Disseminated histoplasmosis: cutneous presentation

Introduction

Histoplasmosis is caused by spores of the dimorphic fungus Histoplasma capsulatum. Most cases are mild or asymptomatic. It can occur as Acute or progressive disorder, disseminated disease or as a chronic disorder. Skin lesions may occur with all the three form or rarely as primary cutaneous histoplasmosis. The disseminated disease commonly occur in persons with Immunocompromised state such as AIDS and is often rapidly fatal. The incidence and severity of fungal infection appears to increase with progression of HIV infection.[3]

We are reporting a case of disseminated histoplasmosis in a HIV positive individual presented in cutaneous form treated with amphotericin and ketoconazole with excellent response.

Case Report

A 37-year-old patient reported with complaints of multiple raised skin lesions on face, neck and hands of 2-3 months duration. History of fever and loss of weight was also present. General examination revealed undernourished, ill looking cachectic individual with gross pallor and significant generalised lymphadenopathy. Dermatological examination revealed multiple papules and nodules, distributed on face, neck, shoulders and dorsum of both hands [Figure - 1]. Few lesions showed cheesy exudate and purulent discharge also. Abdominal examination revealed hepatosplenomegaly. Respiratory system examination was essentially normal.

On investigation, he was found to be HIV positive by ELISA method and confirmed by western blot. Skin biopsy revealed granulomatous changes and fibrosis in dermis with masses of fungal cells [Figure - 2]. Bone morrow aspirate revealed PAS positive intracellular organisms. He was diagnosed as a case of Disseminated histoplasmosis and treated with Amphotericin in dosage of 0.5 mg/kg/day for 4 weeks and Ketoconazole 200 mg twice a day for 3 months with excellent response. He was continued with ketoconozole 200 mg/d fro another one year to prevent relapse.

Discussion

Cutaneous lesions in cases of disseminated histoplasmosis can be papule, pustule or plaque, ulcers, wart like and rarely may present as erythema nodosum. In AIDS patients the skin involvement in histoplasmosis should always be included in the differential diagnosis specially in patients with face and trunk papules associated with fever and hepatosplenomegaly. Skin and bone marrow cultures are the most reliable diagnostic methods.[4] The various drugs employed in treatment of hisoplasmosis are amphotericin, Ketoconazole, itraconazole and terbinafine. Itraconazole is the drug of choice for histoplasmosis.[5] Disseminated histoplasmosis in immunocompromised host go a poor prognosis. For disseminated fungal infections, suppressive therapy must be continued to prevent relapse. In the case ketoconazole was continued in low dose of 200mg OD for one year. The clinical evolution of the disease was wxceptional in this case, with disappearance of all skin lesions after the treatment with no evidence of relapse after one year.