Cutaneous histoplasmosis associated with acquired immunodeficiency syndrome (AIDS)

Abstract

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/mm3. 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. 1 Initial lesions: nodules, ulcers, and verrucous lesions involving the face Histologic evaluation showed a dense infiltration of lymphocytes and histiocytes, many of which were markedly vacuolated. A number of intracellular yeast‐like cells that were easily stained with hematoxylin and eosin and periodic acid–Schiff (PAS) were evident inside the histiocytes ( Fig. 2). We concluded that the granulomatous process was suggestive of histoplasmosis. 2 Histopathology. Higher magnification demonstrated intracellular yeast‐like cells of Histoplasma capsulatum inside histiocytes (periodic acid–Schiff stain; ×100) Histoplasma capsulatum was eventually cultured from the skin biopsy specimens. A histoplasmin skin test was negative; precipitin and complement fixation tests using the same antigen were both positive, the latter with an initial titer of 1 : 320. The confirmatory diagnosis of acquired immunodeficiency syndrome (AIDS)‐associated cutaneous histoplasmosis prompted us to begin treatment with amphotericin B 1 mg/kg/day, heparin 5 IU/day, hydrocortisone 500 mg/day, and itraconazole 400 mg/day. Also, the main laboratory tests were repeated. When an accumulated dose of 535 mg of amphotericin B had been reached, an elevation of serum creatinine to 1.48 mg/dL occurred, and a glomerular filtration rate of 57.8%, a urinary volume of 1350 mL/24 h, and a potassium (K) of ...

Disseminated cutaneous histoplasmosis in acquired immunodeficiency syndrome: report of 23 cases

“…Several authors mention that the dermatoses in DCH present with papules and crusting plaques. This clinical picture is common and has been reported previously in Latin American populations 16,17 . Other lesions have been reported such as punch ulcers, purpuric lesions and localized or generalized dermatitis 3,13,18,19 .…”

“…Recent studies have shown liposomal amphotericin B to be more effective 14,25 . In patients who do not need to be admitted to hospital, treatment consists of itraconazole 200 mg three times daily for 3 days, followed by 200 mg twice daily for 12 weeks 16,24 . Another therapeutic option is fluconazole 800 mg/day with follow‐up of patients to monitor and avoid relapses 25 (Fig.…”

“…Maintenance therapy may be lifelong, using itraconazole 200 mg 1–2 times a day. The antigen level in serum and urine must be monitored every 3–6 months 16,24,25 . An alternative maintenance therapy is amphotericin B 50 mg/week, but it is often not well accepted or tolerated by patients.…”

“…This clinical picture is common and has been reported previously in Latin American populations. 16,17 Other lesions have been reported such as punch ulcers, purpuric lesions and localized or generalized dermatitis. 3,13,18,19 Other findings include: nodules, molluscoid lesions, vegetations, rosacea-like rash, keratotic papules with transepidermal elimination, ulcers, erythema, polymorphous and erythroderma syndromes, pyoderma gangrenosum, panniculitis, and diffuse hyperpigmentation.…”

“…The antigen level in serum and urine must be monitored every 3-6 months. 16,24,25 An alternative maintenance therapy is amphotericin B 50 mg ⁄ week, but it is often not well accepted or tolerated by patients. Several studies have shown that azoles decrease the risk of acquiring histoplasmosis, therefore prophylaxis with itraconazole at a dose of 200 mg ⁄ day should be considered in HIV-infected patients who live or have lived in endemic areas and who have a CD4+ count < 150 or 100 ⁄ mm 3 .…”