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
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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 6 | 6 | 12 |
| 2024 Octubre | 71 | 58 | 129 |
| 2024 Septiembre | 60 | 25 | 85 |
| 2024 Agosto | 91 | 59 | 150 |
| 2024 Julio | 95 | 31 | 126 |
| 2024 Junio | 85 | 26 | 111 |
| 2024 Mayo | 88 | 35 | 123 |
| 2024 Abril | 83 | 28 | 111 |
| 2024 Marzo | 83 | 23 | 106 |
| 2024 Febrero | 68 | 31 | 99 |
| 2024 Enero | 69 | 33 | 102 |
| 2023 Diciembre | 86 | 20 | 106 |
| 2023 Noviembre | 90 | 20 | 110 |
| 2023 Octubre | 111 | 19 | 130 |
| 2023 Septiembre | 67 | 21 | 88 |
| 2023 Agosto | 51 | 21 | 72 |
| 2023 Julio | 69 | 32 | 101 |
| 2023 Junio | 59 | 20 | 79 |
| 2023 Mayo | 90 | 23 | 113 |
| 2023 Abril | 81 | 25 | 106 |
| 2023 Marzo | 65 | 29 | 94 |
| 2023 Febrero | 55 | 20 | 75 |
| 2023 Enero | 91 | 27 | 118 |
| 2022 Diciembre | 81 | 41 | 122 |
| 2022 Noviembre | 23 | 23 | 46 |
| 2022 Octubre | 25 | 23 | 48 |
| 2022 Septiembre | 29 | 40 | 69 |
| 2022 Agosto | 22 | 33 | 55 |
| 2022 Julio | 24 | 30 | 54 |
| 2022 Junio | 31 | 28 | 59 |
| 2022 Mayo | 51 | 34 | 85 |
| 2022 Abril | 53 | 38 | 91 |
| 2022 Marzo | 50 | 43 | 93 |
| 2022 Febrero | 51 | 21 | 72 |
| 2022 Enero | 45 | 42 | 87 |
| 2021 Diciembre | 33 | 31 | 64 |
| 2021 Noviembre | 52 | 45 | 97 |
| 2021 Octubre | 69 | 47 | 116 |
| 2021 Septiembre | 44 | 33 | 77 |
| 2021 Agosto | 63 | 28 | 91 |
| 2021 Julio | 95 | 23 | 118 |
| 2021 Junio | 30 | 18 | 48 |
| 2021 Mayo | 30 | 43 | 73 |
| 2021 Abril | 98 | 50 | 148 |
| 2021 Marzo | 86 | 27 | 113 |
| 2021 Febrero | 50 | 32 | 82 |
| 2021 Enero | 45 | 14 | 59 |
| 2020 Diciembre | 34 | 23 | 57 |
| 2020 Noviembre | 25 | 21 | 46 |
| 2020 Octubre | 21 | 13 | 34 |
| 2020 Septiembre | 28 | 14 | 42 |
| 2020 Agosto | 26 | 19 | 45 |
| 2020 Julio | 23 | 12 | 35 |
| 2020 Junio | 29 | 33 | 62 |
| 2020 Mayo | 29 | 19 | 48 |
| 2020 Abril | 36 | 17 | 53 |
| 2020 Marzo | 31 | 11 | 42 |
| 2020 Febrero | 8 | 0 | 8 |
| 2020 Enero | 2 | 0 | 2 |
| 2019 Diciembre | 9 | 0 | 9 |
| 2019 Noviembre | 2 | 0 | 2 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Agosto | 2 | 0 | 2 |
| 2019 Julio | 6 | 0 | 6 |
| 2019 Junio | 12 | 0 | 12 |
| 2019 Mayo | 5 | 0 | 5 |
| 2019 Abril | 3 | 4 | 7 |
| 2019 Marzo | 1 | 1 | 2 |
| 2019 Febrero | 3 | 0 | 3 |
| 2019 Enero | 4 | 0 | 4 |
| 2018 Diciembre | 9 | 0 | 9 |
| 2018 Noviembre | 2 | 0 | 2 |
| 2018 Octubre | 8 | 0 | 8 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Febrero | 40 | 2 | 42 |
| 2018 Enero | 38 | 12 | 50 |
| 2017 Diciembre | 52 | 7 | 59 |
| 2017 Noviembre | 37 | 7 | 44 |
| 2017 Octubre | 69 | 8 | 77 |
| 2017 Septiembre | 42 | 5 | 47 |
| 2017 Agosto | 48 | 6 | 54 |
| 2017 Julio | 38 | 7 | 45 |
| 2017 Junio | 42 | 6 | 48 |
| 2017 Mayo | 42 | 6 | 48 |
| 2017 Abril | 31 | 7 | 38 |
| 2017 Marzo | 23 | 5 | 28 |
| 2017 Febrero | 25 | 12 | 37 |
| 2017 Enero | 29 | 7 | 36 |
| 2016 Diciembre | 38 | 17 | 55 |
| 2016 Noviembre | 36 | 16 | 52 |
| 2016 Octubre | 31 | 28 | 59 |
| 2016 Septiembre | 1 | 0 | 1 |
| 2016 Agosto | 1 | 0 | 1 |
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