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Endgames Case Review

Nodules in a sporotrichoid (lymphangitic) distribution

BMJ 2022; 376 doi: (Published 24 March 2022) Cite this as: BMJ 2022;376:e067649
  1. Devon E McMahon, first year resident1,
  2. Cristina Thomas, fifth year postgraduate resident1,
  3. Rhea Singh, fourth year medical student2,
  4. Esther E Freeman, director, Global Health Dermatology1
  1. 1Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, US
  2. 2Virginia Commonwealth University School of Medicine, Richmond, VA, USA
  1. Correspondence to: E E Freeman efreeman{at}

A man in his 20s with well controlled Crohn’s disease on infliximab (treated for four years) presented with a two year history of painful, crusted, and ulcerated nodules in a sporotrichoid (lymphangitic) distribution on the dorsum of his left hand and distal arm (fig 1). While working on a marsh prior to symptom onset, he noticed a splinter in his left second finger. A few weeks after the splinter was removed, he developed redness of the area and multiple skin lesions. At the time, the patient was diagnosed with cellulitis, and treated with vancomycin without improvement. As the redness spread and nodules developed, there was clinical suspicion for sporotrichosis (fungal infection from Sporothrix schenckii). The patient was empirically treated with oral itraconazole for six …

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