrichosis fungal infection of lung is rare and may observed in individual suffering with chronic obstructive lung disease and alcoholism. The laryngeal infection of Sporothrix Schenckii fungi rare and been published in scientific journal.

Following symptoms are observed following respiratory tract Sporothrix Schenckii fungi infection.

Symptoms of Sporothrix Schenckii Fungal Infection of Skeletal System

Osteoarticular Sporotrichosis is rare and seen in patient suffering with alcoholism and HIV. Following clinical manifestations are observed-

  • Joint pain at rest and during movements
  • Joint swelling
  • Joint inflammation indication signs of warm skin, tender joint to touch and painful joint movements.

Meningitis-

Meningitis occurs rarely even in immunosuppressed patients. Systemic infection of Sporotrichosis rarely transmits spores and particles through blood to brain and meningitis. Few published case reports suggest Sporotrichosis infection does cause meningitis. Following are the symptoms of meningitis:

  • Headache
  • Nausea and Vomiting
  • Dizziness

Lab Studies To Diagnose Sporotrichosis or Rose Gardener’s Disease

Blood Examination

  1. White blood cells count (WBC)- Sporotrichosis or Rose Gardener’s Disease causes increased number of WBC. Higher white blood cell count suggests the immune system is active and white blood cells are fighting against the multiplication of particles of fungus and also spores. Lower white blood cell count during infection suggest there is higher risk of spread of infection as WBCs are less active.
  2. CD4 count- The CD4 cells are the white blood cells also known as T cells. Increased CD4 cell count means the blood immune system is active and T cells are fighting to destroy the Sporothrix Schenckii Fungi. CD4 cells are either absent or present in very less number in patient suffering with HIV disease. The condition thus known as immunosuppress disease.
  3. Tuberculosis test- The blood test is performed to rule out tuberculosis. The microscopic smear examination of the specimen and study of culture confirms the cause of cavitation either tuberculosis or Sporothrix Schenckii fungi infection. Absence of tuberculosis bacteria and presence of fungi suggests the diagnosis of Sporotrichosis or Rose Gardener’s Disease.
  4. Electrolyte and Kidney Function Test- – Electrolyte and kidney function test is performed to evaluate kidney function and dehydration. The test performed are checking of level of sodium, potassium, chloride, blood urea nitrogen (BUN), creatinine, and glucose. These electrolyte levels are changed if patient is suffering with dehydration or kidney infection because of prolonged infection and complications.
  5. Liver Function Tests (LFTs)- Sporotrichosis or Rose Gardener’s Disease may cause symptoms like loss of appetite, nausea and vomiting. These symptoms are also common in Liver diseases. The liver function test is performed to evaluate the liver condition. The test performed to check the level alkaline phosphatase, ALT, AST, albumin, and bilirubin.

Histological Examination

Microscopic Examination- The tissue samples and biopsy materials from skin, lymph node and lung may show spores and fungi. The diagnosis of Sporotrichosis or Rose Gardener’s Disease is confirmed if smear sample shows the signs of fungi or spores.

Specimen Culture Study- The specimen is collected by needle biopsy or excision of infected tissue. The sample mold obtained from the culture of the specimen is then studied under microscope to identify characteristics of spores and fungi.

Radiological Studies

Radiological studies may not be diagnostic tool for cutaneous and meningeal Sporotrichosis. MRI and CT scan study does help to evaluate lymph node, lung, skeletal, meningeal and brain infection when caused by Sporothrix Schenckii fungi.

Treatment of Sporotrichosis or Rose Gardener’s Disease

Medications to Treat Sporotrichosis

  1. Saturated Potassium Iodide Solution- This is the most common and effective medication used for skin and lung Sporotrichosis infection and lesions. The mechanism of anti-fungal action is unknown. The droplets of saturated potassium iodide is taken 3 to 4 times a day. The treatment may last for 3 to 6 months. The lymph node, lung, bones and brain lesion does not respond to potassium iodide therapy.
  2. Itraconazole (Sporanox)- Sporanox is used for treatment of skin, lung and skeletal Sporotrichosis fungal infection. The treatment may last for 6 months or longer up to 12 months. Itraconazole is currently the drug of choice for all type of Sporotrichosis fungal infection and is significantly more effective than fluconazole. The pills of itraconazole are prescribed as oral 200 mg tabs once daily for skin infection. Initial treatment is given for 6 to 8 weeks and extended depending on response. Itraconazole dosage for systemic infection affecting lung, lymph node, bones and brain is 6–10 mg/kg to a maximum of 400 mg orally daily. In most adult cases 200 mg tablet prescribed twice a day. The medication dosage is continued 4 weeks after symptoms are completely subsided.
  3. Flucanzole- Fluconazole is less effective than Itraconazole in treating Sporotrichosis or Rose Gardener’s Disease. Fluconazole is prescribed when individual adversely react to treatment of other anti-fungal medications. The effective dosages are 400–800 mg daily.
  4. Amphotericin B- Amphotericin B is used against several other fungal infections. Amphotericin B is combined with Itraconazole in children and resistant cases. But during pregnancy Sporotrichosis infection is treated with only Amphotericin B. Amphotericin B therapy causes side effects fever, nausea, and vomiting. In such cases replacement of lipid formulations of amphotericin B is better tolerated. Similarly, Amphotericin B is combine with 5-fluorocytosin to treat fungal meningitis or brain infection. The dosage of lipid formulation of Amphotericin B is 3–5 mg/kg daily.
  5. 5-Fluorocytosine- The 5-Flurocytosine is used to treat skin and lung lesion. The drug is combined with Amphotericin B to treat skeletal and brain infection. The side effects observed during treatment of 5- Flurocytosine is nausea, vomiting, loss of appetite, and diarrhea. Prolonged treatment may cause bone marrow suppression.
  6. Terbinafine- The resistant cases of Sporotrichosis to Itraconazole or Flucanazole is treated with Terbinafine. The antifungal medication is given as a tablet in dosage of 500 mg and 1000 mg daily dosages for 6 to 12 weeks. The medication is most effective to treat cutaneous disease. The combination with Amphotericin has been tried for systemic Sporotrichosis disease.
  7. Newer triazoles- Several published studies suggest posaconazole and voriconazole may provide better results in short term treatment of Sporotrichosis.
    Antifungal medications potassium iodide, itraconazole (Sporanox), and amphotericin are effective to treat cutaneous and lung infection caused by Sporothrix Schenckii fungi. If lung infection is associated with cavity formation, then area of lung filled with cavity is surgically removed. Similarly, combination of antifungal medications may work to eliminate brain infection. The treatment may last for 6 to 12 months.

Surgery for Treating Sporotrichosis or Rose Gardener’s Disease

Bone infection- The residual movement abnormality of joint is treated with surgical treatment.

Lung nodules and cavities are treated with partial or complete lobectomy.

Treating Sporotrichosis or Rose Gardener’s Disease With Heat Therapy

The heat treatment is known as local hyperthermia therapy. The treatment is effective to treat cutaneous (skin) lesions. The progression and expansion of nodule and ulcer is restricted by heat therapy. The temperature of the skin occupied by nodule or ulcer is maintained t about 440 – 450 C for 2 hours 3 to 4 times a day for 6 weeks.

Treatment is effective and widely used in pregnant women suffering with cutaneous Sporotrichosis.

Treatment of Ulcer

The skin ulcer caused by cutaneous Sporotrichosis is treated with antifungal medications, heat therapy and isolated ulcer therapy. Ulcer therapy includes treating ulcer with local antifungal medication, keep the skin clean and covered the area of ulcer to prevent secondary bacterial infection.

Prevention of Sporotrichosis or Rose Gardener’s Disease

The prevention is the best treatment to avoid getting infected. The spores and fungi particles are transmitted to human skin and lungs from soil, infected trees, commercial garden soil, fertilizer and commercial plants. The transmission is prevented by wearing gloves and avoid exposing skin by wearing shirt with long sleeves, socks and pant while working in garden or handing trees. Avoid garden work or handling trees or plants if you have skin cuts, abrasion or injuries. Avoid pet animal and getting scratch.

References

  1. Sporothrix schenckii and Sporotrichosis

    Mônica Bastos de Lima Barros,1,* Rodrigo de Almeida Paes,2 and Armando Oliveira Schubach2, Clin Microbiol Rev. 2011 Oct; 24(4): 633–654.

  2. Histopathologic Diagnosis of Fungal Infections in the 21st Century

    Jeannette Guarner1,* and Mary E. Brandt2, Clin Microbiol Rev. 2011 Apr; 24(2): 247–280.

  3. Disseminated sporotrichosis as a manifestation of immune reconstitution inflammatory syndrome.

    Gutierrez-Galhardo MC, do Valle AC, Fraga BL, Schubach AO, Hoagland BR, Monteiro PC, Barros MB., 2010 Jan;53(1):78-80.

  4. Erythema nodosum associated with sporotrichosis.

    Gutierrez Galhardo MC, de Oliveira Schubach A, de Lima Barros MB, Moita Blanco TC, Cuzzi-Maya T, Pacheco Schubach TM, dos Santos Lazéra M, do Valle AC

    Int J Dermatol. 2002 Feb;41(2):114-6. No abstract available

  5. Global epidemiology of sporotrichosis.

    Chakrabarti A, Bonifaz A, Gutierrez-Galhardo MC, Mochizuki T, Li S., Med Mycol. 2015 Jan;53(1):3-14.

  6. New Diagnostic Applications in Sporotrichosis

    Rosely Maria Zancope-Oliveira, Rodrigo de Almeida-Paes, Manoel Marques Evangelista de Oliveira, Dayvison Francis Saraiva Freitas and Maria Clara Gutierrez Galhardo Instituto de Pesquisa Clínica Evandro Chagas – Fundação Oswaldo Cruz

  7. Sporothrix schenckii and Sporotrichosis

    Mônica Bastos de Lima Barros

    Clinical Microbiology Review

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