Disseminated histoplasmosis detected by lingual and tonsillar erosions in an immunocompetent patient

BACKGROUND: Histioplasmosis is a usually asymptomatic fungal infection. In the immunocompetent patient, it leads to chronic disseminated infection. Mucosal involvement is common and can provide the diagnosis. CASE REPORT: A metropolitan Frenchman with a history of alcoholism and smoking and living in Guyana consulted for lingual and tonsil erosion. Squamous cell carcinoma was suspected but not confirmed at pathology. The patient had a bi-apical infiltration on the chest x-ray and was treated empirically for tuberculosis. The diagnosis of histoplasmosis was reached when rare Histoplasma capsulatum were evidenced from a buccal swab. Itraconazole led to cure in 6 months. DISCUSSION: This case illustrates the importance of mucosal signs in the diagnosis of disseminated histoplasmosis in immunocompetent subjects. Histoplasmosis is rarely the cause of active infection in immunocompetent subjects. In these patients, the fungal infection generally progresses to chronic dissemination. Mucosal signs are frequent in this form but are rare in case of cutaneous histoplasmosis. Itraconazole (200 mg/d) is indicated for 6 months.     

Disseminated primary cutaneous histoplasmosis successfully treated with itraconazole

A 60-year-old immunocompetent lady with disseminated primary cutaneous histoplasmosis is reported. Histology showed a granulomatous skin infiltrate with numerous intracellular PAS positive rounded yeast cells within macrophages. Culture on Sabouraud's dextrose agar yielded a typical cottony white colony characteristic of Histoplasma capsulatum. Treatment with itraconazole showed an excellent response.     

Progressive disseminated histoplasmosis in acquired immune deficiency syndrome: presentation as a steroid-responsive dermatosis

We describe a patient with acquired immune deficiency syndrome (AIDS) and disseminated histoplasmosis. He presented with a mild inflammatory dermatitis that improved with topical steroid treatment but was proven to be cutaneous histoplasmosis. The clinical presentations, diagnosis, histopathologic basis, and treatment of disseminated Histoplasma capsulatum in patients with AIDS are discussed.     

Cutaneous ulcer in an immunosuppressed patient with adult onset Still's disease: primary cutaneous histoplasmosis?

Histoplasmosis is caused by the dimorphic fungus Histoplasma capsulatum.Primary infection occurs through inhalation of spores from the air. Immunocompetent individuals are usually asymptomatic, but may develop pulmonary disease. Immunocompromised patients tend to present systemic histoplasmosis with cutaneous lesions occurring by secondary invasion. In this case report, we describe a probable primary cutaneous histoplasmosis (PCH) in a patient with adult onset Still''s disease under immunosuppression.     

Disseminated Cutaneous Histoplasmosis,an Initial Manifestation of HIV,Diagnosed with Fine Needle Aspiration Cytology

Acute progressive disseminated histoplasmosis (PDH) may be the initial manifestation of human immunodeficiency virus (HIV). However, cutaneous involvement is very rare. We present an unusual case of acute PDH with multiple diffuse cutaneous papulonodular lesions predominantly on the face, trunk, and upper extremities, diagnosed initially with fine needle aspiration cytology (FNAC). Subsequent serological tests revealed positivity for antibodies for HIV 1 and 2. The cytomorphological features were further confirmed by biopsy and histochemical stains. FNAC is a rapid, cost-effective tool that may be utilized in the diagnosis of papulonodular forms of PDH and for initiating prompt therapy. We discuss the clinical features, clinical differentials, and treatment of the condition.     

Mucocutaneous nasal histoplasmosis in an immunocompetent young adult

A case of mucocutaneous nasal histoplasmosis in an immunocompetent host is described below. A 30-year-old male had a broadened nose with swelling and repeated blockage of nasal passages for the past six months. Diagnosis was made on the basis of histological demonstration of characteristic yeast cells of Histoplasma capsulatum var. capsulatum occurring within histiocytes and extracellularly in stained smears of fine needle aspirates and biopsy from the lesions in ala of the nose and perioral region. The patient showed appreciable regression of lesions after three weeks of itraconazole therapy but was not available for re-assessment.     

Cutaneous lesions of histoplasmosis with transepidermal elimination in a patient with acquired immunodeficiency syndrome

Histoplasma capsulatum is a dimorphic pathogenic fungus that produces a variety of self-limiting disease syndromes in healthy persons, but commonly disseminates in immunocompromised hosts. Although histoplasmosis has been recently described in patients with acquired immunodeficiency syndrome, it is an uncommon finding, occurring in fewer than 0.5 percent of patients with acquired immunodeficiency syndrome. We are reporting a second case of disseminated histoplasmosis presenting as keratotic papules with transepidermal elimination of Histoplasma capsulatum. Our case demonstrates the importance of including histoplasmosis in the differential diagnosis of keratotic papules occurring in patients with acquired immunodeficiency syndrome.     

Manifestaciones mucocutáneas de la infección por Histoplasma capsulatum en pacientes inmunosuprimidos

Histoplasmosis is a systemic mycosis caused by the dimorphous fungus Histoplasma capsulatum (H. capsulatum). The fungus enters the body through the respiratory tract in the form of microconidia, which are transformed into intracellular yeast-like structures in the lungs before disseminating hematogenously. Primary infection is usually asymptomatic and self-resolving. Some patients develop severe disease with acute or chronic respiratory involvement. Immunosuppressed patients, mainly those with altered cellular immunity, may have disseminated disease with variable mucocutaneous involvement characterized by papules, nodules, gummas, or ulcers with a granulomatous base. We report the case of 3 HIV-negative patients infected by H capsulatum in whom diagnosis based on the skin lesions proved essential for early initiation of treatment.     

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 manifestations of deep mycosis: an experience in a tropical pathology laboratory

Background:

Cutaneous manifestations of deep mycotic infection are fraught with delayed or misdiagnosis from mainly cutaneous neoplastic lesions.

Aim:

This study is designed to present our experience of these mycoses in a pathology laboratory in the tropics.

Materials and Methods:

A clinicopathologic analysis of deep mycotic infections was conducted over a 15 years period Formalin fixed and paraffin wax processed biopsies were stained with hematoxylin and eosin, periodic acid Schiff (PAS), and Grocott''s methenamine silver (GMS) for the identification of fungus specie. Patients’ bio-data and clinical information were obtained from records.

Results:

Twenty males and seven females presented with 6 months to 6 years histories of varying symptoms of slow growing facial swellings, nodules, subcutaneous frontal skull swelling, proptosis, nasal blockage, epistaxis, discharging leg sinuses, flank mass, convulsion and pain. Of the 27 patients, four gave antecedent history of trauma, two had recurrent lesions which necessitated maxilectomy, two presented with convulsion without motor dysfunction while one had associated erosion of the small bones of the foot. None of the patients had debilitating illnesses such as diabetes mellitus, tuberculosis, and HIV infection. Tissue histology revealed histoplasmosis (10), mycetoma (9), subcutaneous phycomycosis (6), and phaeohyphomycosis (2).

Conclusion:

Deep mycoses may present primarily as cutaneous lesions in immunocompetent persons and often elicit distinct histologic inflammatory response characterized by granuloma formation. Diagnosis in resource constraint setting can be achieved with tissue stained with PAS and GMS which identifies implicated fungus. Clinical recognition and adequate knowledge of the pathology of these mycoses may reduce attendant patient morbidity.     

Blastomycosis presenting as solitary nodule: a rare presentation

Blastomycosis is a chronic granulomatous and suppurative mycosis, caused by Blastomyces dermatitidis, which in the great majority of cases presents as a primary pulmonary disease. Primary cutaneous blastomycosis is very rare. We present a 57-year-old female patient with a solitary, slowly progressive nodule over upper lip of 2½ months duration. Initially, differential diagnosis of cutaneous leishmaniasis, pyoderma and deep mycoses were entertained. Slit smear preparation was suspicious of deep mycotic infection which was subsequently confirmed by biopsy and culture.     

Trichoepithelioma and Basal Cell Carcinoma with Squamous Differentiation: Is it Causal or Coincidental?

Trichoepitheliomas (TEs) are benign cutaneous tumors that occur either as solitary non-familial or multiple familial. We report a case of multiple familial trichoepithelioma (MFT) in a 55-year-old female patient and her son who came with complaints of single ulcerated mass involving the left nasolabial fold and cheek. She had multiple papules and nodules all over the face and neck since 25 years. Histopathological examination of an ulcerated lesion revealed features of basal cell carcinoma (BCC) with squamous differentiation, which was confirmed by immunohistochemistry. A skin biopsy obtained from the papule on neck showed features of TE. However, whether BCC developed independently or by transformation from TE was uncertain. Her 36-year-old son presented with similar lesions on the face and a skin biopsy showed features of TE. Though malignant transformation of TE is quite rare, awareness of the potential for evolution of carcinoma in patients with MFT is important for management of these patients.     

Atypical Cutaneous Sporotrichosis in an Immunocompetent Adult: Response to Potassium Iodide

Cutaneous sporotrichosis, also known as “Rose Gardener''s disease,” caused by dimorphic fungus Sporothrix schenkii, is usually characterized by indolent nodular or nodulo-ulcerative lesions arranged in a linear pattern. We report bizarre nonlinear presentation of Sporotrichosis, in an immunocompetent adult occurring after a visit to Amazon rain forest, speculating infection with more virulent species of Sporothrix. The diagnosis was reached with the help of periodic acid-Schiff positive yeast cells and cigar shaped bodies seen in skin biopsy along with the therapeutic response to potassium iodide.     

Hemorrhagic Skin Nodules and Plaques: A Diagnostic Clue to Underlying Primary Plasma Cell Leukemia

Plasma cell leukemia (PCL) is a rare lymphoproliferative disorder characterized by a malignant proliferation of plasma cells (PC) in blood and marrow. Cutaneous involvement is very rare in PCL. We present the case of a 45-year-old lady who presented with multiple hemorrhagic nodules and plaques in the skin. Her total leucocyte count was 2,00,200/cmm with 85% abnormal plasmacytoid cells in peripheral smear. Biopsy of the skin lesions revealed diffuse infiltration by plasma cells with ‘choked’ blood vessels. A diagnosis of plasma cell leukemia with cutaneous involvement was made. On the second day of admission, the patient expired probably because of intracranial bleed due to thrombocytopenia. Post-mortem bone marrow and liver biopsy also showed diffuse infiltration by plasma cells. Monoclonality of the cells was proven by demonstrating the production of only kappa light chains.     

Skin lesions in histoplasmosis

Histoplasmosis is a granulomatous infection caused by Histoplasma capsulatum, a dimorphic fungus. It is distributed worldwide and prevalent in certain regions of North and Central America. Pulmonary involvement is the most common clinical presentation. Cutaneous manifestations are reported to occur in 10% to 25% of AIDS patients with disseminated histoplasmosis. The skin lesions are polymorphic papules, plaques with or without crusts, pustules, nodules, mucosal ulcers, erosions, punched out ulcers, lesions resembling molluscum contagiosum, acneiform eruptions, erythematosus papules and keratotic plaques, purpuric lesions, and localized and generalized vegetant forms of dermatitis, sometimes an eruption similar to rosacea, keratotic papules with transepidermal elimination, polymorphous erythema, erythroderma syndromes, pyoderma gangrenosum, panniculitis, diffuse hyperpigmentation, abscesses, and cellulitis.     

Congenital cutaneous candidiasis: a rare and unpredictable disease

Congenital cutaneous candidiasis (CCC) is an extremely rare disorder that presents within the first 6 days of life. The manifestations ranges from diffuse skin eruption without any systemic symptoms to respiratory distress, hepatosplenomegaly, sepsis, and death. We report a neonate who presented with generalized skin eruptions at birth, characterized by erythematous macules and papules. The eruption involved head, face, neck, trunk, and extremities. Candida albicans was demonstrated on direct KOH smear, skin biopsy. The disease implies a congenital intrauterine infection and is different from neonatal candidiasis, which manifests as thrush or diaper dermatitis. The infection is acquired from the maternal genital tract in an ascending fashion. Clinical features, direct smear examination of specimen, and appropriate cultures are useful in differentiating the lesions from other more common dermatoses of the neonatal period. Topical antifungal therapy is sufficient unless systemic candidiasis is present. Prognosis for congenital cutaneous candidiasis is good.     

Chromoblastomycosis Associated with Bone and Central Nervous Involvement System in an Immunocompetent Child Caused by Exophiala Spinifera

Chromoblastomycosis is a chronic granulomatous infection of the skin and subcutaneous tissue caused by specific group of dematiaceous fungi. The infection results from traumatic injury and is seen more commonly on feet and lower legs. It is rarely seen in children and metastatic spread to other systems is exceptionally rare. We report a 12-year-old immunocompetent male child diagnosed with chromoblastomycosis on the lower leg, who in a span of few months developed osteomyelitis and left hemiparesis. Fungal culture showed growth of Exophiala spinifera. Child showed good improvement with voriconazole and itraconazole after 1 year of treatment. Skin lesions healed with minimal scarring and his power improved.     

Acquired immunodeficiency syndrome-related oral and/or cutaneous histoplasmosis: a descriptive and comparative study of 21 cases in French Guiana

BACKGROUND: Oral or cutaneous acquired immunodeficiency syndrome (AIDS)-related histoplasmosis is a rare presentation of disseminated histoplasmosis. OBJECTIVE: To describe this clinical presentation and to compare it with other forms of AIDS-related disseminated histoplasmosis. METHODS: A cross-sectional study of patients with AIDS-related disseminated histoplasmosis was performed. CD4 counts and survival were compared between patients with oral or cutaneous histoplasmosis and patients with nonmucocutaneous disseminated histoplasmosis. RESULTS: The mean CD4 lymphocyte count was lower in patients with mucocutaneous lesions than in patients with nonmucocutaneous disseminated histoplasmosis (29 vs. 72/mm3, P = 0.002). The proportion of survivors 1 month after diagnosis did not differ significantly between the two groups (13/21 vs. 32/45, P = 0.4). At 6 months, the proportion of survivors was significantly lower for patients with mucocutaneous lesions (6/21 vs. 22/39, P = 0.03). CONCLUSIONS: These results suggest that mucocutaneous lesions occur at a later stage of human immunodeficiency virus infection, but are not, in themselves, associated with a higher level of mortality. The excess mortality at 6 months reflects deaths from other complications of severe immunodepression. This study confirms the polymorphism of mucocutaneous lesions, emphasizing the need for systematic testing for Histoplasma in all cases of mucocutaneous lesions in AIDS patients.     

Multisystem Langerhans cell histiocytosis in adult

Langerhans cell histiocytosis (LCH), is a rare disorder, clinically presents with heterogeneous manifestations, and has an unpredictable outcome. Commonly seen in infancy or early childhood, the disorder is characterized by proliferation of abnormal and clonal Langerhans cell in skin, bone, lymph nodes, lungs, liver, spleen, and bone marrow. Occurrence of LCH in adults is rare. Here, we report the case of an adult with acute onset of polymorphic eruptions all over the body, which on biopsy showed features of multisystem LCH, and was confirmed by immunohistochemistry. Although multisystem LCH has a poor prognosis, our patient responded well to chemotherapy.