A 38-year-old man comes to the office due to 2 weeks of mildly pruritic and uncomfortable skin lesions. He first noticed a papule on his right index finger that soon ulcerated and began draining an odorless discharge. He then developed similar nodules on his right forearm. The patient has no prior medical problems. He drinks 1 or 2 cans of beer daily. He works as a landscaper and recently began living with his girlfriend, who owns a cat. Temperature is 36.9 C (98.4 F), blood pressure is 120/80 mm Hg, and pulse is 74/min. There is a nodular ulceration with nonpurulent drainage and surrounding erythema on the right index finger. Several proximal nontender subcutaneous nodules are palpable on his right forearm. No lymphadenopathy is present. Which of the following is the most likely cause of this patient's current condition?

Question

A 38-year-old man comes to the office due to 2 weeks of mildly pruritic and uncomfortable skin lesions.  He first noticed a papule on his right index finger that soon ulcerated and began draining an odorless discharge.  He then developed similar nodules on his right forearm.  The patient has no prior medical problems.  He drinks 1 or 2 cans of beer daily.  He works as a landscaper and recently began living with his girlfriend, who owns a cat.  Temperature is 36.9 C (98.4 F), blood pressure is 120/80 mm Hg, and pulse is 74/min.  There is a nodular ulceration with nonpurulent drainage and surrounding erythema on the right index finger.  Several proximal nontender subcutaneous nodules are palpable on his right forearm.  No lymphadenopathy is present.  Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d46d_43ce_bc81_6b468fd10698_MD0003_00 Sporothrix schenckii is a fungus found in decaying vegetation and soil. Infections occur via direct inoculation; landscapers and gardeners are primarily affected. A papule forms at the site of entry and soon ulcerates, draining an odorless, nonpurulent fluid. Several proximal lesions may develop along lines of lymphatic drainage. Infections rarely extend to deeper tissues or lymph nodes. Diagnosis requires aspiration or biopsy with culture. Treatment with several months of oral itraconazole is almost always curative. (Choice A) Cat scratch fever is marked by a cutaneous lesion (vesicular, erythematous, or papular) with prominent, tender, regional lymphadenopathy and possible systemic spread. This patient has no lymphadenopathy, making cat scratch fever unlikely. (Choice C) Lymphatic filariasis is caused by a nematode that is endemic to Africa, Asia, Latin America, and some parts of the Caribbean. Patients with acute disease often have systemic symptoms (fever), painful lymphadenopathy, and lymphangitis. Chronic symptoms include disfiguring edema. This patient does not have fever, lymphangitis, or lymphadenopathy. (Choice D) Hookworm larvae may cause a papular lesion at the site of entry (usually lower extremity) and proximal, intensely pruritic, reddish-brown tracks from larval migration. Multiple, nodular, ulcerating lesions that are mildly pruritic would be uncommon. (Choice E) Skin cancer typically develops from lesions that have been present for years. This patient developed multiple lesions in 2 weeks, making malignancy unlikely. (Choice F) Herpes simplex virus tends to cause painful vesicular lesions on an erythematous base, not nodular, ulcerating lesions with discharge. Educational objective: Sporothrix schenckii is a dimorphic fungus found in decaying plant matter and soil and primarily infects gardeners and landscapers (direct cutaneous inoculation). Typically, a papule forms at the inoculation site, which may ulcerate and drain nonpurulent, odorless fluid. Additional, proximal papular lesions may form along lines of lymphatic drainage. Deeper tissues and lymph nodes are usually spared, and systemic spread is rare.

A 38-Year-Old Man Comes to the Office Due to 2