The Deep Mycoses (Essentially or Potentially Systemic) L95 



exclude another mycotic infection such as coccidioidomycosis, syphilis, 

 tuberculosis, tularemia and pyoderma. The incidence <>l coccidioidomy- 

 cosis is highest in California and ol sporotrichosis in the Middle West. 

 The evolution of the lesions is usually Faster with sporotrichosis than with 

 coccidioidomycosis, and the lesions tend to ulcerate more rapidly. In coc- 

 cidioidomycosis, secondary lesions usually develop at a remote point. The 

 lesion ot actinomycosis or of blastomycosis usually differs greatly from that 

 of sporotrichosis, sinuses draining from deep lesions being present ill the 

 former condition and verrucous lesions containing miliary abscesses in 

 the latter. A syphilitic chancre or minima may be suggested when the initial 

 lesion alone is present. Absence ol concomitant symptoms and signs ol 

 syphilis may aid, but a cultural diagnosis should here be definitely estab- 

 lished, particularly since it can usually be made without difficulty. Tuber- 

 culosis develops more slowly, lesions of this character usually occurring in 

 butchers or in patients with foci elsewhere; the pus is usually not so thick or 

 profuse as in sporotrichosis, and the reaction to a high dilution of tuberculin 

 is positive. 



Since culture is the only definite method or diagnosis and since' it is 

 usually reliable, pus from any suspected lesion should be streaked on agar 

 as described on page 324. If no growth results, agglutination and cutaneous 

 tests may aid in diagnosis. The inoculation of pus into laboratory animals 

 may help. Guinea-pigs are usually immune, but rats are usually susceptible. 



The absence of enlargement of lymph nodes and of fever is usualh 

 sufficient to rule out tularemia. Pyoderma of granulomatous character is 

 unlikely unless the blood sugar level is elevated. 



(g) Prognosis.— Most patients respond well to treatment, even if the 

 disease has escaped diagnosis for several months. In rare instances, when 

 the internal organs become involved, the outlook is more serious and ther- 

 apy may not prove curative. As with the other deep mycoses, early diag- 

 nosis is of paramount importance. 



(h) Treatment.— (I) Iodides.— -The usual procedure is to administer 

 potassium iodide by mouth three times daily, beginning with 10 drops of 

 the saturated solution. The dose is increased 5 drops daily until the limit 

 of tolerance is reached. The medication should be sustained for several 

 weeks at this point, until long after all signs or symptoms of the disease have 

 disappeared. Sometimes tincture ot iodine, Lugol's solution, or colloidal 

 iodine is used, but these forms have no demonstrated superiority except in 

 isolated instances, when they may be better tolerated. The effect of iodides 

 is probably indirect, although Shaffer and Zackheim cured a patient after 

 13 weeks of therapy with iontophoresis, using a strong solution ot iodine, 

 U.S. P. According to Davis, fibroblastic elements arc stimulated, and the pro- 



