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Sporotrichosis is a chronic fungal infection caused by Sporothrix schenckii It is worldwide in distribution; most patients have had contact with soil, sphagnum moss, or decaying wood Infection takes place when the organism is inoculated into the skin usually on the hand, arm, or foot, especially during gardening The most common form of sporotrichosis begins with a hard, nontender subcutaneous nodule This later becomes adherent to the overlying skin and ulcerates Within a few days to weeks, similar nodules develop along the lymphatics draining this area, and these may ulcerate as well The lymphatic vessels become indurated and are easily palpable Disseminated sporotrichosis is rare in the immunocompetent person but may present with widespread cutaneous, lung, bone, joint, and central nervous system involvement in immunocompromised patients, especially those with AIDS and alcohol abuse Cultures are needed to establish diagnosis Antibody tests may be useful for diagnosis of disseminated disease, especially meningitis Itraconazole, 200 400 mg orally daily for several months, is now the treatment of choice for localized disease and some milder cases of disseminated disease Terbinafine, 500 mg twice daily, also appears to have good efficacy in lymphocutaneous disease Amphotericin B intravenously, 1 2 g (see Additional Reading at the end of the chapter), is used for severe systemic infection Surgery is usually contraindicated

CHROMOBLASTOMYCOSIS (CHROMOMYCOSIS)

Chromoblastomycosis is a chronic, principally tropical cutaneous infection usually affecting young men who are agricultural workers and caused by several species of closely related black molds; Cladophialophora carrionii and Fonsecaea pedrosoi are the most common etiologic agents Lesions usually follow puncture wounds and are slowly progressive, occurring most frequently on a lower extremity The lesion begins as a papule or ulcer Over months to years, papules enlarge to become vegetating, papillomatous, verrucous elevated nodules Satellite lesions may appear along the lymphatics There may be secondary bacterial infection Elephantiasis may result The fungus is seen as brown, thick-walled, spherical, sometimes septate cells in potassium hydroxide preparations of pus or skin scrapings, which are quite sensitive for diagnosis The type of reproduction found in culture determines the species Itraconazole, 200 400 mg/d orally for 6 18 months, achieves a response rate of 65% Response rates may be

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The principal clinical features of the two major types of diabetes mellitus are listed for comparison in Table 27 4 Patients with type 1 diabetes have a characteristic symptom complex An absolute deficiency of insulin results in accumulation of circulating glucose and fatty acids, with consequent hyperosmolality and hyperketonemia Patients with type 2 diabetes may or may not have characteristic features The presence of obesity or a strongly positive family history for mild diabetes suggests a high risk for the development of type 2 diabetes

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1 Type 1 diabetes Increased urination is a consequence of osmotic diuresis secondary to sustained hyperglycemia This results in a loss of glucose as well as free water and electrolytes in the urine Thirst is a consequence of the hyperosmolar state, as is blurred vision, which often develops as the lenses are exposed to hyperosmolar fluids Weight loss despite normal or increased appetite is a common feature of type 1 when it develops subacutely The weight loss is initially due to depletion of water, glycogen, and triglycerides; thereafter, reduced muscle mass occurs as amino acids are diverted to form glucose and ketone bodies

Insulin Resistance Syndrome (Syndrome X; Metabolic Syndrome)

Twenty-five percent of the general nonobese nondiabetic population has insulin resistance of a magnitude similar to that seen in type 2 diabetes These insulin-resistant nondiabetic individuals are at much higher risk for developing type 2 diabetes than insulin-sensitive persons In addition to diabetes, these individuals have increased risk for elevated plasma triglycerides, lower high-density lipoproteins (HDLs), and higher blood pressure a cluster of abnormalities termed syndrome X These associations have now been expanded to include small, dense, low-density lipoprotein (LDL), hyperuricemia, abdominal obesity, prothrombotic state with increased levels of plasminogen activator inhibitor type 1 (PAI-1), and proinflammatory state These clusters of abnormalities significantly increase the risk of atherosclerotic disease It has been postulated that hyperinsulinemia and insulin resistance play a direct role in these metabolic abnormalities, but supportive evidence is inconclusive Although hyperinsulinism and hypertension often coexist in whites, that is not the case in blacks or Pima Indians Moreover, patients with hyperinsulinism due to insulinoma are not hypertensive, and there is no fall in blood pressure after surgical removal of the

Type 1 Diabetes Polyuria and thirst Weakness or fatigue Polyphagia with weight loss Recurrent blurred vision Vulvovaginitis or pruritus Peripheral neuropathy Nocturnal enuresis Often asymptomatic ++ ++ ++ + + + ++ Type 2 Diabetes + + ++ ++ ++ ++

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