TROPICAL/INFECTOPARASITARY DERMATOLOGY
Therapeutic failure with itraconazole in sporotrichosis due to bariatric surgery
Larissa Crestani
, Bruno de Castro e Souza, Priscila Kakizaki, Neusa Yuriko Sakai Valente
Corresponding author
Department of Dermatology, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil
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"paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "241" "paginaFinal" => "243" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Larissa Crestani, Bruno de Castro e Souza, Priscila Kakizaki, Neusa Yuriko Sakai Valente" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Larissa" "apellidos" => "Crestani" "email" => array:1 [ 0 => "lari_crestani@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Bruno de Castro e" "apellidos" => "Souza" ] 2 => array:2 [ "nombre" => "Priscila" "apellidos" => "Kakizaki" ] 3 => array:2 [ "nombre" => "Neusa Yuriko Sakai" "apellidos" => "Valente" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Dermatology, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 962 "Ancho" => 1674 "Tamanyo" => 117974 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Clinical picture after finishing treatment. Complete regression of lesions.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sporotrichosis is a deep mycosis caused by the dimorphic fungus of the genus <span class="elsevierStyleItalic">Sporothrix</span>. Infection occurs after inoculation and can be confined to the insertion site, reach the lymphatic system or spread.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–4</span></a> Treatment is carried out with oral or intravenous antifungals, depending on the clinical form.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a case of lymphocutaneous sporotrichosis in a patient with previous Roux-en-Y Gastric Bypass (RYGB) and unresponsive to itraconazole.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 39-year-old female patient sought care at another hospital presenting two lesions on the back of her hand and the history of previous contact with a cat knowingly affected by sporotrichosis. Due to her clinical–epidemiological diagnosis, therapy with itraconazole was initiated at 200<span class="elsevierStyleHsp" style=""></span>mg/day. However, following progression of the disease despite doubling and even tripling the dose of the medication, the patient was led to our hospital.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The examination showed nodules, 2<span class="elsevierStyleHsp" style=""></span>cm in diameter, painful, discreetly erythematous and fluctuant, following the lymphatic drainage of the right upper limb (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient reported that she had undergone RYGB surgery two years before justified by obesity.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In view of the clinical picture and therapeutic failure, we chose to perform a biopsy of a cutaneous lesion, which showed suppurative granulomatous dermatitis and was negative staining for infectious agents. The sporotrichosis diagnosis was confirmed by culture in Sabouraud agar medium and microculture (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Due to therapeutic failure, terbinafine 1<span class="elsevierStyleHsp" style=""></span>g/day was initiated. Following a four-month course, there was clinical cure following complete regression of the lesions (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In the treatment of fixed cutaneous and lymphocutaneous forms, it is recommended itraconazole at 200<span class="elsevierStyleHsp" style=""></span>mg/day while resistant patients may use up to 400<span class="elsevierStyleHsp" style=""></span>mg/day of itraconazole, initiate terbinafine 500<span class="elsevierStyleHsp" style=""></span>mg twice daily or use potassium iodide solution.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Itraconazole is a highly lipophilic medicament, requiring acidic media for absorption. Thus, factors that increase gastric pH significantly reduce its absorption.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> The absorption of terbinafine is not influenced by gastric pH.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients undergoing bariatric surgery have great potential to present malabsorption of medicines, depending on the type of procedure performed, the pharmacokinetics and pharmacodynamics of the medicament. Factors following surgical procedure that influence intestinal absorption are: delayed gastric emptying; decreased exposure of the medicine to intestinal mucosa; and changes in gastric pH.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In RYGB, there is an increase in gastric pH, altering the dissolution and solubility of some drugs, such as itraconazole. In addition to this, lipophilic drugs depend on interaction with bile acids to increase solubility, while gastric bypass decreases the exposition of these medicines with bile acids, thus affecting their absorption.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Therefore, the therapeutic failure with itraconazole is more likely related to the decrease in the absorption of the drug after changes in the gastrointestinal tract's physiology caused by the RYGB, such as the increased gastric pH and the decreased time of contact between the medication and bile acids. Terbinafine's absorption is not influenced by the above factors.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors’ contributions</span><p id="par0065" class="elsevierStylePara elsevierViewall">Larissa Crestani: Elaboration and writing of the manuscript; critical review of the literature; critical review of the manuscript.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Bruno de Castro e Souza: Conception and planning of the study; obtaining, analysis, and interpretation of the data; critical review of the literature; critical review of the manuscript.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Priscila Kakizaki: Obtaining, analysis, and interpretation of the data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Neusa Yuriko Sakai Valente: Effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:3 [ "identificador" => "xres1327254" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1223483" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-12-14" "fechaAceptado" => "2019-04-19" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1223483" "palabras" => array:4 [ 0 => "Bariatric surgery" 1 => "Itraconazole" 2 => "Sporotrichosis" 3 => "Treatment failure" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sporotrichosis is a deep mycosis of subacute or chronic evolution, caused by the dimorphic fungus of the genus <span class="elsevierStyleItalic">Sporothrix</span>. The treatment is carried out with antifungal orally or intravenously. Therapeutic success can be affected by several factors, such as altered gastrointestinal physiology by surgery. More and more patients are submitted to bariatric surgeries and the literature for the alterations of the absorption of medications in this context is very scarce. We intend to contribute to a better understanding with this case report of cutaneous-lymphatic sporotrichosis in a patient after bariatric surgery without response to itraconazole treatment, even at high doses.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Crestani L, Souza BC, Kakizaki P, Valente NYS. Therapeutic failure with itraconazole in sporotrichosis due to bariatric surgery. An Bras Dermatol. 2020;95:241–3.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 599 "Ancho" => 1740 "Tamanyo" => 77276 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical picture prior to treatment with terbinafine. Nodules approximately 2<span class="elsevierStyleHsp" style=""></span>cm in diameter, discretely erythematous that followed the lymphatic drainage pathway of the right upper limb. In some lesions there was formation of central ulcers.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1684 "Ancho" => 1207 "Tamanyo" => 98667 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Culture in Sabouraud agar medium.</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" => 962 "Ancho" => 1674 "Tamanyo" => 117974 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Clinical picture after finishing treatment. Complete regression of lesions.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Zoonotic epidemic of sporotrichosis: cat to human transmission" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "I.D. Gremião" 1 => "L.H. Miranda" 2 => "E.G. Reis" 3 => "A.M. Rodrigues" 4 => "S.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 20 | 13 | 33 |
| 2024 October | 106 | 66 | 172 |
| 2024 September | 129 | 80 | 209 |
| 2024 August | 164 | 97 | 261 |
| 2024 July | 138 | 124 | 262 |
| 2024 June | 126 | 84 | 210 |
| 2024 May | 119 | 73 | 192 |
| 2024 April | 129 | 87 | 216 |
| 2024 March | 121 | 68 | 189 |
| 2024 February | 103 | 80 | 183 |
| 2024 January | 69 | 48 | 117 |
| 2023 December | 68 | 62 | 130 |
| 2023 November | 84 | 84 | 168 |
| 2023 October | 71 | 85 | 156 |
| 2023 September | 100 | 74 | 174 |
| 2023 August | 68 | 40 | 108 |
| 2023 July | 67 | 33 | 100 |
| 2023 June | 58 | 42 | 100 |
| 2023 May | 33 | 23 | 56 |
| 2023 April | 22 | 15 | 37 |
| 2023 March | 49 | 49 | 98 |
| 2023 February | 32 | 37 | 69 |
| 2023 January | 63 | 57 | 120 |
| 2022 December | 62 | 28 | 90 |
| 2022 November | 55 | 55 | 110 |
| 2022 October | 88 | 52 | 140 |
| 2022 September | 37 | 62 | 99 |
| 2022 August | 40 | 61 | 101 |
| 2022 July | 31 | 56 | 87 |
| 2022 June | 41 | 55 | 96 |
| 2022 May | 31 | 58 | 89 |
| 2022 April | 33 | 61 | 94 |
| 2022 March | 40 | 57 | 97 |
| 2022 February | 25 | 44 | 69 |
| 2022 January | 45 | 69 | 114 |
| 2021 December | 53 | 53 | 106 |
| 2021 November | 42 | 60 | 102 |
| 2021 October | 43 | 90 | 133 |
| 2021 September | 37 | 51 | 88 |
| 2021 August | 34 | 42 | 76 |
| 2021 July | 29 | 44 | 73 |
| 2021 June | 27 | 43 | 70 |
| 2021 May | 41 | 82 | 123 |
| 2021 April | 92 | 273 | 365 |
| 2021 March | 51 | 45 | 96 |
| 2021 February | 28 | 18 | 46 |
| 2021 January | 26 | 16 | 42 |
| 2020 December | 30 | 23 | 53 |
| 2020 November | 15 | 11 | 26 |
| 2020 October | 16 | 8 | 24 |
| 2020 September | 17 | 8 | 25 |
| 2020 August | 13 | 7 | 20 |
| 2020 July | 9 | 5 | 14 |
| 2020 June | 13 | 18 | 31 |
| 2020 May | 12 | 12 | 24 |
| 2020 April | 2 | 4 | 6 |
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