Lymphocutaneous sporotrichosis of face with verrucous lesion
A 14-year-old boy from a rural background presented with a large warty lesion with minimal purulent discharge on the tip of the nose and ala nasi, as well as erythematous small plaques on the left cheek for 3 months. The lesion on the tip of the nose started as small asymptomatic erythematous papule which gradually increased to attain the present size, and later became ulcerated, crusted and warty, and enlarged to involve the adjoining left nare and ala nasi.

He also developed two more nontender, well-defined, erythematous, papulo-plaques over the left cheek along the lymphatics. He denied any history of insect bite, local trauma, or traumatic manipulation of the initial lesion, or staying in areas endemic for cutaneous leishmaniasis. His medical and family history were unremarkable. He had received repeated treatments with antibiotics at a health center without improvement. Hair and nails were normal. General physical and systemic examination did not reveal any abnormality. He was further investigated with the clinical diagnosis of chromoblastomycosis, TBVC, lupus vulgaris, and cutaneous leishmaniasis. Routine biochemistry and hematological investigations including chest X-ray were normal. Mantoux test was negative. Repeated examination for yeast cells and/or sclerotic bodies in 10% KOH mounts from lesional scrapings or Leishman Donovan (LD) bodies in Giemsa-stained tissue smears yielded no organism.

A skin biopsy from the lesion showed pseudoepitheliomatous hyperplasia with micro-abscesses formation and chronic granulomatous inflammatory infiltrate comprising lymphocytes, histiocytes, epithelioid histiocytes, and occasional multinucleated giant cells. Biopsy specimens subjected to culture on LJ medium grew no pathogen. Growth of characteristic white to grayish colonies were seen at 1 week after incubation at 25°C on Sabouraud's dextrose agar (SDA) containing chloramphenicol and cyclohexamide. These colonies became grayish black on prolonged incubation. S. schenckii species complex was identified from colony characteristics by temperature dimorphism and conversion to yeast form by subculture on brain heart infusion blood agar and incubation at 37°C for 7–10 days.

Characteristic thin hyaline septate hyphae, sessile pigmented conidia with rosette arrangement in lactophenol cotton blue (LCB) mounts were noted. The isolate could not be confirmed by gold standard molecular techniques due to unavailability. This is a limitation of the present case report. The lesions healed completely after treatment with itraconazole 100mg two times a day and supersaturated solution of potassium iodide (SSKI) 5 drops three times a day which was increased to 20 drops three times a day for 16 weeks without significant adverse effects.

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