II. Pathophysiology

  1. Saprophytic, Dimorphic fungus
  2. Prototypal example of Nodular Lymphangitis

III. Exposure risks

  1. Soil or plant debris
  2. Thorns
  3. Sphagnum moss
  4. Timber
  5. Animal Bites or scratches

IV. Signs

  1. Primary lesion after 1-12 week incubation
    1. Nodular lesion develops at site of inoculation
  2. Secondary lesions
    1. Erythematous Papules, Nodules develop up lymph chain
    2. Lesions ulcerate and drain clear serous fluid
  3. Other findings
    1. Rarely fever or regional adenopathy occur

V. Differential Diagnosis

VI. Labs

  1. Routine fluid culture negative
  2. Culture of biopsied tissue shows saprophytic fungi

VII. Management

  1. Apply warm compresses for 40 to 60 minutes per day
  2. Antifungal for 2 months after lesion resolution
    1. Itraconazole 200 mg PO qd (preferred)
    2. Terbinafine (Lamisil) 250 mg PO bid
    3. SSKI 5 drops PO tid (titrated to 40-50 drops tid)

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