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Epidemiologic Notes and Reports Sporotrichosis Associated with Wisconsin Sphagnum Moss
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: 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.
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