Abstract

Numerous organisms can result in the development of ascending nodular lymphangitis. The most common organisms responsible for the development of nodular lymphangitis include Sporothrix schenckii, Nocardia brasiliensis, nontuberculous mycobacterium, Leishmania, and Francisella tularensis. Although several organisms can be responsible, typically, one organism can be isolated and treated. The importance of determining the underlying organism is illustrated by the vast differences in treatment regimens tailored to treating fungal, mycobacterial, bacterial, or other underlying causal etiologies. We present a healthy 40-year-old male admitted to the hospital with a two-month history of non-healing, painful nodules that progressed along the arm in a sporotrichoid pattern that began after sustaining a laceration while hunting animals in the forests of Virginia. The patient was placed on broad-spectrum intravenous antibiotics. Initial biopsy with hematoxylin and eosin staining of the specimen revealed a spongiotic epidermis with a dense mixed inflammatory infiltrate composed primarily of neutrophils and lymphocytes along with neutrophil fragments, histiocytes, foamy histiocytes, and red blood cells within the dermis. Fite staining highlighted numerous mycobacteria within foamy histiocytes and a preliminary diagnosis of an atypical mycobacterial infection was suspected. Polymerase chain reaction performed at the Centers for Disease Control and Prevention was positive for Mycobacterium Lentiflavum; however, the patient’s tissue culture (obtained while on high dose IV broad-spectrum antibiotics) grew Sporothrix schenckii, clouding the clinical picture and treatment regimen. This is an interesting case of a healthy patient presenting with nodular lymphangitis complicated by the presence of two different organisms resulting in recurrence after treatment for only Sporothrix schenckii, suggesting a pathogenic role for the mycobacterial organisms in this unusual co-infection.

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