Case for Diagnosis
A Lesion on the Ear Resulting From Infection Acquired in the Tropics
Lesión infecciosa del pabellón auricular en el trópico
C.M. Arenas-Soto, A.M. Téllez-Kling
, Z.L. Alvarado-Álvarez
Corresponding author
Centro Dermatológico Federico Lleras Acosta, E.S.E, Bogotá, D.C., Colombia
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Arenas-Soto, A.M. Téllez-Kling, Z.L. Alvarado-Álvarez" "autores" => array:3 [ 0 => array:2 [ "nombre" => "C.M." "apellidos" => "Arenas-Soto" ] 1 => array:4 [ "nombre" => "A.M." "apellidos" => "Téllez-Kling" "email" => array:1 [ 0 => "anamatellezkling@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "Z.L." "apellidos" => "Alvarado-Álvarez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Centro Dermatológico Federico Lleras Acosta, E.S.E, Bogotá, D.C., Colombia" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesión infecciosa del pabellón auricular en el trópico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 701 "Ancho" => 435 "Tamanyo" => 74575 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient, a 48-year-old woman from Marandúa, in Vichada, Colombia, was seen for an erythematous lesion that had developed on her right ear 3 months earlier. She denied any history of trauma or insect bite. On her own decision, she had taken oral fluconazole and had used topical corticosteroids and antibiotics, with no improvement.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">On physical examination, a shiny, infiltrated, edematous erythematous plaque with smooth borders and occasional pustules was observed on the helix and concha of the right ear (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The lesion was not tender and there were no palpable regional lymph nodes.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Skin biopsy revealed epidermal hyperplasia with corneal pustules, a chronic diffuse dermal inflammatory infiltrate rich in plasma cells, epithelioid granulomas that contained numerous giant cells and some polymorphonuclear cells, and abscesses that extended from the dermis to the infundibula (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, A and<span class="elsevierStyleHsp" style=""></span>B).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">Direct microscopy and culture for <span class="elsevierStyleItalic">Leishmania</span> were negative. Culture on Sabouraud agar and potato dextrose agar to detect deep mycoses was positive for <span class="elsevierStyleItalic">Sporothrix schenckii</span> after 10 days of incubation at 25<span class="elsevierStyleHsp" style=""></span>°C (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>, A and<span class="elsevierStyleHsp" style=""></span>B). The yeast form was observed on Seneca agar (nutrient agar for the isolation of <span class="elsevierStyleItalic">Leishmania</span> spp.) after 15 days of incubation (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a><span class="elsevierStyleHsp" style=""></span>C). The microscope image of the mycelial phase showed sympodial conidiation in a daisy-petal pattern (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>D).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Fixed cutaneous sporotrichosis.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was treated with oral itraconazole in pulses of 200<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>hours for 7 consecutive days per month for 6 months,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a> leading to resolution of the condition.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Sporotrichosis is a deep mycosis with a subacute or chronic course. It is caused by the dimorphic fungus <span class="elsevierStyleItalic">S schenckii</span>. It typically affects farmers and is more common in men.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,4</span></a> The main route of inoculation is by trauma to skin soiled with contaminated material. Classic or lymphangitic sporotrichosis is the most common form of presentation. Other forms include fixed cutaneous and systemic sporotrichosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Fixed cutaneous sporotrichosis usually affects exposed areas such as the face, neck and limbs; involvement of the ears is unusual. The disease presents as an infiltrated, verrucous, or ulcerated nodule or plaque with no lymph node enlargement; it can simulate other diseases such as cutaneous leishmaniasis, lupus vulgaris, scrofuloderma, lobomycosis, nocardiosis cutaneous, chromomycosis, cutaneous B-cell lymphoma, or sarcoidosis.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,3,5</span></a> According to the literature, its fixed form is due to a good immune response in patients who have had previous contact with the microorganism, limiting the infection to the site of inoculation.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a> The frequency of the different presentations varies between geographical areas; the fixed form accounts for 10% to 30% of cases, compared with 85% for the classic lymphangitic form.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Culture is the diagnostic method of choice. The colonies have a radial appearance and have a whitish color that usually becomes coffee colored at 25<span class="elsevierStyleHsp" style=""></span>°C (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>, A and<span class="elsevierStyleHsp" style=""></span>B). The definitive diagnosis is made on observing transition from the filamentous phase to the yeast form at 37<span class="elsevierStyleHsp" style=""></span>°C (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a><span class="elsevierStyleHsp" style=""></span>C). Microscopically, mycelia formation is observed with microconidia in a daisy-petal or peach flower arrangement,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,5</span></a> as was seen in our case (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>D).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Histopathology shows no specific pattern, but can suggest the diagnosis. Epidermal hyperplasia is present, with or without ulceration, and there is a chronic inflammatory reaction with the formation of suppurative granulomas containing neutrophilic microabscesses surrounded by epithelial cells and giant cells and an external region made up of lymphocytes, plasma cells, and fibroblasts. Asteroid bodies are only observed in 20% of cases and are not therefore pathognomic.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">We have presented a patient with fixed cutaneous sporotrichosis on the auricle of the right ear, an uncommon presentation at an unusual site. The clinical characteristics of this disease can mimic other diseases of noninfectious origin, such as sarcoidosis and cutaneous B-cell lymphoma, or of infectious origin, such as scrofuloderma, lobomycosis, nocardiosis, chromomycosis, or cutaneous leishmaniasis. In tropical countries such as Colombia, the main differential diagnosis is with cutaneous leishmaniasis.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Additional Tests" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Arenas-Soto CM, Téllez-Kling AM, Alvarado-Álvarez ZL. Lesión infecciosa del pabellón auricular en el trópico. Actas Dermosifiliogr. 2016;107:599–600.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 701 "Ancho" => 435 "Tamanyo" => 74575 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 372 "Ancho" => 995 "Tamanyo" => 152024 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Epidermal hyperplasia. Dermis showing chronic diffuse inflammatory infiltrate rich in plasma cells, with granulomas with numerous giant cells and occasional polymorphonuclear neutrophils. A, Hematoxylin and eosin (H&E), original magnification<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2.5. B, H&E, original magnification<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>40.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 269 "Ancho" => 996 "Tamanyo" => 97438 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Culture of <span class="elsevierStyleItalic">Sporothrix schenckii</span>. A and B, On Sabouraud agar and potato dextrose agar after 10 days of incubation at 25<span class="elsevierStyleHsp" style=""></span>°C. C, Yeast form on Seneca agar after 15 days of incubation. D, Microscope image of the mycelial phase, with microconidia in a daisy-petal arrangement.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy and safety of itraconazole pulses vs continuous regimen in cutaneous sporotrichosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Song" 1 => "S.X. Zhong" 2 => "L. Yao" 3 => "Q. Cai" 4 => "J.F. Zhou" 5 => "Y.Y. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 6 | 12 |
| 2024 October | 71 | 58 | 129 |
| 2024 September | 60 | 25 | 85 |
| 2024 August | 91 | 59 | 150 |
| 2024 July | 95 | 31 | 126 |
| 2024 June | 85 | 26 | 111 |
| 2024 May | 88 | 35 | 123 |
| 2024 April | 83 | 28 | 111 |
| 2024 March | 83 | 23 | 106 |
| 2024 February | 68 | 31 | 99 |
| 2024 January | 69 | 33 | 102 |
| 2023 December | 86 | 20 | 106 |
| 2023 November | 90 | 20 | 110 |
| 2023 October | 111 | 19 | 130 |
| 2023 September | 67 | 21 | 88 |
| 2023 August | 51 | 21 | 72 |
| 2023 July | 69 | 32 | 101 |
| 2023 June | 59 | 20 | 79 |
| 2023 May | 90 | 23 | 113 |
| 2023 April | 81 | 25 | 106 |
| 2023 March | 65 | 29 | 94 |
| 2023 February | 55 | 20 | 75 |
| 2023 January | 91 | 27 | 118 |
| 2022 December | 81 | 41 | 122 |
| 2022 November | 23 | 23 | 46 |
| 2022 October | 25 | 23 | 48 |
| 2022 September | 29 | 40 | 69 |
| 2022 August | 22 | 33 | 55 |
| 2022 July | 24 | 30 | 54 |
| 2022 June | 31 | 28 | 59 |
| 2022 May | 51 | 34 | 85 |
| 2022 April | 53 | 38 | 91 |
| 2022 March | 50 | 43 | 93 |
| 2022 February | 51 | 21 | 72 |
| 2022 January | 45 | 42 | 87 |
| 2021 December | 33 | 31 | 64 |
| 2021 November | 52 | 45 | 97 |
| 2021 October | 69 | 47 | 116 |
| 2021 September | 44 | 33 | 77 |
| 2021 August | 63 | 28 | 91 |
| 2021 July | 95 | 23 | 118 |
| 2021 June | 30 | 18 | 48 |
| 2021 May | 30 | 43 | 73 |
| 2021 April | 98 | 50 | 148 |
| 2021 March | 86 | 27 | 113 |
| 2021 February | 50 | 32 | 82 |
| 2021 January | 45 | 14 | 59 |
| 2020 December | 34 | 23 | 57 |
| 2020 November | 25 | 21 | 46 |
| 2020 October | 21 | 13 | 34 |
| 2020 September | 28 | 14 | 42 |
| 2020 August | 26 | 19 | 45 |
| 2020 July | 23 | 12 | 35 |
| 2020 June | 29 | 33 | 62 |
| 2020 May | 29 | 19 | 48 |
| 2020 April | 36 | 17 | 53 |
| 2020 March | 31 | 11 | 42 |
| 2020 February | 8 | 0 | 8 |
| 2020 January | 2 | 0 | 2 |
| 2019 December | 9 | 0 | 9 |
| 2019 November | 2 | 0 | 2 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 2 | 0 | 2 |
| 2019 July | 6 | 0 | 6 |
| 2019 June | 12 | 0 | 12 |
| 2019 May | 5 | 0 | 5 |
| 2019 April | 3 | 4 | 7 |
| 2019 March | 1 | 1 | 2 |
| 2019 February | 3 | 0 | 3 |
| 2019 January | 4 | 0 | 4 |
| 2018 December | 9 | 0 | 9 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 8 | 0 | 8 |
| 2018 September | 4 | 0 | 4 |
| 2018 February | 40 | 2 | 42 |
| 2018 January | 38 | 12 | 50 |
| 2017 December | 52 | 7 | 59 |
| 2017 November | 37 | 7 | 44 |
| 2017 October | 69 | 8 | 77 |
| 2017 September | 42 | 5 | 47 |
| 2017 August | 48 | 6 | 54 |
| 2017 July | 38 | 7 | 45 |
| 2017 June | 42 | 6 | 48 |
| 2017 May | 42 | 6 | 48 |
| 2017 April | 31 | 7 | 38 |
| 2017 March | 23 | 5 | 28 |
| 2017 February | 25 | 12 | 37 |
| 2017 January | 29 | 7 | 36 |
| 2016 December | 38 | 17 | 55 |
| 2016 November | 36 | 16 | 52 |
| 2016 October | 31 | 28 | 59 |
| 2016 September | 1 | 0 | 1 |
| 2016 August | 1 | 0 | 1 |
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