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measuring 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm in diameter &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; One month after the onset of the condition&#44; painful erythematous nodules were observed on the lower limbs&#44; more palpable than visible&#44; accompanied by feverish episodes&#44; without any use of medication or other infectious complaints in the period &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The chest radiography did not reveal any abnormalities&#44; and no skin reaction was observed in the tuberculin skin test&#46; Samples of the ulcerated lesion were collected&#59; the direct microscopy examination &#40;DME&#41; did not show fungal structures or amastigote forms of <span class="elsevierStyleItalic">Leishmania</span> spp&#46;&#44; the polymerase chain reaction for leishmaniasis was negative&#44; and <span class="elsevierStyleItalic">Sporothrix</span> spp&#46; was observed in the culture for fungi &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46; The histopathological examination of the ulcerated lesion showed inflammation in the hypodermis with the formation of granulomas&#44; but no fungi were observed with Grocott staining&#46; The diagnosis of immunoreactive cutaneous sporotrichosis was established due to the appearance of erythema nodosum in association with the fungal infection&#44; with no other evident cause&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">In Brazil&#44; sporotrichosis has been an emerging zoonosis for the last 20 years&#46; With the advent of molecular biology techniques&#44; it has been shown that the classic agent <span class="elsevierStyleItalic">Sporothrix</span> spp&#46; consists of a group of species among which <span class="elsevierStyleItalic">S&#46; brasiliensis</span>&#44; <span class="elsevierStyleItalic">S&#46; schenckii</span>&#44; <span class="elsevierStyleItalic">S&#46; globosa</span>&#44; and <span class="elsevierStyleItalic">S&#46; luriei</span> stand out as human pathogens&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> With the epidemic of zoonotic sporotrichosis&#44; clinical forms hitherto uncommon are being described&#44; such as hypersensitivity reactions&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4&#8211;6</span></a> which can present as erythema multiforme&#44; Sweet&#39;s syndrome&#44; or erythema nodosum&#46; Patients with such presentations have an exacerbated immune response to the fungus&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a> In the present case&#44; it is interesting to observe that such immunological competence may have prevented dissemination of the pathogen through the lymphatic pathway&#44; avoiding the most common lymphocutaneous manifestation&#44; and exhibiting a localized cutaneous clinical presentation&#44; evidenced at first by the patient&#46; This clinical form is of difficult differentiation from ulcerated lesions caused by other tropical dermatoses such as tuberculosis&#44; paracoccidioidomycosis&#44; and leishmaniasis&#44; also endemic in the country&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The gold standard for the diagnosis of sporotrichosis is the isolation of the fungal agent from clinical samples&#46; Elongated yeast structures are rarely seen on direct examination&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;3&#44;7</span></a> Isolation of the agent in culture media has superior sensitivity and specificity&#46; The colonies present a blackish color and a membranous appearance&#44; sometimes showing whitish areas &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#59; in the microculture&#44; septate hyaline hyphae and conidiophores that originate primary hyaline conidia in a &#8220;daisy&#8221; arrangement are observed&#46; Similar to the direct examination&#44; most of the time histopathology has low sensitivity&#44; due to the scarcity of fungal elements in the sample&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The report of this case of sporotrichosis illustrates a rare presentation of this condition&#44; aiming to contribute to early diagnosis and treatment&#44; reducing the chronicity and morbidity of the disease&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors&#8217; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Gustavo de S&#225; Menezes Carvalho&#58; Elaboration and writing of the manuscript&#59; obtaining&#44; analyzing&#44; and interpreting the data&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">John Verrinder Veasey&#58; Approval of the final version of the manuscript&#59; conception and planning of the study&#59; elaboration and writing of the manuscript&#59; obtaining&#44; analyzing&#44; and interpreting the data&#59; effective participation in research orientation&#44; critical review of the literature&#44; critical review of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Tropical/Infectoparasitary Dermatology
Immunoreactive cutaneous sporotrichosis
Gustavo de Sá Menezes Carvalho
Autor para correspondência
gustavo.carvalho@msn.com

Corresponding author.
, John Verrinder Veasey
Dermatology Clinic, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sporotrichosis is an infection that affects humans and animals&#44; with a typically subacute or chronic evolution&#44; caused by the dimorphic fungus <span class="elsevierStyleItalic">Sporothrix</span> spp&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a> Approximately 80&#37; of patients affected by the disease present with the lymphocutaneous form<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a>&#59; cases of hypersensitivity reaction to <span class="elsevierStyleItalic">Sporothrix</span> spp&#46; are rare&#44; with few reports in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> The authors report a case of a 12-year-old girl who presented a single ulcerated lesion on the left arm with a raised erythematous edge and granular bottom&#44; measuring 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm in diameter &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; One month after the onset of the condition&#44; painful erythematous nodules were observed on the lower limbs&#44; more palpable than visible&#44; accompanied by feverish episodes&#44; without any use of medication or other infectious complaints in the period &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The chest radiography did not reveal any abnormalities&#44; and no skin reaction was observed in the tuberculin skin test&#46; Samples of the ulcerated lesion were collected&#59; the direct microscopy examination &#40;DME&#41; did not show fungal structures or amastigote forms of <span class="elsevierStyleItalic">Leishmania</span> spp&#46;&#44; the polymerase chain reaction for leishmaniasis was negative&#44; and <span class="elsevierStyleItalic">Sporothrix</span> spp&#46; was observed in the culture for fungi &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46; The histopathological examination of the ulcerated lesion showed inflammation in the hypodermis with the formation of granulomas&#44; but no fungi were observed with Grocott staining&#46; The diagnosis of immunoreactive cutaneous sporotrichosis was established due to the appearance of erythema nodosum in association with the fungal infection&#44; with no other evident cause&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">In Brazil&#44; sporotrichosis has been an emerging zoonosis for the last 20 years&#46; With the advent of molecular biology techniques&#44; it has been shown that the classic agent <span class="elsevierStyleItalic">Sporothrix</span> spp&#46; consists of a group of species among which <span class="elsevierStyleItalic">S&#46; brasiliensis</span>&#44; <span class="elsevierStyleItalic">S&#46; schenckii</span>&#44; <span class="elsevierStyleItalic">S&#46; globosa</span>&#44; and <span class="elsevierStyleItalic">S&#46; luriei</span> stand out as human pathogens&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> With the epidemic of zoonotic sporotrichosis&#44; clinical forms hitherto uncommon are being described&#44; such as hypersensitivity reactions&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4&#8211;6</span></a> which can present as erythema multiforme&#44; Sweet&#39;s syndrome&#44; or erythema nodosum&#46; Patients with such presentations have an exacerbated immune response to the fungus&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a> In the present case&#44; it is interesting to observe that such immunological competence may have prevented dissemination of the pathogen through the lymphatic pathway&#44; avoiding the most common lymphocutaneous manifestation&#44; and exhibiting a localized cutaneous clinical presentation&#44; evidenced at first by the patient&#46; This clinical form is of difficult differentiation from ulcerated lesions caused by other tropical dermatoses such as tuberculosis&#44; paracoccidioidomycosis&#44; and leishmaniasis&#44; also endemic in the country&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The gold standard for the diagnosis of sporotrichosis is the isolation of the fungal agent from clinical samples&#46; Elongated yeast structures are rarely seen on direct examination&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;3&#44;7</span></a> Isolation of the agent in culture media has superior sensitivity and specificity&#46; The colonies present a blackish color and a membranous appearance&#44; sometimes showing whitish areas &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#59; in the microculture&#44; septate hyaline hyphae and conidiophores that originate primary hyaline conidia in a &#8220;daisy&#8221; arrangement are observed&#46; Similar to the direct examination&#44; most of the time histopathology has low sensitivity&#44; due to the scarcity of fungal elements in the sample&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The report of this case of sporotrichosis illustrates a rare presentation of this condition&#44; aiming to contribute to early diagnosis and treatment&#44; reducing the chronicity and morbidity of the disease&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors&#8217; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Gustavo de S&#225; Menezes Carvalho&#58; Elaboration and writing of the manuscript&#59; obtaining&#44; analyzing&#44; and interpreting the data&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">John Verrinder Veasey&#58; Approval of the final version of the manuscript&#59; conception and planning of the study&#59; elaboration and writing of the manuscript&#59; obtaining&#44; analyzing&#44; and interpreting the data&#59; effective participation in research orientation&#44; critical review of the literature&#44; critical review of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Sporothrix</span> spp&#46; infection can occur through the inoculation of the organism in the skin through direct contact with the soil &#40;sapronotic infection&#41;&#44; through contact with animals&#44; such as infected cats and dogs &#40;zoonotic infection&#41;&#44; or less frequently <span class="elsevierStyleItalic">via</span> inhalation&#46; With a subacute or chronic evolution&#44; approximately 80&#37; of patients affected by the disease present with the lymphocutaneous form&#59; episodes associated with a hypersensitivity reaction are rare&#46; The authors report the case of a 12-year-old child with immunoreactive sporotrichosis manifested clinically as erythema nodosum lesions in the lower limbs&#44; associated with an ulcerated lesion in the left arm&#46;</p></span>"
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