Disseminated histoplasmosis presenting as pyoderma gangrenosum-like lesions in a patient with acquired immunodeficiency syndrome

A 33-year-old Hispanic woman with newly diagnosed human immunodeficiency virus (HIV) infection, a CD4 T-lymphocyte count of 2, viral load of 730,000 copies/mL, candidal esophagitis, seizure disorder, a history of bacterial pneumonia, and recent weight loss was admitted with tonic clonic seizure. On admission, her vital signs were: pulse of 88, respiration rate of 18, temperature of 37.7 degrees C, and blood pressure of 126/76. Her only medication was phenytoin. On examination, the patient was found to have multiple umbilicated papules on her face, as well as painful, erythematous, large, punched-out ulcers on the nose, face, trunk, and extremities of 3 months' duration (Fig. 1). The borders of the ulcers were irregular, raised, boggy, and undermined, while the base contained hemorrhagic exudate partially covered with necrotic eschar. The largest ulcer on the left mandible was 4 cm in diameter. The oral cavity was clear. Because of her subtherapeutic phenytoin level, the medication dose was adjusted, and she was empirically treated with Unasyn for presumptive bacterial infection. Chest radiograph and head computed tomography (CT) scan were within normal limits. Sputum for acid-fast bacilli (AFB) smear was negative. Serologic studies, including Histoplasma antibodies, toxoplasmosis immunoglobulin M (IgM), rapid plasma reagin (RPR), hepatitis C virus (HCV), and hepatitis B virus (HBV) antibodies were all negative. Examination of the cerebrospinal fluid was within normal limits without the presence of cryptococcal antigen. Blood and cerebrospinal cultures for bacteria, mycobacteria, and fungi were all negative. Viral culture from one of the lesions was also negative. The analysis of her complete blood count showed: white blood count, 2300/microl; hemoglobin, 8.5 g/dL; hematocrit, 25.7%; and platelets, 114,000/microl. Two days after admission, the dermatology service was asked to evaluate the patient. Although the umbilicated papules on the patient's face resembled lesions of molluscum contagiosum, other infectious processes considered in the differential diagnosis included histoplasmosis, cryptococcosis, and Penicillium marnefei. In addition, the morphology of the ulcers, particularly that on the left mandible, resembled lesions of pyoderma gangrenosum. A skin biopsy was performed on an ulcer on the chest. Histopathologic examination revealed granulomatous dermatitis with multiple budding yeast forms, predominantly within histiocytes, with few organisms residing extracellularly. Methenamine silver stain confirmed the presence of 2-4 microm fungal spores suggestive of Histoplasma capsulatum (Fig. 2). Because of the patient's deteriorating condition, intravenous amphotericin B was initiated after tissue culture was obtained. Within the first week of treatment, the skin lesions started to resolve. Histoplasma capsulatum was later isolated by culture, confirming the diagnosis. The patient was continued on amphotericin B for a total of 10 weeks, and was started on lamivudine, stavudine, and nelfinavir for her HIV infection during hospitalization. After amphotericin B therapy, the patient was placed on life-long suppressive therapy with itraconazole. Follow-up at 9 months after the initial presentation revealed no evidence of relapse of histoplasmosis.     

Cutaneous histoplasmosis associated with acquired immunodeficiency syndrome (AIDS)

A 30‐year‐old man, who had originally been admitted to the Centro Dermatológico Pascua for medical attention and was later transferred to the Hospital General de México, presented with a 2‐month history of progressive dermatosis affecting the head (face, ear lobes, oral cavity), trunk (all faces), upper and lower limbs (including the palms and soles), external genitalia, and the perianal region. The patient had no history of homosexuality, but did have a long history of sexual intercourse with prostitutes in the city of Ciudad del Carmen (island in southeastern Mexico), where he was born and lives. The dermatosis consisted of multiple nodules and ulcerative lesions, some of them isolated and others with junctions between them, forming verrucous plaques. He complained of mild pruritus and pain. The lesions had first appeared on the face and, over the course of 2 months, had increased in size and number and were accompanied by malaise, fever, and loss of 6 kg of body weight ( Fig. 1 ). The presumptive clinical diagnosis was leishmaniasis, an endemic disease in the area where he lives. Laboratory parameters at presentation included the following: hemoglobin 11.5 g/dL; hematocrit 34%; white blood cells (WBC) total 7900 cells/mm³ ; lymphocytes total 1414 cells/mm³ ; platelets 449,000/mm³ ; CD4+ lymphocytes 1.5% and CD8+ lymphocytes 81.0%, with a CD4/CD8 ratio of 0.18 cells/mm^3. Blood chemistry, hepatic function tests, and serum electrolyte determinations were all within normal ranges. A chest roentgenogram was also normal. Human immunodeficiency virus (HIV) seropositivity was tested by enzyme‐linked immunosorbent assay (ELISA) and confirmed by Western blot.

Figure 1 Open in figure viewer PowerPoint Initial lesions: nodules, ulcers, and verrucous lesions involving the face     

Cutaneous cytomegalovirus infection in a patient with acquired immunodeficiency syndrome

Cytomegalovirus (CMV) infection in immunocompromised patients is a common opportunistic systemic infection which can lead to death, and usually presents with visceral manifestations, especially of the lung, brain, eye, and gastrointestinal tract. Cutaneous CMV infection is, however, relatively rare in immunocompromised patients. Cutaneous CMV infection can have variable clinical and histologic manifestations, and thus can be easily missed. We report a case of cutaneous CMV infection in a patient with acquired immunodeficiency syndrome, presenting as a generalized, pruritic, erythematous, maculopapular eruption.     

Cutaneous cryptococcus resembling molluscum contagiosum in a patient with acquired immunodeficiency syndrome

A hemophiliac man who tested positive for the human immunodeficiency virus presented with facial lesions resembling molluscum contagiosum as the initial manifestation of systemic cryptococcal infection. Widespread molluscum contagiosum is being seen with increasing frequency in patients who have been exposed to the human immunodeficiency virus, and examination of biopsy specimens to rule out atypical fungal infection is mandatory.     

Cutaneous cryptococcosis and Kaposi's sarcoma occurring in the same lesions in a patient with the acquired immunodeficiency syndrome

A 34-year-old woman presented with a history of fever, malaise and skin lesions. A diagnosis of Kaposi's sarcoma and acquired immunodeficiency syndrome (AIDS) was established, and in addition, the skin lesion which was biopsied also demonstrated cryptococcal infection. Disseminated cryptococcosis was later confirmed and the disease ran a florid course. The co-existence of different diseases within the same lesion is a feature of human immunodeficiency virus (HIV) infection, this being the third documented case of simultaneous Kaposi's sarcoma and cutaneous cryptococcosis occurring at the same site in a patient with AIDS. The nature of this co-existence is discussed with reference to the pathogenesis of Kaposi's sarcoma.     

Cutaneous localizations of disseminated Histoplasma capsulatum histoplasmosis in a case of acquired immunodeficiency

A widespread maculo-papular cutaneous rash appeared on a HIV-positive young bisexual Cambodian man. He was treated for Mycobacterium tuberculosis and Pneumocystis carinii infections. He had been residing in France for seven years. Histology showed, within the dermis, abundant extracellular and intramacrophagic yeast-like organisms suggestive of histoplasmosis. Cultured specimens produced a growth of colonies after three weeks on Sabouraud 4 p. 100 dextrose agar at 25 degrees C. Numerous macroconidia were found which made the species diagnosis of Histoplasma capsulatum possible. Despite initiation of therapy with amphotericin B the patient died. Cutaneous involvement with or without specific features is uncommon in disseminated histoplasmosis. The specific cutaneous lesions are protean. They rarely are the presenting sign of initial infection. Disseminated histoplasmosis has a poor prognosis in acquired immunodeficiency syndrome: amphotericin B is not curative. Maintenance suppressive therapy with ketoconazole has been recommended following amphotericin B completion, although break-through has been reported.     

Cutaneous aspergillosis and acquired immunodeficiency syndrome

BACKGROUND: Primary cutaneous aspergillosis is an uncommon finding in patients with acquired immunodeficiency syndrome (AIDS); only 13 cases have been reported in the literature. OBSERVATIONS: We describe 11 patients with primary cutaneous aspergillosis and AIDS. There does not seem to be an age, sex, race, or human immunodeficiency virus risk factor predisposition. This is a late manifestation of AIDS; patients typically have low CD4 counts (<0.050 x 10(9)/L [<50/microL]) and other AIDS-defining illnesses. The most frequent presentation is in patients with cytomegalovirus disease and neutropenia caused by ganciclovir therapy. Lesions developed at the site of occlusive dressings for an indwelling intravenous catheter site in 10 patients. Neutrophil counts may be normal at the time of diagnosis. A minor presentation is in the patient without neutropenia as a result of traumatic inoculation. Histological findings and/or culture results are required for diagnosis. Patients develop cutaneous lesions despite prophylactic therapy with fluconazole. Lesions can be treated with excision and lifelong therapy with itraconazole. CONCLUSION: Because of the potential morbidity and mortality of cutaneous aspergillosis, a high level of suspicion and prompt institution of therapy is required.     

Cutaneous T-cell lymphoma associated with the acquired immunodeficiency syndrome

Four cases of T-cell lymphoma occurring in the setting of the acquired immunodeficiency syndrome (AIDS) have been reported previously. We describe a 46-year-old man with AIDS in whom a cutaneous T-cell lymphoma with lymph node involvement developed. Immunohistochemical staining of the skin revealed the lymphoid infiltrate to be CD3+, CD4+, CD8+, and T-cell antigen receptor alpha/beta positive. Co-infection with human T-cell lymphotropic virus type I was not detected by polymerase chain reaction. Human immunodeficiency virus infection may have contributed to the development of this patient's lymphoma. This case represents the rare occurrence of cutaneous T-cell lymphoma and AIDS.