Sporotrichosis, Plain of Jars, Lao People's Democratic Republic

tures of four successive annual outbreaks of bubonic plague in Mahajanga, Madagascar. To the Editor: In May 2003, a previously healthy, 42-year-old rice farmer and miller, living on the Plain of Jars (Xieng Khuang Province) in northeast Lao People's Democratic Republic (PDR) (Laos), dehusked and polished glutinous rice in her hand-operated rice mill. While milling, her hand slipped, removing the skin covering the interpharyngeal joint of her right index finger, on a dusty, wooden part of the machine. She did not recall the implantation of a wood splinter. During the following 4 weeks, multiple firm, erythematous lesions developed , which were not tender, fluctu-ant, or itchy, at the site of the injury and on the medial and anterior aspects of the lower and upper arm (Figure). The lesions spread proximally from the site of injury, but they remained confined to her right arm. She had no fever, and no lymphadenopathy developed. Her household had no domestic animals, including cats. No systemic disease developed, and she showed no evidence of immunosup-pression, diabetes, or alcoholism. While waiting for a diagnosis, she persuaded a surgeon to excise all the lesions, but they soon recurred. She believed that the only solution would be to have her arm amputated. Initial biopsy specimens demonstrated no organisms and showed no growth on Sabouraud dextrose agar. Without facilities for further fungal diagnostic work in Lao PDR, but with a probable clinical diagnosis of sporotrichosis, we sent one of the excised lesions to Taiwan for molecular analysis by previously described methods (1,2). Polymerase chain reaction (PCR) was negative for mycobacteria but positive for Sporothrix schenckii, the cause of sporotrichosis, and the diagnosis was confirmed by sequencing the 18S rRNA gene, which showed 100% identity to that of S. schenckii (1,2). The lesions resolved with 6 months of oral itraconazole therapy (100 mg every 12 h). S. schenckii is a dimorphic fungus found in soil, hay, decaying vegetation , and moss. Persons exposed to these environmental foci, such as farmers and gardeners, are especially at risk. Percutaneous inoculation is presumably the main method of infection , although inhalation and insect and mammal bites and scratches, especially from armadillos and cats, have been implicated (3,4). Our patient presumably contracted the fungus from the wood frame of the milling machine. In the 1940s, contamination from untreated wood was responsible for an epidemic that affected ≈3,000 gold miners in South Africa (from tim-bers …