Severe Multifocal Cutaneous Sporotrichosis Caused by Sporothrix brasiliensis in People Living with HIV in Southern Brazil: Cases and Review

Background: Sporothrix brasiliensis-associated sporotrichosis is an emerging zoonotic mycosis in South America, especially in Brazil. Whereas sporotrichosis is classically described as a lymphangitic disease, multifocal forms occur, predominantly in people living with HIV (PLHIV). We report two cases of severe multifocal cutaneous sporotrichosis caused by S. brasiliensis in PLHIV from a hyperendemic region in southern Rio Grande do Sul, Brazil, and review the relevant literature. Methods and Results: Both patients presented advanced immunosuppression, low CD4+ T-cell counts, and poor adherence to antiretroviral therapy, which contributed to disease progression. The first patient developed recurrent multifocal lesions over a two-year period, whereas the second progressed from extensive mucocutaneous involvement to multifocal disease with partial destruction of nasal cartilage, resulting in permanent sequelae. In both cases, S. brasiliensis was confirmed by culture and species-specific polymerase chain reaction. Isolates from both cases exhibited wild-type susceptibility to itraconazole. Treatment with itraconazole was given, with no susceptibility changes in sequential isolates recovered during disease progression nor after antifungal therapy abandonment. Conclusion: These cases highlight that extensive tissue destruction and permanent deformities, resembling that from other systemic mycoses, can occur in PLHIV. Our findings and review reinforces the importance of early HIV investigation, adherence to antiretroviral and antifungal therapies, and continuous epidemiological and antifungal susceptibility surveillance in hyperendemic regions.