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Letter
Sporotrichosis, Plain of Jars,
Lao People's Democratic Republic
Paul N. Newton,*† Wen-Hung Chung,‡ Rattanaphone Phetsouvanh,* and
Nicholas J. White*†§![Comments](https://webarchive.library.unt.edu/eot2008/20090117111623im_/http://www.cdc.gov/ncidod/eid/images/email.gif)
*Mahosot Hospital, Vientiane, Lao People's Democratic Republic; †Churchill
Hospital, Oxford, United Kingdom; ‡Chang Gung Memorial Hospital, Taipei,
Taiwan, Republic of China; and §Mahidol University, Bangkok, Thailand
Suggested
citation for this article
To the Editor: In May 2003, a previously healthy, 42-year-old
rice farmer and miller, living on the Plain of Jars (Xieng Khuang Province)
in northeast Lao People's Democratic Republic (PDR) (Laos), dehusked and
polished glutinous rice in her hand-operated rice mill. While milling,
her hand slipped, removing the skin covering the interpharyngeal joint
of her right index finger, on a dusty, wooden part of the machine. She
did not recall the implantation of a wood splinter. During the following
4 weeks, multiple firm, erythematous lesions developed, which were not
tender, fluctuant, or itchy, at the site of the injury and on the medial
and anterior aspects of the lower and upper arm (Figure).
The lesions spread proximally from the site of injury, but they remained
confined to her right arm. She had no fever, and no lymphadenopathy developed.
Her household had no domestic animals, including cats. No systemic disease
developed, and she showed no evidence of immunosuppression, diabetes,
or alcoholism. While waiting for a diagnosis, she persuaded a surgeon
to excise all the lesions, but they soon recurred. She believed that the
only solution would be to have her arm amputated. Initial biopsy specimens
demonstrated no organisms and showed no growth on Sabouraud dextrose agar.
Without facilities for further fungal diagnostic work in Lao PDR, but
with a probable clinical diagnosis of sporotrichosis, we sent one of the
excised lesions to Taiwan for molecular analysis by previously described
methods (1,2). Polymerase chain reaction (PCR) was negative
for mycobacteria but positive for Sporothrix schenckii, the cause
of sporotrichosis, and the diagnosis was confirmed by sequencing the 18S
rRNA gene, which showed 100% identity to that of S. schenckii
(1,2). The lesions resolved with 6 months of oral itraconazole
therapy (100 mg every 12 h).
S. schenckii is a dimorphic fungus found in soil, hay,
decaying vegetation, and moss. Persons exposed to these environmental
foci, such as farmers and gardeners, are especially at risk. Percutaneous
inoculation is presumably the main method of infection, although inhalation
and insect and mammal bites and scratches, especially from armadillos
and cats, have been implicated (3,4). Our patient presumably
contracted the fungus from the wood frame of the milling machine. In the
1940s, contamination from untreated wood was responsible for an epidemic
that affected ≈3,000 gold miners in South Africa (from timbers in
the mine). Lymphocutaneous sporotrichosis is the most frequent presentation,
and the traditional treatments are oral saturated potassium iodide solution
and local hyperthermia, but oral itraconazole for 3 to 6 months is now
recommended (3,4).
Sporotrichosis has been described from North and South America, Europe,
and Japan. In Asia and Australasia, it has been described from India (5),
Taiwan (1), Australia (6), and Thailand
(7), but apparently not from Laos, Cambodia, and Burma
(Myanmar). Serologic evidence for human sporotrichosis infection is found
in highland areas of southwest Vietnam (8). At least
in part, the relative paucity of reports probably reflects the lack of
sophisticated fungal diagnostic techniques in much of Southeast Asia.
Some evidence suggests that sporotrichosis is more prevalent in tropical
environments with relatively cool temperatures and high humidity such
the Peruvian Andes (9), northwest India (5),
southwestern Vietnam (8), and in Laos in the Plain of
Jars. If this environmental association is correct, sporotrichosis may
occur more extensively in the cooler humid areas of Asia, such as the
highlands of China, Laos, Vietnam, and Burma. Sporotrichosis can disseminate
in HIV-infected patients, and this syndrome may increase as the prevalence
of HIV infection rises in these areas.
With 73% of the Lao population living on <US$2/day (10)
and one accessible microbiologic culture laboratory in Laos, PCR is not
an available local routine diagnostic technique. We were fortunate to
have access to an overseas diagnostic facility, which allowed confirmation
of the clinical diagnosis before the patient received a prolonged course
of a drug with adverse effects and drug interactions.
Diagnosis by histopathologic examination and culture may be difficult,
and identifying laboratories in different regions of the subtropics and
tropics with an interest in diagnosis of sporotrichoid lesions and the
capability to perform culture and PCR would facilitate the diagnosis and
awareness of this disease. Itraconazole, which has become the drug of
choice for lymphocutaneous sporotrichosis, is expensive. Saturated solution
of potassium iodide is an inexpensive alternative and appears to be effective,
although adverse effects occur frequently (3,4).
Acknowledgments
We thank the patient
and Chanpheng Thammavong, Tran Xuan Mai, Mayfong Mayxay, and Tran Duc
Si for their help.
This study was part
of the Wellcome Trust–Mahosot Hospital–Oxford Tropical Medicine Research
Collaboration, funded by the Wellcome Trust of Great Britain.
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Suggested citation
for this article:
Newton PN, Chung W-H,
Phetsouvanh R, White NJ. Sporotrichosis, Plain of Jars, Lao People's Democratic
Republic [letter]. Emerg Infect Dis [serial on the Internet]. 2005 Sep
[date cited]. Available from http://www.cdc.gov/ncidod/EID/vol11no09/05-0240.htm
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