GUIDELINE for Sporotrichosis
The rare opportunistic mycoses guidelines were first published by Albert Lloret et al. in 2013 in the Journal of Feline Medicine and Surgery 15: 619-623; the present update has been compiled by Michèle Bergmann and ABCD colleagues with valuable input from Prof. Ralf Mueller, LMU Small Animal Clinic, Munich, Germany.
Key points
- Feline sporotrichosis is an emergent zoonotic fungal infection and is endemic in some (sub)tropical areas, with especially high prevalence in Brazil.
- Transmission between cats but also from cats to humans typically results from (traumatic) inoculation of contaminated plants and soil or via bites and scratches from infected animals, especially cats.
- Cats are most often presented with isolated or multiple skin lesions, especially nodules and ulcers. Lymphadenopathy, respiratory signs, and even fatal systemic dissemination may also occur.
- Diagnosis in general veterinary practice relies on cytology/histology and confirmation by PCR or culture.
- Treatment consists of systemic antifungal drugs, with itraconazole as first choice.
- Prognosis is usually good, if owner compliance is appropriate and adverse drug effects do not occur. Recurrence can occur if treatment is discontinued too early.
- Prevention measures include keeping cats indoors and using personal protective equipment when handling cats with skin lesions.
Agent properties
Sporothrix infections can occur in many mammalian species (including horses, camels, cattle, swine, dogs as well as in humans) but amongst domestic animals, cats are the most frequently infected; an infection was first reported in 1971 (Werner et al., 1971). Feline sporotrichosis is a deep cutaneous zoonotic mycosis, mainly caused by Sporothrix (S.) brasiliensis (predominant in South America) or S. schenckii (worldwide). Due to its worldwide distribution, the present guideline focusses mainly on S. schenckii.
The fungus exists as a hyphal or mycelial form at environmental temperatures (below 37 °C) and as a yeast form at body temperature. Several subtypes have been detected by molecular techniques; in humans, these are not correlated with the various clinical pictures or with susceptibility to treatment (Galhardo et al., 2008). In cats, however, differences in virulence have been found between subtypes of S. schenckii isolated from cats with different clinical signs, with differences between isolates from skin lesions compared to those from cats with systemic disease (Nobre et al., 2005).
Epidemiology
Prevalence
The prevalence of the disease varies markedly between regions. In South America, sporotrichosis represents the most common deep mycosis among cats. In endemic countries, like Brazil (Dos Santos et al., 2024), where large outbreaks caused by S. brasiliensis occur, feline sporotrichosis has emerged as a significant zoonotic risk (Schubach et al., 2002; Galhardo et al., 2008; Schubach et al., 2008; Oliveira et al., 2011; Rodrigues et al., 2013; Montenegro et al., 2014; Sanchotene et al., 2015). An outbreak affecting humans, cats, and dogs was reported from Rio de Janeiro (Schubach et al., 2002; Galhardo et al., 2008; Schubach et al., 2008). More than 2000 cats have been reported within seven years in just one institution showing the magnitude of the epidemics and difficulties associated with disease control (Pereira et al., 2014). Argentina experienced an increase in feline sporotrichosis cases from 2011 to 2019 (Etchecopaz et al., 2021) and, in 2022, Chile reported its first outbreak in cats in the Magallanes region (Thomson et al., 2023).
In contrast, both human and animal disease is rare in Europe, the USA, Asia, Africa and Australia. In those regions, cases have been described in particular areas, e.g. in Germany (Weingart et al., 2010; Scheufen et al., 2015), Italy (Gonzalez Cabo et al., 1989; Criseo et al., 2008), UK (Barnacle et al., 2022), Southeastern and Southwestern USA (Dunstan et al., 1986; Caravalho et al., 1991), India (Yegneswaran et al., 2009), Thailand (Yingchanakiat et al., 2023), Malaysia (Han et al., 2017), Japan (Nakamura et al., 1996; Sakai et al., 2024), South-Africa (Motswaledi et al., 2011; Fuchs et al., 2024), Western and Northern Australia (Feeney et al., 2007; McGuinness et al., 2016). Within Europe, most cases have been reported from Italy, mainly Apulia (Gonzalez Cabo et al., 1989; Barile et al., 1993; Monno et al., 2021). Thailand (Bangkok) reported an outbreak affecting 38 cats from 2017 to 2021 (Yingchanakiat et al., 2023). In the USA, 14 of 23 cases in various mammalian species in California occurred in cats (Crothers et al., 2009).
Predisposing factors
Outdoor access poses a considerable risk, especially in (endemic) areas with presence of rotting vegetation or soil (Davies and Troy, 1996). The disease is mainly reported in free-roaming intact male cats, at least in Brazil (Pereira et al., 2014).
Transmission
Most infections are thought to occur through direct contact, e.g. when the fungus is inoculated into a wound caused by a bite or scratch from an infected cat. It can be isolated from claws and skin lesions, but also from nasal and oral cavities (Fig. 1) (Schubach et al., 2001; Schubach et al., 2008). Transmission by inhalation of aerosolized fungal propagules (e.g. from cats with signs of upper respiratory tract infection) is possible but seems to occur rarely (Gremião et al., 2017; Do Monte Alves et al., 2020; De Oliveira et al., 2021).
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Fig. 1. Ulcerative lesions around the claw in a cat with sporotrichosis (Courtesy of Dr Larsson, São Paulo, Brazil)
Pathogenesis
After inoculation, infection can remain in the skin/mucosa at the site of entry or spread through the regional lymphatic system causing lymphangitis and lymphadenitis. Multiple cutaneous lesions can arise from autoinoculation during grooming or spread (De Miranda et al., 2023). Systemic dissemination throughout the body and involvement of (many) other organs, especially the lung and liver are possible (Schubach et al., 2004a; Crothers et al., 2009). The incubation period typically ranges from a few days to (occasionally several) months with an average of about 2–3 weeks in both human (Mercurio and Elewski, 1993) and animal sporotrichosis (Werner and Werner, 1994).
Immunity
Similar to humans, cats are thought to develop some immunity over time, but without reliable long-term protection; re-infection and development of lesions can occur upon re-exposure to the fungus (Gremião et al., 2015).
Th1-dependent immunity, driven by CD4+ cells and activated macrophages, is essential for the defense against the fungus; the immune response to more virulent fungal strains appears to shift toward a Th2-dominant profile, as demonstrated in both mouse and human models (Tachibana et al., 1999; Uenotsuchi et al., 2006). Cellular immunity is also considered crucial for the immune response in cats (De Miranda et al., 2016). Locally infected cats that are otherwise clinically unremarkable often have a lower fungal load and a higher proportion of CD4+ cells in their peripheral blood compared to those with systemic sporotrichosis and a poor physical condition. Although cellular immunity plays the key role, humoral immune response also contributes to the overall defense against sporotrichosis (Nascimento and Almeida, 2004).
Clinical signs
Cats with feline sporotrichosis commonly have single or multiple skin lesions (nodules/ulcers/crusts) with or without mucosal involvement and lymphadenomegaly (Schubach et al., 2004a). Lesions are frequently localised on the head (especially the nasal region and the pinna) (Fig. 2), limbs (Fig. 3, 4), digits and tail-base region, but can also be found elsewhere on the body, reflecting common areas of bites and scratches during fights. In some cases, the lesions become necrotic, exposing underlying tissues (Welsh, 2003; Crothers et al., 2009). Plaques and tumor-like lesions have also been observed (Pereira et al., 2015).
Fig. 2. Ulcerative crusted lesions in the facial area of a cat with sporotrichosis (Courtesy of Dr Larsson, São Paulo, Brazil)
Fig. 3. Multiple ulcerative crusted lesions on the forelimb of a cat with sporotrichosis
Fig. 4. Ulcerative lesions on the hind limb of a cat with sporotrichosis
Respiratory signs (sneezing, nasal discharge, dyspnoea) occur in about one third of cases and are caused by mucosal lesions (Welsh, 2003; Leme et al., 2007; Gremião et al., 2015; Scheufen et al., 2015).
Cats with systemic disease commonly suffer from systemic unspecific systemic signs (lethargy, anorexia, and fever) (Welsh, 2003; Leme et al., 2007). Some cats with systemic disease are also infected with feline immunodeficiency virus (FIV), but immunosuppression is not required for infection or clinical manifestation of Sporotrix spp. Some FIV-infected cats affected with sporotrichosis have been treated successfully, with complete resolution of the fungal lesions (Welsh, 2003; Schubach et al., 2004b).
Diagnosis
Although uncommon in Europe, sporotrichosis should be included in the differential diagnosis in cats with nodular and ulcerative skin disease. This is particularly true for outdoor (fighting) cats, if a bacterial cause was initially suspected, but the response to antibiotic treatment is poor and/or if the cat originates from an endemic area.
Cytology is often diagnostic (yeast-like organisms suggestive for Sporothrix spp.; Fig. 5).
Fig. 5. Impression smear of a cat with sporotrichosis showing neutrophils (blue arrow), erythrocytes (purple arrow)
If cytology shows yeast-like organisms intracellularly but cryptococcosis or histoplasmosis are possible clinical differential diagnoses, or if cytology is negative, PCR can be performed. While awaiting PCR results, treatment should be initiated in cases with suspected sporotrichosis. Culture should only be considered in exceptional suspicious cases, in which other tests reveal negative results.
When sampling/handling a (potentially) infected cat, it is essential to securely restrain the animal to prevent scratches or bites and for the handler to wear personal protective equipment.
Laboratory changes
Laboratory abnormalities, such as mild anaemia, neutrophilia (with or without left shift), monocytosis, eosinophilia, lymphocytosis or lymphopenia, hyperglobulinaemia, hypoalbuminaemia, and elevated liver enzyme activities, that have been reported in cats with feline sporotrichosis are not specific and are consistent with an unspecific response to an inflammatory condition (Welsh, 2003; Schubach et al., 2004a; De Miranda et al., 2023).
Diagnostic imaging
Little information is available on diagnostic imaging in feline sporotrichosis. However, pulmonary interstitial infiltrates, soft tissue swelling of bones that underlie skin lesions and osteomyelitis have been described as radiographic findings in some cases (Schubach et al., 2003a; De Miranda et al., 2023). Masses within the nasal cavity can sometimes be visualised on CT (De Miranda et al., 2023).
Detection of the infectious agent
Clinical, laboratory, and radiological signs are nonspecific and diagnosis of feline sporotrichosis requires further tests. An accurate early diagnosis is crucial for effective treatment and the control of zoonotic spread.
Direct detection
Cultur was considered the confirmatory test of choice in the past (Barros et al., 2011). However, it needs to be done in biosafety laboratories and, due to the slow-growing nature of the fungus (especially true for S. schenckii), it can take several weeks to obtain results. Promising molecular tools for diagnosis of feline sporotrichosis, such as PCR, are accessible in the meantime; they offer fast results (within days) and represent a useful alternative to culture. While awaiting results (PCR or culture), a preliminary diagnosis can be obtained quickly by cytology (or histopathology) (Domingos et al., 2025).
Cytology
Cytology can be done easily with direct microscopic detection and it is often diagnostic in cats with sporotrichosis (Pereira et al., 2011; Jessica et al., 2015; Silva et al., 2018). Smears from ulcers or fine needle aspirates from nodules should therefore always be examined (in-house). Routine staining methods are Romanowsky, Wright, Gram or Giemsa (Clinkenbeard, 1991; Gremião et al., 2021); a 40x, followed by a 100x objective lens is recommended for microscopic examination. Yeast-like organisms suggestive for Sporothrix spp. (round, oval or cigar-shape, around 3–5 µm in diameter and 5–9 µm in length) can appear within macrophages and neutrophils or sometimes also can be found extracellularly (Welsh, 2003; Pereira et al., 2011; Jessica et al., 2015). Good sensitivity (79-87%) of cytopathological examination, as compared to culture, has been demonstrated at least in cats without antifungal pretreatment (Pereira et al., 2011; Jessica et al., 2015; Silva et al., 2018). However, it has to be considered that sensitivity drops drastically after onset of antifungal treatmnt (De Miranda et al., 2018). Importantly, a negative cytology result does not rule out infection, especially when fungal burden is low (Gremião et al., 2021; De Miranda et al., 2023). Suspicious samples can be submitted for confirmatory PCR, histopathology or fungal culture.
PCR
The accuracy of PCR is influenced by several factors (PCR assay, sample selection, time of sampling). However, according to the results of a recent metaanalysis on different diagnostic tests, PCR has become a highly effective tool for diagnosing feline sporotrichosis, especially in mild or early-stage infections when the fungal burden load is (still) low and culture might still be negative. PCR from skin lesions in cats revealed a high sensitivity and high specificity (between 90–95%) and can easily be performed with (non-invasive) swab samples, especially from ulcerative lesions (Schubach et al., 2002; Civila et al., 2004; Barros et al., 2010; Domingos et al., 2025). PCR commonly used to identify S. schenckii target specific regions of the fungal genome, such as the internal transcribed spacer (ITS) or elongation factor 1-alpha (EF1α) genes. A remarkable diagnostic sensitivity (98.6%) of a (newly introduced) multiplex qPCR assay for human and feline sporotrichosis has been reported in a recent study; it has become available for cats in Europe in the Netherlands (Faculty of Veterinary Medicine, Utrecht University) (Della Terra et al., 2022).
Histopathology
Histopathological examination is useful to diagnose sporotrichosis e.g. in cases with intact nodules; however, biopsies are required. The histopathological pattern is similar to other fungal infections with a nodular to diffuse pyogranulomatous inflammatory reaction involving the dermis and subcutaneous tissues, sometimes extending into deeper tissues (Crothers et al., 2009; De Miranda et al., 2010; De Miranda et al., 2013). The organisms, usually inside macrophages, are usually numerous and readily visualised upon hematoxylin-eosin staining (Fig. 6); when they are scarce, special periodic acid-Schiff (PAS) staining is useful to improve sensitivity (Crothers et al., 2009). Cats with few and well-organised granulomas tend to have low numbers of fungal organisms in the lesions. Cats with poor general condition and many granulomas have larger numbers of fungal organisms (De Miranda et al., 2013).
Fig. 6. Pyogranulomatous inflammatory reaction showing numerous sporothrix organisms within macrophages
Fungal culture
Biopsies should be taken in cats with nodules (Schubach et al., 2004a; Madrid et al., 2012). Exudate swab samples are best collected from ulcers (Pereira et al., 2011; De Miranda et al., 2023). Blood fungal culture is recommended if systemic disease is suspected (Schubach et al., 2003b). In cats with respiratory signs, the fungus has (also) been successfully cultured from nasal swabs and bronchoalveolar lavage samples (Leme et al., 2007). It is important not to do a commercial fungal culture in private practice without protective measures but to send it to a laboratory and notify the laboratory of the suspicion of Sporotrix spp. infection for adequate handling of the samples.
Indirect detection
An ELISA for the detection of Sporothrix spp. antibodies has been developed and evaluated in cats with sporotrichosis from endemic areas, showing good sensitivity and specificity (over 90%) in these populations. It could serve as a screening and treatment monitoring tool for feline sporotrichosis (Fernandes et al., 2011), but at present it is not routinely used in veterinary practice and further studies are needed.
Treatment
Systemic antifungal treatment
Prospective studies on the treatment of feline sporotrichosis are scarce. The first-line treatment for feline sporotrichosis is itraconazole (Crothers et al., 2009; Pereira et al., 2010; Barros et al., 2011; Barrs et al., 2024). The oral itraconazole solution (1.25 to 3 up to even 4 mg/kg q24h PO) has a higher bioavailability compared to capsules (Barrs et al., 2024; Gremião et al., 2021). When giving capsules, absorption can be increased when given with food (5 mg/kg q12h or 10 to 12.5 mg/kg q12–24h PO) (De Miranda et al., 2023; Barrs et al., 2024). Itraconazol treatment should be continued for one month beyond clinical cure; for a successful outcome, it often has to be given for at least 4–6 (and up to 12) months (Clinkenbeard, 1991; Barrs et al., 2024).
Itraconazol monotherapy in cats with multiple lesions and a high fungal burden or nasal lesion and respiratory signs can be associated with recurrence of signs (Pereira et al., 2010; De Miranda et al., 2018; De Souza et al., 2018); therefore, in cats with nasal lesions and respiratory signs, treatment should be maintained for two months beyond clinical cure (Gremião et al., 2021). Itraconazole is potentially hepatotoxic and thus contraindicated in cats with severe concurrent liver disease. Baseline measurements of serum liver enzyme activity (especially alanine aminotransferase) should be performed before treatment initiation and subsequently monthly during treatment. Furthermore, cat owners should be alerted to clinical signs suggestive for hepatic disease (e.g. jaundice). If hepatotoxicity occurs, treatment should be stopped for approximately 7 days until liver enzyme activities return to normal. Afterwards, the dose can be reduced by 50% at restart, or an alternative azole with similar efficacy but a lower hepatotoxicity profile can be considered. Besides liver toxicity, gastrointestinal signs, especially anorexia and vomiting, have also been described during itraconazole therapy (Barrs et al., 2024).
Oral potassium iodide is the treatment of choice for sporotrichosis in dogs. A study in 48 cats treated with potassium iodide capsules (variable doses from 2.5 mg/kg to 20 mg/kg every 24 hours) showed a success rate of only 47.9% (Reis et al., 2012). However, the combination of potassium iodide and itraconazole revealed a success rate of 96.2% in 30 cats (Reis et al., 2016). Adverse effects of potassium iodine include anorexia, vomiting, hypothermia, hyperthermia, cardiovascular failure, cardiomyopathy, hyperexcitability, muscular spasm, ptyalism, and diarrhoea (Dunstan et al., 1986; Reis et al., 2016). In Brazil, the combination of itraconazole and potassium iodide is considered as an effective option in cases suspicious for treatment failure with itraconazole alone (Da Rocha et al., 2018; Gremião et al., 2021).
Ketoconazole is (commonly) used in dogs as an alternative to potassium iodide. It has also been used in cats, but adverse hepatic effects are more frequent compared to itraconazole and therefore it is not a first-choice drug in cats (Pereira et al., 2010).
Terbinafine (allylamine derivative) also has efficacy in humans and dogs with sporotrichosis (Francesconi et al., 2009; Francesconi et al., 2011; Viana et al., 2018). It might be an alternative for the treatment of cats that do not tolerate itraconazole (Meinerz et al., 2007). A synergistic effect of itraconazole and terbinafine was also reported, making it a recommended option for first-line combination therapy (Barrs et al., 2024).
In a large retrospective study in Brazil, various regimens and combinations of antifungals, including itraconazole plus potassium iodide, itraconazole plus fluconazole, itraconazole plus terbinafine and ketoconazole alone were examined. With these varied treatment protocols, about one fifth of the cats was cured (68/347); in the remaining cats, some clinical improvement was observed (Schubach et al., 2004a). In a retrospective study in California, 8/12 cats were successfully treated with itraconazole and reached clinical cure within 2–6 months. One cat received treatment with sodium iodide for six weeks, during which new lesions appeared and were only resolved following itraconazole treatment. Efficacy of potassium iodide given to one cat during one week prior to itraconazole treatment remains unknown. One cat with systemic disease was treated with fluconazole; remission of skin lesions and respiratory signs was observed within three months. When treatment was withdrawn three months after clinical cure, disease signs re-emerged within three weeks. Fluconazole was restarted (and applied for one year) and led to clinical cure (Crothers et al., 2009).
Local antifungal treatment
Intralesional amphotericin B treatment was documented in case reports and in a case series of 26 cats (in combination with itraconazole) and was successful to treat refractory skin disease (Meinerz et al., 2007; Francesconi et al., 2009; Gremião et al., 2009; Gremião et al., 2011).
Local surgical treatment
Surgical resection (Gremião et al., 2006; Hirano et al., 2006), cryosurgery (Souza et al., 2016) and thermotherapy (Honse et al., 2010) can be alternative options or can be combined with antifungal treatment. However, depending on the affected area, conventional surgical procedures might be difficult or even impossible to perform; particularly in cases involving facial lesions. The combination of cryosurgery and antifungal treatment was shown to be effective and led to cure of 11/13 cats with skin lesions (Souza et al., 2016).
Supportive treatment
Concurrent bacterial infection, which is common, must be treated with an appropriate antibiotic for 1–2 months based on culture and sensitivity (De Miranda et al., 2023).
Prognosis
The prognosis is usually good, if treatment duration and owner compliance are adequate (Welsh, 2003; Crothers et al., 2009). However, prognosis is poor in systemic infections or if treatment is discontinued before the end of the recommended regime (Welsh, 2003).
Vaccination
So far, vaccines for preventing sporotrichosis are not available.
Prevention
As a preventive measure, cats should be kept indoors or in confined outdoor areas in endemic regions to avoid contact with infected cats. Owners moving to endemic areas, like Central and South America, should be informed about sporotrichosis, especially if cats will be allowed to have access to outdoors; those cats should be neutered to reduce roaming (Gremião et al., 2021).
Disease control in specific situations
Early diagnosis and antifungal treatment of infected cats is crucial for disease control. Infected cats should be isolated from other animals and humans. Surfaces that are (potentially) contaminated should be cleaned and disinfected with sodium hypochlorite solution (1%) for 10 minutes followed by alcohol (70%) (Schubach et al., 2005). Carcasses should not be buried outside due risk of contamination (Silva et al., 2012). Public awareness and population education can help to control the spread of the fungus.
Zoonotic risk
S. schenckii is found worldwide in soil, wood, plants and decaying organic material. Human infections are mainly caused by (traumatic) inoculation of contaminated soil or organic material (sphagnum moss, hay bales, mould, plant thorns, wood splinters) which occur most commonly in forestry workers, but also after contact with animals (fish spines, squirrel bites, armadillo scratches as well as contact to draining lesions, scratches or bites of infected cats or dogs) (De Miranda et al., 2023). Many human cases are considered to originate from infected cats. Even healthy cats that had been in contact with infected cats pose a risk, as samples in the oral cavity, nasal cavity and/or nails in healthy cats have tested positive in culture (Schubach et al., 2002; Kovarik et al., 2008).
Close contact to infected cats is an important source of zoonotic infection. In recent years, a growing number of human cases has been described, which were infected after contact with sick or healthy carrier cats in endemic countries, like Brazil or India (Barros et al., 2004; Yegneswaran et al., 2009; Cordeiro et al., 2011). A genuine epidemic of human sporotrichosis associated with transmission by cats occurred in Brazil in the past (Schubach et al., 2005; Santos et al., 2024). This route of human infection is considered very important and more common than spread from vegetal or organic environmental sources. Cats are more efficient transmitters than other animals, presumably because larger amounts of the fungus are present in tissues, exudates and even faeces, and the infection can be even transmitted in the absence of penetrating skin lesions (Dunstan et al., 1986).
Veterinarians and persons handling infected cats are at a high risk of acquiring the infection. It is recommended to always wear personal protective equipment including disposable gloves when handling cats with any kind of (ulcerated) skin lesions, especially in areas where the infection is endemic. When sampling/handling a (potentially) infected cat, care must be taken to avoid scratches and bites (Barros et al., 2008). Also when handling samples of infected cats (e. g., in a laboratory) specific protection methods have to be considered. Immunocompromised humans should avoid contact to infected animals (Hardman et al., 2005; Moreira et al., 2015); they are particularly at risk (Queiroz-Telles et al., 2019; Lima et al., 2023). Pregnant women might have more severe disease courses and foetal risk poses an additional challenge in disease management (Freitas et al., 2024).
Acknowledgement
The ABCD Europe is grateful to Dr. Han Hock Siew, CityU Veterinary Medical Centre, Hongkong, China, and Prof. Lluís Ferrer of the Department of Animal Medicine and Surgery, Malalties infeccioses-inflamatòries en animals de companyia (MIAC), Veterinary School of the Universitat Autònoma de Barcelona (UAB), Spain, who have contributed to this article. ABCD gratefully acknowledges the support of Boehringer Ingelheim (the founding sponsor of the ABCD), MSD Animal Health, Vetoquinol, Virbac and IDEXX.
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