On February 2, 1981, the Wisconsin Division of Health, Bureau
of
Community Health and Prevention (BCHP), was notified of a diagnosis
of
sporotrichosis in two brothers employed at a garden center in
southeastern Wisconsin. An investigation of the garden center by
the
BCHP revealed two additional cases of sporotrichosis among the
employees. All four cases involved male high school students, aged
16
and 17, who worked part-time at the garden center. Each had
developed
an ulcerating lesion on his hand or wrist during December 1980 and
was
initially treated with antibiotics without resolution. In three of
the cases, non-tender ascending lymphangitis subsequently
developed.
Swabs of the lesions were sent to local hospital laboratories for
fungus culture; two were positive for Sporothrix schenckii. All
four
individuals were successfully treated with potassium iodide.
The garden center consists of a retail store and wholesale
greenhouse and employs approximately 80 people. Sixteen workers
made
approximately 1,000 gravesprays* during the months of November and
December 1980. The sphagnum moss used was harvested from bogs
located
in central Wisconsin and was purchased from one wholesale dealer.
Of seven male workers regularly involved in making gravesprays,
four developed sporotrichosis. The four ill workers were younger
than
the other three (mean age 16.5 vs. 31.8 years), had been employed
for
a shorter time (mean duration of employment 5.5 vs. 134 months),
and
wore gloves less often. Of three additional male employees who
occasionally helped with the production of gravesprays and six
female
employees who were involved in final decorative preparations, none
developed sporotrichosis. In an investigation of a local cemetery
where 12 employees produce 2,000-3,000 gravesprays per autumn using
sphagnum moss purchased from the same Wisconsin supplier, no
additional cases were noted. Samples of the sphagnum moss used in
December during the gravespray production at the garden center and
tested at the Mycology Laboratory, Wisconsin State Laboratory of
Hygiene, were culture-positive for S. schenckii. Additional
samples
of sphagnum moss from fresh bags at the garden center, from the
cemetery production site, and from another local garden center were
culture negative.
Reported by PL Remington, JM Vergeront, MD, Bureau of Community
Health
and Prevention, JP Davis, MD, State Epidemiologist, Wisconsin State
Dept of Health and Social Svcs; Respiratory and Special Pathogens
Br,
Bacterial Diseases Div, Center for Infectious Diseases, CDC, JF
Stoebig,
Wisconsin State Laboratory of Hygiene.
Editorial Note
Editorial Note: Sporotrichosis is a well-described, yet uncommon,
chronic infection caused by S. schenckii, a dimorphic fungus
present
worldwide in soil, plants, and decaying vegetation. Some of the
outbreaks reported among florists (1) and nursery and forestry
workers (2,3) have been associated with sphagnum moss grown in
Wisconsin (2-4). Central Wisconsin, one of the largest areas of
sphagnum-moss production in the nation, supplies moss for
horticultural use throughout the United States and Japan. Although
S.
schenckii has not been cultured from the Wisconsin bogs where the
moss
grows, this outbreak demonstrates that positive cultures can be
obtained from the moss at its point of usage.
Traumatic inoculation from the fungus results from handling
contaminated articles such as wood, rose bushes, or sphagnum moss.
Typically, lymphocutaneous sporotrichosis appears after a 1- to
12-week incubation period; it is characterized by a painless
papule,
usually on an upper extremity, which enlarges and often ulcerates.
Subsequently, multiple painless nodules may appear along the route
of
lymphatic drainage of the original lesion. Sporotrichosis is
rarely
associated with systemic symptoms. Misdiagnosis of isolated cases
has
resulted in prolonged antibiotic therapy with significant morbidity
and cost to patients (5). The diagnosis of sporotrichosis may be
made
on clinical grounds alone and can be confirmed by culturing S.
schenckii from a lesion. Lymphocutaneous sporotrichosis is
effectively treated with potassium iodide; antifungal agents are
reserved for extracutaneous involvement.
This outbreak reconfirms sphagnum moss as a vehicle for
sporotrichosis and suggests that workers in contact with the moss
may
reduce their risk of acquiring disease by wearing protective
clothing. It also emphasizes the need for physicians to consider
the
possibility of sporotrichosis when patients present non-healing
ulcerating lesions on their extremities.
References
Gastineau FM, Spolyar LW, Haynes E. Sporotrichosis: report of
six
cases among florists. JAMA 1941;117:1074-7.
Grotte M, Younger B. Sporotrichosis associated with sphagnum
moss
exposure. Arch Pathol Lab Med 1981;105:50-1.
Powell KE, Taylor A, Phillips BJ, et al. Cutaneous
sporotrichosis
in forestry workers. Epidemic due to contaminated sphagnum
moss.
JAMA 1978;240:232-5.
D'Alessio DJ, Leavens LJ, Strumpf GB, Smith CD. An outbreak of
sporotrichosis in Vermont associated with sphagnum moss as the
source of infection. N Engl J Med 1965;272:1054-8.
Kohl S, Rosen T. An unresponsive skin ulcer. Hosp Pract
1980;15:149.
*A decorative winter covering for grave sites, constructed by
weaving
balsam boughs through a matting of water-soaked sphagnum moss.
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