Nodules in a sporotrichoid (lymphangitic) distribution

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 …