Cutaneous histoplasmosis disclosing an HIV-infection
An urban 57-year-old male patient reported a cutaneous lesion on his nose. The lesion\nhad been initially noticed three months before. General complaints included a 3-kg\nweight loss, sporadic fever and malaise. Dermatologic examination showed a crusted\nulcerated lesion surrounded by an erythematous halo on the nose and few erythematous\npapular nodules on his mentum ( and ). Oral examination revealed a sublingual atypical\nulcerated lesion suggesting a traumatic etiology. Clinical examination was unremarkable.\nMicroscopic examination of representative cutaneous lesions and of the oral lesion\nshowed chronic lymphohistiocytic inflammation with granuloma formation on the dermis.\nMultiple intracellular structures were observed in the cytoplasm of histiocytes and\ngiant cells, which were better observed and demonstrated on especial staining, such as\nGrocott-Gomori ( and ). Culture from biopsy material in Sabouraud dextrose-agar and\nMycosel® was positive for Histoplasma capsulatum ().\nAdditional investigation revealed interstitial infiltration and nodules on both lungs\nwhich were suggestive of pulmonary histoplasmosis. Serology tests were positive for HIV\ninfection, at that point unknown to the patient and negative for HBV and HCV. Blood\nCD4+ cell count was 7/mm3; CD8+ cell count was\n236/mm3 and HIV RNA measurement performed on plasma revealed a viral load\nof 241,265 copies and a log of 5.383.\nThe patient was treated with amphotericin B deoxycholate, 2065 mg of total dose,\nfollowed by itraconazole 200mg/daily as a maintenance treatment, with clinical\nresolution of all lesions and improvement of general conditions. Anti-retroviral therapy\nand nutritional support were added to treatment as well.