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EW RESIDENTS 156 March 2015 by Jared R. Jackson, MD, and Alex Cohen, MD, PhD Best corrected visual acuity was 20/20 in each eye. Pupils, confron- tation visual fields, and motility were normal. Slit lamp examination revealed raised, erythematous, gran- ulomatous lesions of the palpebral conjunctiva and caruncles bilateral- ly, left greater than right. The right cornea was clear with no fluorescein staining, and the left cornea exhibit- ed punctate epithelial erosions. The anterior chambers were deep and quiet in each eye. Dilated fundus examination was normal bilaterally. Cutaneous examination revealed erythematous, crusted lesions on the hands and arms. Discussion Conjunctival granulomas have multiple etiologies. In a patient with feline contact, Parinaud oculoglan- dular syndrome caused by Bartonella henselae should be high on the list of possible causes. Our patient did not have the typical glandular involve- ment or any history of cat scratch as would likely occur with Bartonella infection. Other causes of conjuncti- val granulomas, such as sarcoidosis, mycotic or parasitic disease, con- nective tissue disease, tuberculosis, and Kaposi sarcoma should also be considered. Given our patient's cutaneous findings and apparent zoonotic transmission, mycotic or parasitic infection was suspected. After dis- cussion with the infectious disease specialist and the veterinarian who treated the patient's cat, we were highly suspicious of mycotic infec- tion with Sporothrix spp. The patient was thus started on itraconazole 500 mg daily. The initial ocular treatment approach was to continue aggressive lubrication with artificial tears and monitor response to oral itracon- azole therapy. The patient returned to clinic 1 week later with mildly enlarged lesions, especially in the right inferior palpebral conjunctiva, and decreased visual acuity to 20/30 -2 in the right eye and 20/30 in the left, attributed to disrupted tear film and epitheliopathy. After informed consent was obtained, we proceeded with excisional "debulking" biop- sy of the inferior palpebral lesions bilaterally under local anesthesia. Excised tissue was sent for gram stain, culture, and pathologic eval- uation. Intralesional and subcon- junctival injections of fluconazole 2 mg/mL were administered to all lesions. The patient was also started on neomycin sulfate/polymyxin B sulfate/dexamethasone ophthalmic ointment twice daily, and continued on systemic itraconazole. Histopa- thology revealed mixed neutrophilic and granulomatous inflammation with giant cells and rare yeast. Gram stain showed no organisms and only a few white blood cells. Cultures grew Sporothrix schenckii. Sporothrix schenckii is a dimor- phic fungus endemic to temperate and tropical areas worldwide. Spo- rotrichosis typically presents with subacute to chronic cutaneous or lymphocutaneous involvement fol- lowing inoculation through minor skin trauma contaminated by soil or decomposing vegetable matter. 1 Airborne and zoonotic transmission may also occur. Pulmonary, osteo- articular, and disseminated forms have been documented, especially in immunocompromised hosts. 1,2 Ocular and periocular tissues may also become involved via direct in- oculation, with or without anteced- ent trauma, or through endogenous spread. 3,4 Zoonotic transmission of sporo- trichosis from cats to humans may occur without associated penetrating injury. 4,5 It is suggested that cats may be the only animal vector that can readily infect humans because feline sporotrichosis is unique in the large number of organisms associat- ed with cutaneous lesions, making non-traumatic transmission possi- ble. 5 Inoculation from feline hosts has been documented in various areas, including Brazil where it is ep- idemic in the Rio de Janeiro region. 6 Occasional cases have been reported in India, 7 the Netherlands, 8 and the United States. 4,5,9,10 Our review of the literature reveals this is the first re- ported case with ocular involvement following zoonotic transmission in the United States. Sporothrix may cause a variety of ophthalmic infections, including keratitis, 11 conjunctiva l3,12,13 and retinal granulomas, 14 scleritis, 15 nec- rotizing retinochoroiditis, 16 anterior uveitis, 17 endophthalmitis, 17,18,19,20 cutaneous eyelid infection, 21 da- cryocystitis, 22 and even a mucormy- cosis-like presentation of invasive sinusitis. 23 Ocular sporotrichosis in the United States was initially Conjunctival and cutaneous lesions following Introduction from R. Michael Siatkowski, MD, residency program director We chose this case to illustrate the broad range of pathology that residents from the Dean McGee Eye Institute encounter, as well as to highlight the work of clinician/sci- entist Alex Cohen, MD, one of our many award-winning educators at the University of Oklahoma. Case presentation A 48-year-old female was referred by an infectious disease specialist for evaluation of conjunctival lesions. The patient reported rescuing a stray cat with multiple ulcerated skin le- sions approximately 2 months prior to presentation. Shortly after initial contact with the cat, she noticed erythematous bullae on her upper extremities. These bullae eventual- ly burst, leaving crusted, ulcerated cutaneous lesions on both arms and hands. She denied any history of cat-scratch or trauma. She reported lesions inside both eyelids 1 month later, with bilateral, intermittent blurry vision secondary to excessive tearing. The patient also reported a chronic, low-grade fever during this time. The infectious disease specialist cultured and biopsied the cutaneous lesions; no organisms were identified. Past medical history was posi- tive for arthritis and migraine, for which she was taking meloxicam and hydrocodone/acetaminophen as needed, and gastroesophageal reflux. She had a surgical history of appendectomy, Caesarian section, gastric banding, and tonsillectomy. She denied HIV positivity, history of immunosuppression, and intrave- nous drug use. Academic grand rounds: Dean McGee Eye Institute Conjunctival granulomas caused by Sporothrix schenckii involving the bulbar and palpebral conjunctiva, as well as the caruncle. A: Right upper lid. B: Left upper lid. C: Right lower lid. D: Left lower lid Cutaneous lesions with areas of nodular erythema with ulceration and crusting. A: Left wrist. B: Left hand. C: Left elbow. D: Right forearm Source: Dean McGee Eye Institute A B D C A B D C

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