Cryotherapy for treatment of sporotrichosis-rapid cure with adjuvant cryotherapy: case report.

backgroundSporotrichosis is a subcutaneous mycosis caused by various sporothrix fungus species. This ubiquitous fungal infection is more commonly seen in field/farm workers in tropical and subtropical regions. This prevalence could largely be attributed to the climatic condition favorable for harboring fungi in these regions. Cutaneous infection often occurs via inoculation of fungus into the intact skin owing to traumatic skin injuries. Clinically apparent lesions can occur anywhere in exposed part of the body and mostly these occur over upper extremities, which are prone to trauma during field, farm, agricultural works, and pet handling. Other sites of involvement are lower extremities, face, eyes, and mucous membrane rarely. Onset of clinical feature is usually seen in 2-4 weeks after inoculation of the dimorphic fungus. Various cutaneous manifestations of sporotrichosis can occur ranging from those limited to skin with ulcero-nodular lesions along lymphatics to systemic dissemination to lungs and meninges rarely. Localized form of cutaneous sporotrichosis occur in those with high degree of immunity, whereas the systemic disseminated forms occur in immunocompromised individuals. Treatment of sporotrichosis is done with oral antifungal for months until clinical recovery and in recalcitrant cases with systemic dissemination-intravenous infusion of Amphotericin-B can be used. However, this prolonged dosing until clinical recovery can be hazardous to those with hepato-cardiac comorbidity and also in pregnant females. Given the systemic side-effects that can underlie the use of antifungals for prolonged duration, treatment should be sought towards adjuvant physical modality along with oral antifungal, which decreases the risks of systemic side effects. CASE PRESENTATION: Here we report two cases- one fixed cutaneous form and other lymphangitic form of sporotrichosis, in a 32 year old and 40 year old Asian male working in rural part of Nepal. Both the patients had long standing history of ulceronodular lesions over extremities along the lymphatic channels, who were treated successfully with adjunct physical modality of treatment i.e., cryotherapy of 4-5 sessions along with oral itraconazole 200 mg for 4-5 weeks. There was complete resolution of lesion with rampant remission and no recurrence post therapy till date.

conclusionAs there is possibility of prolonged use of over-the-counter antifungal medication, lack of regular follow up and lack of laboratory monitoring, especially in the rural parts of Nepal, therapy should be tailored toward onsite physical treatment with cryotherapy in addition to oral antifungals, which can be cost effective and with decreased systemic side-effects. With proper diagnosis, overall prevalence of the disease can be estimated and clinical therapeutic trials can be performed with timely prevention of dreadful systemic complications.