Indian Journal of Medical Microbiology Medknow Publications on behalf of Indian Association of Medical Microbiology ISSN: 0255-0857 EISSN: 1998-3646 Vol. 28, Num. 4, 2010, pp. 404-406

Indian Journal of Medical Microbiology, Vol. 28, No. 4, October-December, 2010, pp. 404-406

Case Report

Cutaneous histoplasmosis in AIDS

C Chande, S Menon, A Gohil, S Lilani, J Bade, S Mohammad, A Joshi

Department of Microbiology, Grant Medical College & Sir J. J. Hospital, Mumbai - 400 008, India
Correspondence Address: C Chande, Department of Microbiology, Grant Medical College & Sir J. J. Hospital, Mumbai - 400 008, India
cachande@gmail.com

Date of Submission: 14-Dec-2009
Date of Acceptance: 05-Aug-2010

Code Number: mb10120

PMID: 20966584
DOI: 10.4103/0255-0857.71850

Abstract

Keywords: Cutaneous histoplasmosis, histoplasma capsulatum, opportunistic fungal infection

Introduction

Histoplasmosis has been increasingly reported from India in the past few years and most of the cases are found to be associated with HIV infection. ^{[1],[2],[3],[4],[5]} Histoplasmosis is an opportunistic fungal infection caused by the fungus Histoplasma capsulatum frequently associated with AIDS and other immunocompromised patients. Disseminated histoplasmosis is the most common form associated with AIDS. ^[2],[6] Cutaneous involvement is not the manifestation commonly found in the reports from India. Cutaneous lesions in histoplasmosis can be divided as primary or secondary lesions. Primary cutaneous infection of the skin is rare and usually cutaneous involvement is the manifestation of systemic disease. Cutaneous involvement is reported in nearly 10% of HIV-associated histoplasmosis cases. ^[6] Here we report a case of cutaneous histoplasmosis in an HIV-infected patient.

Case Report

A 25-year-old woman, married, native and resident of Dhamangaon, Maharashtra, India was admitted at the skin and venereology department of Sir JJ Group of Hospitals, Mumbai presenting with erythaematous, raised, papular lesions on the upper extremities, back, face and buccal mucosa. The lesions had been present for three months, which initially developed on the upper extremity and then progressed to face. The patient was a known HIV-seropositive.

On examination, patient had erythaematous, maculopapular lesions, few with overlying brown coloured scales on upper and lower extremities, trunk and face [Figure - 1]. The lesions were surrounded by hypopigmented halo. Examination of oral cavity revealed presence of well-defined papules on lips, tongue [Figure - 2] and buccal mucosa along with oral thrush. She had bilateral inguinal lymphadenopathy, cervical lymphadenopathy and moderate enlargement of liver and spleen.

Admission laboratory evaluation included a total leukocyte count of 6000/mm ³ , with a differential count of neutrophils 70%, lymphocytes 28% and monocytes and eosinophils 1% each. The hemoglobin was 8 mg%. The CD4 counts were 47 per millilitre. The serum was positive for HIV antibodies by both Combaids - RS Advantage dot immunoassay kit supplied by Span Diagnostics Ltd., Surat, India and RETROSCREEN-HIV, a sandwich immunoassay supplied by Qualpro Diagnostics, Goa, India.

A skin scraping from the cutaneous lesions showed two morphological forms of yeast cells, one about 3−4 μ × 2−3 μ in size and the other about 8−12 μ, spherical, budding yeast cells surrounded by distinct clear zone indicating presence of capsule and morphologically resembling Cryptococcus [Figure - 3]. Histopathological examination of biopsy from the cutaneous lesion showed numerous parasitized macrophages containing small, round to ovoid yeast-like organisms, 2−4 μ diameter and with the characteristic clear halo and lymphocytic infiltration in the surrounding tissue. Periodic acid-Schiff (PAS) and Gφmφri methenamine silver (GMS) stains confirmed the presence of fungus. Scrapings from the cutaneous as well as papules from oral lesions were inoculated each on two Sabouraud's dextrose agar slants with antibiotics and incubated at room temperature at 37°C. An off-white, cottony growth was observed on the Saboraud's Dextrose Agar (SDA) slants incubated at room temperature on 10 ^th day [Figure - 4], which on microscopic examination showed hyaline hyphae with tuberculated macroconidia and smooth walled, oval microconidia [Figure - 5]. The macroscopic and microscopic features were morphologically consistent with Histoplasma capsulatum. The dimorphic nature of the isolate was confirmed by repeated subcultures on Brain Heart Infusion Agar and incubation at 37°C. An attempt to grow the fungus from the blood failed and also the yeast forms that morphologically resembled Cryptococcus did not grow on culture and hence the suspected coexistence of Histoplasma capsulatum and Cryptococcus could not be confirmed by culture. Treatment with Amphotericin B followed by Itraconazole was initiated on clinical grounds and histopathological report. The lesions almost subsided within 60 days. The patient was re-admitted with the recurrence of similar lesions after four months with the further decline in CD4 counts and started again with the same antifungal regimen. The patient is still being followed-up.

Discussion

Histoplasmosis is the most common opportunistic infection in areas endemic for histoplasmosis and hence has been included in the definition of diagnostic criteria of AIDS by CDC. The disease is not very frequently reported from India except for the north-eastern Indian states like West Bengal, which is considered as the endemic region for histoplasmosis. ^[7],[8] In the last two decades, histoplasmosis has been reported with increased frequency from other regions as well and most of the cases are associated with AIDS. Respiratory tract is the usual portal of entry for the organism and the lesions generally occur in lungs. Oropharyngeal histoplasmosis is the commonest manifestation observed in the cases reported in the pre-AIDS era from India. ^[9] The disseminated disease is the most commonly reported form in immunocompromised individuals. Skin lesions are usually the manifestations of disseminated histoplasmosis. The primary cutaneous histoplasmosis is very rare. In the present case, though there were no signs of pulmonary involvement, the presence of hepatosplenomegaly, lymphadenopathy and generalized distribution of the lesions indicate secondary cutaneous histoplasmosis. Cutaneous lesions may be an initial presentation of histoplasmosis in about 10% cases and may serve as marker for AIDS in areas endemic for histoplasmosis. Progressive, cutaneous form of disseminated histoplasmosis may appear as granulomas, ulcerations or papulonecrotic lesions. In most of the cases reported so far from India, diagnosis was mostly based on histopathological findings and only few cases are culture-proven. In the present case, Histoplasma capsulatum could be isolated from oral as well as cutaneous lesions. The yeast forms morphologically resembling Cryptococcus, which were seen in the scrapings from the cutaneous lesion on anterior abdominal wall, could not be confirmed by the culture. The coexistence of Cryptococcus and Histoplasma in cutaneous lesions in AIDS has been documented in the literature.^[10] The present case report indicates that Histoplasma capsulatum is endemic in this region as the patient had never been to any known endemic region, and hence in an immunocompromised patient presenting with cutaneous lesions, histoplasmosis should be kept in mind for early diagnosis and proper management.

References

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7.	Sanyal M, Thanmayya A. Histoplasma capsulatum in the soil of Gangetic plain in India. Indian J Med Res 1975;63:1020-8.  Back to cited text no. 7
8.	Sanyal M, Thanmayya A. Skin sensitivity to histoplasmin in Calcutta and its neighbourhood. Indian J Dermatol Venereol Leprol 1980;46:94-8.  Back to cited text no. 8
9.	Padhye A, Pathak A, Katkar V, Hazare V, Kaufman L. Oral histoplasmosis in India: A case report and an overview of cases reported during 1968-92. J Med Vet Mycol 1994;32:92-103.  Back to cited text no. 9
10.	Supparatpinyo K, Kwangsuksatith C, Hirunsri P, Uthammachai C, Sirisanthana T. J Systemic mycosis caused by Cryptococcus neoformans, Penicillium marneffei and Histoplasma capsulatum in a patient with Acquired Immunodefficiency Syndrome. Infect Dis Antimicrob Agents 1992;9:77-9.  Back to cited text no. 10

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