An Uncommon Etiology of Destructive Nasal Lesion

Abstract

BACKGROUNDSporotrichosis is a subacute to chronic infection caused by the dimorphic fungus of the genus Sporothrix. It is a condition found worldwide, with the majority of cases being reported in tropical countries. The most common cause of infection in humans is the Sporothrix schenckii. The incubation period can take days to months after exposure. The infection can be divided into different clinical syndromes, including cutaneous, pulmonary and disseminated. The skin disease develops after inoculation of the fungus, which is more common in activities of constant contact with the soil (gardeners and farmers) and contaminated cats. Despite being relatively common in cats, we did not find any reports or images of destructive nasal lesions in humans. CASE REPORTWe report a 58-year-old female patient, smoker, with a history of subacute lupus for 16 years, currently using hydroxychloroquine and corticosteroids ranging from 20 to 60 mg/day, without regular medical follow-up. The patient, during her first appointment in our outpatient clinic, had a 3-month history of an ulcerated, progressive and destructive lesion at the tip of her nose. Recent medical records revealed treatment for syphilis due to positive venereal disease research laboratory (VDRL) and fluorescent treponemal antibody absorption (FTA-ABS), but there was no improvement in the lesion. Given the aesthetic impact, the rapid progression of the lesion, and the lack of diagnosis, we decided to admit the patient to perform a skin biopsy. She received a course of broadspectrum antibiotic with piperacillin-tazobactam to treat a secondary cellulitis, without observable therapeutic response. A computed tomography scan of the sinus showed intact bone walls of the paranasal sinuses. The biopsy sample showed chronic granulomatous inflammation with necrosis and negative fungal investigation. Direct mycological examination of the lesion was also negative, but the culture was positive for S. schenckii, confirming the diagnosis of sporotrichosis. The patient was commenced on Itraconazole 200 mg daily and is currently under outpatient follow-up. CONCLUSIONThe case above represents an extremely rare case of an ulcerated and destructive nasal lesion caused by sporotrichosis in a patient with subacute cutaneous lupus on irregular steroid treatment. Despite these lesions being observed in felines, we did not find similar reports in humans.