Different clinical manifestations of ocular sporotrichosis in the same patient: an alert to ophthalmologists in nonendemic areas

Human and animal sporotrichosis is a subacute or chronic infection caused by thermodimorphic fungi belonging to the genus Sporothrix. It has a cosmopolitan distribution; however, there are notably endemic areas in Latin America, such as Rio de Janeiro, Brazil. This infection is classically transmitted by traumatic subcutaneous inoculation of contaminated materials such as soil, plant, or organic matter, generally associated with occupational activities such as gardening and agricul ture. In Rio de Janeiro, the zoonotic mode of trans mission, through bites, scratch, or contact with secretions of infected cats, is more common

To the editor: Human and animal sporotrichosis is a subacute or chronic infection caused by thermodimorphic fungi belonging to the genus Sporothrix. It has a cosmopoli tan distribution; however, there are notably endemic areas in Latin America, such as Rio de Janeiro, Brazil. This infection is classically transmitted by traumatic subcutaneous inoculation of contaminated materials such as soil, plant, or organic matter, generally asso ciated with occupational activities such as gardening and agricul ture (1) . In Rio de Janeiro, the zoonotic mode of trans mission, through bites, scratch, or contact with secretions of infected cats, is more common (2) .
Currently, sporotrichosis is classified in four types. The lymphocutaneous form (80% of the cases) is cha racterized by nodular or ulcerative lesions in the inocu lation site and progresses along the local lymphangitic channels. The classic cutaneous form manifests as a single lesion at the site of inoculation (1) . The extracu taneous form is uncommon and includes pulmonar, osteoarticular, ocular, or central nervous system disor ders (3) . The disseminated form of sporotrichosis occurs in immunocompromised patients (1,3) . Ocular sporotrichosis occurs due to trauma, autoino culation, or hematogenous dissemination. Granuloma tous conjunctivitis is the commonest presentation. The simultaneous occurrence of conjunctivitis and preauri cular or submandibular lymph nodes is defined as Pa rinaud's oculoglandular syndrome (2) .
Herein, we describe a case of a healthy 25yearold woman who had complaints of ocular hyperemia, mu copurulent discharge, and foreign body sensation in the left eye (OS). Her past ocular history was unremarkable. She stated that her domestic cat had sporotrichosis that was diagnosed before the initiation of ocular symptoms. Ocular examination of the OS disclosed upper eyelid edema and nodular lesions that progressed to regional lymphatic channels ( Figure 1A), bulbar and lower tarsal granulomatous conjunctivitis, and fistulizing dacryocys titis ( Figure 2). Visual acuity, tonometry, and fundoscopy revealed unremarkable findings. Ophthalmic examina tion of the right eye showed normal findings. Left pre auricular and submandibular lymph node enlargement was also observed ( Figure 1B). The patient underwent mycological examination of the ocular secretion, in which the culture was positive to Sporothrix spp. She was trea ted with itraconazole 200 mg/day orally for 3 months with improvement, but the fistula remained open.
Increased rates of human sporotrichosis caused by S. brasiliensis with the zoonotic mode of transmission have been reported in Brazil. The primary referral center for this disease, The Oswaldo Cruz Foundation (Fiocruz), in Rio de Janeiro, had registered 5000 cases of human disease during 19982015 and 5113 cases of feline disease during 19982018 (4) . In 2019, until the month of December, 242 suspected cases were reported to the health department of Rio de Janeiro, of which 214 (88.4%) were confirmed (5) .
A geographic expansion of sporotrichosis has been detected over the past 20 years. The southeastern region has the highest number of cases of human and animal sporotrichosis. In regions where only feline cases are reported, the zoonotic form may be underreported and neglected. Today, there are cases of both human and animal disease in the southeastern regions Rio Grande do Sul and Alagoas. However, cases of feline sporotri chosis, without notifications of human disease, have been reported in Santa Catarina, Paraná, Mato Grosso, and Pernambuco e Rio Grande do Norte. In the states of Paraíba, Mato Grosso do Sul, Pará, and Acre, there were cases of human and feline disease reported from other sources of communication, such as electronic media (4) .
The present case indicates a warning to Brazilian ophthalmologists who are unfamiliar with sporotricho sis. It describes the different clinical manifestations of ocular sporotrichosis in the same patient, i.e., eyelid nodular lesions with progression through lymphangitic channels, Parinaud's oculoglandular syndrome, and dacryocystitis with fistula.
As the epidemic of sporotrichosis has already expan ded from Rio de Janeiro to the other states of the southeas tern region, and progressively to other Brazilian states, there is a need for a high degree of suspicion in these cases. Epidemiological investigation must inquire aspects such as contact with cats, especially those with dermato logical diseases, and recent trips to endemic areas.