Disseminated histoplasmosis with oral and cutaneous manifestations
A 73-year-old man was referred from a private practitioner to Govt. Dental College, Calicut with ulcers in his oral cavity, fever, chest pain and cough since 2 weeks and he also noticed skin lesions over face and forearm.\nOral examination revealed ulcerated and necrotic lesions located on the labial mucosa, lateral borders of tongue, hard and soft palate [Figures and ]. The lesions were covered by a pseudomembrane and were extremely painful to palpation. Bilateral submandibular lymphadenopathy was noted. Extraoral examination revealed multiple nodular lesions on the chin, right side of the face and upper lip with an erythematous surface []. Hair loss was noticed on the chin, upper lip and the eyebrows. Multiple plaques were seen on the ventral surface of the forearm and dorsal aspect of thigh [Figures and ]. They were pale in color compared to the surrounding skin and there was a rise in local temperature. A firm consistency was felt while palpating these lesions.\nThe patient had malaise and fatigue at the time of examination, with a body temperature of 38.2°C, pulse rate of 82/min, respiratory rate of 18 cycles/min and blood pressure of 140/86 mm/Hg. Routine blood investigation showed a hemoglobin level of 9.4 g/dl, 7800 leucocytes (60% neutrophils, 36% lymphocytes and 4% eosinophils) and an elevated erythrocyte sedimentation rate (24 mm/h). Acid fast bacillus (AFB) examination of sputum did not reveal any acid fast bacilli (Zeihl Neelson stain)\nAn incisional biopsy of the labial mucosa showed the presence of epithelioid cell granulomas in the connective tissue with numerous histiocytes, many of which formed multinucleated giant cells. The cytoplasm of the histiocytes showed the presence of small round to oval basophilic bodies surrounded by a clear halo, which is the characteristic feature of histoplasma capsulatum [Figures ]. These organisms stained highly positive with Gomori's Methanimine Silver stain [Figures and ]. The patient was found to be HIV negative (comb and tridot tests).\nAntifungal therapy was started with intravenous liposomal amphotericin B at 0.7 mg/kg/day administered for 10 days which was replaced by oral itraconazole 200 mg BD for 6 months. Patient's respiratory symptoms showed marked improvement after 3 days of medication. The oral and cutaneous lesions resolved after 2 months. Patient is under regular follow up and was free of symptoms at the end of 1 year.