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A Red, Swollen Finger

      A 75-year-old man with atrial fibrillation taking amiodarone and apixaban, heart failure with an ejection fraction of 20%, and long QT interval presented for evaluation of progressive swelling and erythema of the right fifth finger over 5 months. He had no known trauma to the hand or unusual exposures. He owned a cat and enjoyed the outdoors. On examination, he had a small nodular papule on the right fifth digit with surrounding fusiform swelling and erythema (Figure 1). The left hand was unaffected. He underwent magnetic resonance imaging of the right hand and forearm, which revealed a complex fluid collection in the extensor compartment. Aspiration of the digit was obtained, which revealed approximately 87,000 total nucleated cells with 85% neutrophils, concerning for infectious tenosynovitis. Given the chronicity of his presentation and the lack of acute systemic toxicity, indolent processes (primarily fungal, mycobacterial, or Nocardia spp.) were on the differential. The patient underwent surgical debridement. Operative culture revealed yeast forms with rare cigar bodies, which were eventually identified as Sporothrix schenckii (Figures 2 and 3).
      Figure thumbnail gr1
      Figure 1Physical examination of the right hand revealed erythema, fusiform swelling of the fifth digit, and a small papule.
      Figure thumbnail gr2
      Figure 2Cigar bodies in yeast culture, suggestive of Sporothrix spp.
      Figure thumbnail gr3
      Figure 3Conidium of Sporothrix shenckii in yeast culture.
      Sporotrichosis is an endemic mycosis caused by the eponymous dimorphic fungus. Traditionally, it has been associated with inoculation through small breaks in the skin, garnering the name “rose gardener’s disease.”
      • Kauffman C.A.
      • Pappas P.G.
      • Sobel J.D.
      • Pappas P.G.
      Sporotrichosis.
      Culture is the criterion standard for diagnosis, and often several months of treatment with itraconazole
      • de Lima Barros M.B.
      • Schubach A.O.
      • de Vasconcellos Carvalhaes de Oliveira R.
      • Martins E.B.
      • Teixeira J.L.
      • Wanke B.
      Treatment of cutaneous sporotrichosis with itraconazole—study of 645 patients.
      or terbinafine are required to eradicate the infection. This patient was treated with terbinafine because of interactions with itraconazole and apixaban
      • Vranckx P.
      • Valgimigli M.
      • Heidbuchel H.
      The significance of drug-drug and drug-food interactions of oral anticoagulation.
      as well as the negative iontropic effects and QT-prolonging properties of itraconazole.
      • Qu Y.
      • Fang M.
      • Gao B.
      • et al.
      Itraconazole decreases left ventricular contractility in isolated rabbit heart: mechanism of action.

      Acknowledgments

      We specially thank Amber Milone, BS, for providing the culture photos.

      References

        • Kauffman C.A.
        • Pappas P.G.
        • Sobel J.D.
        • Pappas P.G.
        Sporotrichosis.
        in: Kauffman C.A. Pappas P.G. Sobel J.D. Dismukes W.E. Essentials of Clinical Mycology. Springer, New York2011: 387-397
        • de Lima Barros M.B.
        • Schubach A.O.
        • de Vasconcellos Carvalhaes de Oliveira R.
        • Martins E.B.
        • Teixeira J.L.
        • Wanke B.
        Treatment of cutaneous sporotrichosis with itraconazole—study of 645 patients.
        Clin Infect Dis. 2011; 52: e200-e206
        • Vranckx P.
        • Valgimigli M.
        • Heidbuchel H.
        The significance of drug-drug and drug-food interactions of oral anticoagulation.
        Arrhythm Electrophysiol Rev. 2018; 7: 55-61
        • Qu Y.
        • Fang M.
        • Gao B.
        • et al.
        Itraconazole decreases left ventricular contractility in isolated rabbit heart: mechanism of action.
        Toxicol Appl Pharmacol. 2013; 268: 113-122