Borderline tuberculoid leprosy associated with primary cutaneous histoplasmosis

Abstract

Abstract:We describe a case of borderline tuberculoid leprosy associated with primary cutaneous histoplasmosis in a patient who presented at our hospital with skin lesions and joint complaints. Keywords: Granuloma; Histoplasmosis; Leprosy Resumo: Descrevemos um caso de hanseníase dimorfa tuberculoide associada à histoplasmose cutânea primária em um paciente que procurou nosso hospital com lesões dermatológicas e queixas articulares. Palavras-chave: Granuloma; Hanseníase; Histoplasmose ©2012 by Anais Brasileiros de Dermatologia ▲ This case concerns a 65-year-old male patient who suffered pain and lack of mobility in his right wrist a year ago and reported the appearance of erythematous plaques on his body three weeks before presenting at hospital. Examination revealed ulcers on the fingers of his right hand and an erythematousedematous plaque on the dorsum of the right hand, left shoulder and neck (Figures 1 and 2). Biopsy was performed on the dorsum of the hand and neck which showed reactional borderline tuberculoid leprosy (Figure 3). Polychemotherapy and prednisone were started on the assumption that it was "reactional hand." After treatment the joint pains noted at first consultation persisted. We decided to perform a synovial biopsy of the right wrist, with negative culture for bacteria and mycobacteria and positive for Histoplasma capsulatum (Figure 4). After diagnosing histoplasmosis, treatment commenced with itraconazole 200mg daily.

Histoplasmosis of the Upper Extremities: Clinical Case, Treatment Algorithm, and Systematic Review

“…Eight (53.3%) patients were diagnosed with tenosynovitis, 2-4,7-9,11,12 5 (33.3%) with osteomyelitis, 6,10,13-15 1 (6.7%) with carpal tunnel syndrome, 16 and 1 (6.7%) with joint wrist abscess 8 caused by histoplasmosis. Regarding surgical treatment, of the patients diagnosed with tenosynovitis, 5 underwent tenosynovectomy, 2,7-9,12 2 only had a biopsy of the lesion, 3,11 and 1 had an exploration with carpal tunnel release and biopsy. 4 Of the patients diagnosed with osteomyelitis, 2 underwent biopsy alone 10,14 and 3 had debridement of the affected area.…”

“…Overall, 11 (73.3%) patients recovered, 2-4,6-8,12-16 2 (13.3%) were progressing well with treatment, 8,9 1 (6.7%) patient died, 10 and 1 (6.7%) was lost to follow-up. 11…”

“…8 Of the total number of cases, 7 (46.7%) patients were initially mistreated with anti-inflammatory medication or analgesic pain relievers. [2][3][4]8,9,11,16 Four (26.7%) patients had recurrence of the disease. [7][8][9]12 Medical treatment included itraconazole, fluconazole, ketoconazole, and amphotericin B, depending on the case.…”

“…Moreover, histoplasmosis classically presents in immunocompromised patients 2,3,7-10 ; however, there were immunocompetent patients who also developed the disease. 4,6,11-16 Diagnosis and management of the disease remain a challenge due to its infrequent occurrence in the upper extremities, which may explain the lack of a specific protocol to follow in such cases. Below, we describe a point-by-point surgical and medical treatment approach for histoplasmosis affecting the upper extremities, causing tenosynovitis, osteomyelitis, carpal tunnel syndrome, and abscess in the wrist.…”

“…The most common presenting diagnosis of upper extremity histoplasmosis was tenosynovitis. Most cases of tenosynovitis were located in the wrist, 2,7,9,11,12 followed by palm, 4,8 finger, 2,3 and forearm. 9 In patients with symptoms suggesting tenosynovitis with high suspicion of an infectious cause, a complete tenosynovectomy should be performed, and the synovium around the tendon should be excised and sent to pathology and microbiology.…”