A 28-year-old man comes to the office due to a skin rash on his right cheek. He was exploring caves in central Pennsylvania 2 weeks ago when he sustained a scrape to his cheek from a fallen tree branch. The abrasion improved over a few days, but a red bump appeared at the injury site soon after. The bump gradually enlarged and began to drain a clear fluid with no odor. Two similar bumps then developed near the previous lesion. The patient has had no fever, malaise, cough, or shortness of breath. He does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. A 1.5-cm (0.6-in), erythematous nodule with central ulceration is present at the right jaw line. There is a minimal amount of serous drainage from the lesion. Two smaller erythematous nodules are present in the right anterior cervical area. The cervical lymph nodes are enlarged. The remainder of the physical examination is normal. Which of the following is the most likely diagnosis?

Question

A 28-year-old man comes to the office due to a skin rash on his right cheek.  He was exploring caves in central Pennsylvania 2 weeks ago when he sustained a scrape to his cheek from a fallen tree branch.  The abrasion improved over a few days, but a red bump appeared at the injury site soon after.  The bump gradually enlarged and began to drain a clear fluid with no odor.  Two similar bumps then developed near the previous lesion.  The patient has had no fever, malaise, cough, or shortness of breath.  He does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits.  A 1.5-cm (0.6-in), erythematous nodule with central ulceration is present at the right jaw line.  There is a minimal amount of serous drainage from the lesion.  Two smaller erythematous nodules are present in the right anterior cervical area.  The cervical lymph nodes are enlarged.  The remainder of the physical examination is normal.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c17a_e57d_8f63_99f867e4dd5c_MD0005_00 This patient who sustained a scratch from a fallen tree branch developed a nodular, ulcerative lesion at the site of injury and similar lesions along the proximal lymphatic chain, suggesting sporotrichosis. Sporothrix schenckii is a low-virulence, dimorphic fungus found in soil and decaying plant matter. Humans acquire the infection when the organism is inoculated into the skin or subcutaneous tissue. As such, sporotrichosis typically occurs in those who engage in outdoor vocational or recreational activities such as landscaping or gardening. The first manifestation is typically a painless papule at the site of inoculation, which soon ulcerates and drains a nonpurulent, odorless fluid. Over days, similar lesions usually develop along the proximal lymphatic chain. History and physical examination are often sufficient for diagnosis, but cultures from aspirate fluid are typically obtained. Treatment with 3-6 months of itraconazole is usually curative. (Choice A) Blastomycosis is a fungal infection that primarily affects the lungs (pneumonia) but may occasionally cause verrucous skin lesions with heaped-up borders (not papular ulcerative lesions). (Choice B) Cervicofacial actinomycosis is a bacterial infection at or near the jaw. Manifestations include a slow-growing, nontender mass that eventually evolves into multiple abscesses, fistulas, and sinus tracks that drain a thick, yellow, serous discharge with granules. This patient with a nodular papular lesion and similar lesions along the lymphatic chain is more likely to have sporotrichosis. (Choice C) Coccidioidomycosis is a fungal infection that primarily affects the lungs (community-acquired pneumonia) and central nervous system but may occasionally cause skin manifestations. Skin lesions are typically soft tissue abscesses, not slowly growing papules that drain nonpurulent, odorless fluid. (Choice D) Histoplasmosis is a fungus that primarily affects the lungs but may occasionally cause a progressive extrapulmonary infection. Disseminated histoplasmosis may be associated with nodular, papular, or plaque-like skin lesions, but patients usually have systemic symptoms (eg, fever, fatigue, weight loss) and are clinically ill. Educational objective: Sporotrichosis is a fungal infection due to direct inoculation of the fungus Sporothrix schenckii into the skin or subcutaneous tissue. Most cases arise in those who engage in outdoor vocational or recreational activities. Manifestations are subacute or chronic and include a papule at the site of inoculation that eventually ulcerates and drains a clear, odorless fluid. Similar lesions may arise over time along the draining lymphatic chain.

A 28-Year-Old Man Comes to the Office Due to a Skin