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157 EW RESIDENTS March 2015 • Excisional biopsy and intralesion- al antifungal therapy may also be beneficial in treating conjunctival granulomatous disease. EW reported in 1910 by Gifford. 12 To our knowledge, there have only been 15 cases of ophthalmic sporotrichosis documented in the United States since that time. As was the case with our patient, clues in the history and physical exam can lead a physician to investigate Sporothrix spp. as the causative organism. Diagnosis is confirmed with positive culture or histopathology. Cultures can be most effectively obtained from ma- terial aspirated from lesions, excised tissue specimens, sputum, or body fluids. Organisms are often present only in small numbers, and may not be detected on potassium hydroxide preparation or gram stain. Growth may be evident in the mold phase within days of culture but may take weeks to definitively identify. 1,24 The paucity of organisms in many cases means they are frequently not identified on histopathology, which shows a mixed granulomatous and pyogenic process. 1 When Sporothrix spp. are isolated they can be visu- alized with Gomori methenamine silver stain on high magnification. Sporotrichosis treatment varies with the location and extent of disease. Cutaneous and lymphocu- taneous disease is typically treated with oral itraconazole 200 mg daily until 2–4 weeks after resolution of the lesions. 1,25 Reports of successful treatment of conjunctival sporo- trichosis have ranged between 100 and 300 mg of oral itraconazole daily 2,6 with or without adjunctive topical fluconazole. 3 Our patient may be the first case treated with a combination of oral itraconazole, therapeutic debulking, and intrale- sional fluconazole. Outcome At follow-up 2 weeks later, the patient noted improving symptoms and reported visual acuity back to baseline. Her conjunctival lesions were smaller and her cutaneous lesions were also improving. The neomycin sulfate/polymyxin B sul- fate/dexamethasone ointment was tapered, and her conjunctival and cutaneous lesions resolved as she continued oral itraconazole treat- ment over the next few months. Take-home points • Sporotrichosis should be suspected in patients with conjunctival granulomas, especially in cases with concomitant cutaneous lesions. • Zoonotic transmission of Sporo- thrix can occur without mucocuta- neous trauma. • Lymphocutaneous and conjuncti- val sporotrichosis may be effec- tively treated with oral antifungal therapy, with or without adjunct topical therapy. zoonotic transmission from an infected cat continued on page 158

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