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Histoplasmosis is an infection caused by the dimorphic fungus Histoplasma capsulatum. The disease is endemic in several regions of tropical and temperate climate. The fungus presents opportunistic behavior, causing widespread infection in immunocompromised patients, resulting from complication of primary pulmonary infection, due to exogenous reinfection or reactivation of a quiescent source. In immunocompetent individuals, approximately 95% of pulmonary infections are asymptomatic. However, prolonged exposure to high amount spores may lead to acute or chronic lung infection. Due to the low amount of inoculum, primary cutaneous histoplasmosis caused by traumatic implantation is extremely rare and effectively treated with triazoles. Thus, the present study aims to report a case of primary cutaneous histoplasmosis that is difficult to treat in an immunocompetent patient, and to review the literature on the incidence of drug-resistant Histoplasma capsulatum strains in clinical practice.

We describe four cases of histoplasmosis indigenous to Himachal Pradesh (India) that will be of considerable public health interest. A 48-year-old human immunodeficiency virus (HIV)-negative man with cervical and mediastinal lymphadenopathy, hepatosplenomegaly, adrenal mass, and bone marrow involvement was treated as disseminated tuberculosis without benefit. Progressive disseminated histoplasmosis was diagnosed from the fungus in smears from adrenal mass. Another 37-year-old HIV-positive man was on treatment of suspected pulmonary tuberculosis. He developed numerous erythema nodosum leprosum-like mucocutanous lesions accompanied by fever, generalized lymphadenopathy, and weight loss. Pulmonary histoplasmosis with cutaneous dissemination was diagnosed when skin lesions showed the fungus in smears, histopathology, and mycologic culture. Both were successfully treated with amphotericin B/itraconazole. Third patient, a 46-year-old HIV-negative man, had oropharyngeal lesions, cervical lymphadenopathy, intermittent fever, hepatosplenomegaly, and deteriorating general health. Progressive disseminated oropharyngeal histoplasmosis was diagnosed from the fungus in smears and mycologic cultures from oropharyngeal lesions and cervical lymph node aspirates. He died despite initiating treatment with oral itraconazole. Another 32-year-old man 3 months after roadside trauma developed a large ulcer with exuberant granulation tissue over left thigh without evidence of immunosuppression/systemic involvement. He was treated successfully with surgical excision of ulcer under amphotericin B/itraconazole coverage as primary cutaneous histoplasmosis confirmed pathologically and mycologically. A clinical suspicion remains paramount for early diagnosis of histoplasmosis particularly in a nonendemic area. Most importantly, with such diverse clinical presentation and therapeutic outcome selection of an appropriate and customized treatment schedule is a discretion the treating clinicians need to make.

A 63-year-old white man with a history of rheumatoid arthritis on adalimumab was admitted to the hospital for left arm swelling and erythema. On physical examination, the patient was afebrile and non-toxic appearing and there was tense oedema of the left forearm. Initial laboratory work was unremarkable except for elevated inflammatory markers. MRI of the arm showed non-specific findings of inflammation. The patient was started on empiric antibiotics but did not improve. Given the patient’s immunosuppression, early consideration was given to fungal or mycobacterial causes. Initial serum fungal studies were negative and the patient was taken for diagnostic local incision and biopsy of the left volar forearm. Grocott’s methenamine silver and periodic acid–Schiff staining revealed fungal organisms resembling Histoplasma and intraoperative fungal cultures grew Histoplasma capsulatum confirming the diagnosis. The patient was treated with a 6-month course of itraconazole with improvement in his condition and eventual complete resolution.

Histoplasmosis is a genus of dimorphic fungi having various varieties of which the commonest one causing infection is Histoplasma capsulatum known to cause histoplasmosis. It has a varied disease spectrum ranging from an acute infection to chronic disease especially in lungs, disseminated disease and cutaneous disorder. Histoplasma capsulatum usually causes subclinical infection and serious infections only manifest in immunocompromised patients. Frank cases of infection are seen in pulmonary histoplasmosis. The spores of these organisms are seen to be strongly associated with droppings of birds and bats. A combination of these droppings and some soil types provide for an excellent environment for the proliferation of spores. Pulmonary histoplasmosis and disseminated disease are very common in AIDS patients and are a great cause of morbidity and mortality in these patients. Primary cutaneous histoplasmosis is very rare and occurs due to penetrating injuries. Once diagnosis is made, the lesions respond very well to oral itraconazole, fluconazole or amphotericicn B. We report a rare case of Cutaneous Histoplasmosis (CHP) in a 70-year-old male with complaints of multiple nodules all over his body in a HIV seronegative and otherwise immunocompetent patient.

Summary Biopsy of a swollen, painful, right inguinal lymph node of a 15-year-old boy revealed histoplasmic lymphadenitis. Histoplasmic granulomas were also observed at biopsy of right plantar skin ulcer, thought traumatic in origin. The patient was asymptomatic and had a normal chest x-ray. The subject of primary inoculation of mucocutaneous histoplasmosis is being reviewed. Four previous cases with bona fide extra pulmonary primary mucocutaneous histoplasmosis with a benign course have been reported. Zusammenfassung Die Biopsie eines geschwollenen und schmerzhaften rechtsseitigen Leistenlymphknotens eines 15 Jahre alten Jungen ergab eine histoplasmotische Lymphadenitis. Als daraufhin die Probeexcision von einem vermutlich traumatischen Hautulkus an der rechten Fussohle untersucht wurde, fanden sich auch histoplasmotische Granulome. Der Patient war asymptomatisch und hatte ein normales Rontgenbild der Lungen. Nur vier „bona fide”-Falle von primarer mucokutaner Histoplasmose sind bisher mitgeteilt worden.

The patient, a 52-year-old man, presented clinical, labora -tory and radiological findings compatible with RA since childhood. As the disease progressed, regardless of a va -riety of therapies employed, he developed major deformi -ties of the hands, wrists, elbows, hips, knees and ankles. Recently, using low-dose prednisone and methotrexate, he suddenly presented nodular ulcerated lesions on the face as seen in Figures 1 and 2. The diagnostic hypotheses were cutaneous lymphoma, leishmaniasis, sporotrichosis, cryptococcosis, cutaneous tuberculosis, histoplasmosis and tertiary syphilis. Histological examination showed diffuse granulomatous infiltrate with the presence of intracytoplasmic yeast structures (Figure 3). Curettage was performed for culture of material from the necrotic--suppurative areas of ulcerated lesions.

We present the case of a 46 years old gentleman with longstanding ulcerative lesion of the right upper eyelid. Biopsy of the lesion revealed intracellular periodic acid-Schiff positive round to oval organisms with a surrounding clear halo suggestive of histoplasmosis. Histoplasma capsulatum specific polymerase chain reaction was positive. The patient was treated with oral antifungals and showed a prompt response to treatment. We report this rare case of primary cutaneous histoplasmosis of the eyelid in an otherwise healthy adult patient.

We report a case of primary cutaneous histoplasmosis in a fifty-year-old African-American woman with diabetes and multi-infarct dementia. The patient developed fever and crusted, nodulo-ulcerative lesions of the skin after accidental superficial trauma to the forehead. The biopsy revealed suppurative granulomatous inflammation with intracellular and extracellular yeast-like cells with associated clear halo measuring 3-4 mm in size. Systemic involvement was not found. The lesions cleared after treatment with itraconazole 200 mg twice a day for 3 weeks. The medication was continued for a total period of 3 months, with no signs of recurrence after one-year of follow-up.

Importance: This is a case of primary cutaneous histoplasmosis, without any systemic involvement, that occurred without a history of trauma. Due to its rarity and varied clinical presentation, there is much difficulty in diagnosis of this disease entitiy, especially in differentiating it from pyoderma gangreosum. This patient required deep tissue sampling and a DNA probe for Histoplasma to establish a time-sensitive diagnosis as multiple superficial biopsies are nondiagnositic.

Histoplasmosis is caused by the dimorphic fungus Histoplasma capsulatum.Primary infection occurs through inhalation of spores from the air. Immunocompetent individuals are usually asymptomatic, but may develop pulmonary disease. Immunocompromised patients tend to present systemic histoplasmosis with cutaneous lesions occurring by secondary invasion. In this case report, we describe a probable primary cutaneous histoplasmosis (PCH) in a patient with adult onset Still's disease under immunosuppression.

Made available in DSpace on 2016-04-01T18:43:01Z (GMT). No. of bitstreams: 0 Previous issue date: 2015. Added 1 bitstream(s) on 2016-04-01T18:49:06Z : No. of bitstreams: 1 S0365-05962015000200255.pdf: 167655 bytes, checksum: 857aa9a8456b76b83c45f12efbcd7a27 (MD5) A 70-year-old male presenting a 3-month history of genital painless erythematous nodules in the balanopreputial sulcus was referred to our service. Histopathological exam presented a chronic dermatitis with epithelioid granulomas and Grocott staining revealed numerous fungal structures with a suggestive morphology of Histoplasma sp. Cultures evidenced Histoplasma capsulatum var. capsulatum. Treatment with oral itraconazole led to complete remission of lesions. A 70-year-old male presenting a 3-month history of genital painless erythematous nodules in the balanopreputial sulcus was referred to our service. Histopathological exam presented a chronic dermatitis with epithelioid granulomas and Grocott staining revealed numerous fungal structures with a suggestive morphology of Histoplasma sp. Cultures evidenced Histoplasma capsulatum var. capsulatum. Treatment with oral itraconazole led to complete remission of lesions. Universidade Estadual Paulista Júlio de Mesquita Filho, Departamento de Dermatologia e Radioterapia, Faculdade de Medicina (FMB), Botucatu, Campus Universitário de Rubião Jr, Rubião Jr, CEP 18618-970, SP, Brasil Universidade de São Paulo (USP) - São Paulo (SP), Brazil Universidade Estadual Paulista Júlio de Mesquita Filho, Departamento de Dermatologia e Radioterapia, Faculdade de Medicina (FMB), Botucatu, Campus Universitário de Rubião Jr, Rubião Jr, CEP 18618-970, SP, Brasil

A 32-year-old male presented to Dermatology outpatient Department with complaints of a single nonhealing ulcer on his right thigh. This lesion was there for the last 1΍ months. It had begun as a small nodule and increased up to the present size of 3 cm with an oozing and ulcerated surface and thickened everted margins. The systemic investigations were normal which included hemogram, biochemistry, including liver and renal function tests, chest X-ray, ultrasonography of abdomen, computed tomography of the thorax, and abdomen. Skin biopsy revealed multiple rounds to oval spores with surrounding halo intracellularly as well as extracellularly. A diagnosis of deep fungal infection as histoplasmosis was made and confirmed on culture.

We report the first Japanese patient with primary cutaneous histoplasmosis who was infected inside Japan. He was not an immunocompromised host but his cutaneous lesions developed on preexisting papuloerythroderma (Ofuji). The long-term topical corticosteroid treatment for papuloerythroderma, which could have suppressed the local immunological defence system of the skin, might have been responsible for the histoplasma infection in the present case.

É relatado um caso de histoplasmose cutânea primária em um homem de 45 anos, com apresentação de um nódulo eritematoso no dorso da mão direita acompanhado de linfadenomegalia regional indolor, que se desenvolveu após trauma local ocorrido durante treinamento militar em túnel habitado por morcegos. O exame histológico de biópsia da lesão cutânea mostrou um infiltrado granulomatoso, porém não evidenciou elementos fúngicos. O cultivo deste material incubado em Ágar Sabouraud mostrou crescimento de Histoplasma capsulatum. Não foi encontrada evidência de envolvimento sistêmico ou imunossupressão. O tratamento com 400mg diários de itraconazol oral durante 6 meses resultou na remissão completa da lesão, mantida um ano após o término do tratamento. This report describes a case of primary cutaneous histoplasmosis in a 45-year-old male. The presentation consisted of an erythematous nodule on the back of the right hand, accompanied by nontender regional lymphadenomegaly that developed following local trauma that occurred during military training in a tunnel inhabited by bats. Histological examination of a biopsy specimen from the skin lesion showed granulomatous infiltrate, but did not show fungal elements. Culturing of this material, incubated in Sabouraud agar, showed growth of Histoplasma capsulatum. No evidence of systemic involvement or immunosuppression was found. Treatment with 400 mg/day of itraconazole orally for six months resulted in complete remission of the lesion, which was maintained one year after the end of the treatment.

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.

A case of cutaneous histoplasmosis is reported in an 80-year-old man with rheumatoid arthritis who had been treated with steroid therapy for 15 years. The patient developed a large ulcerative lesion on the back of the left hand and on the distal third of the left dorsal forearm after a slight trauma. Diagnosis was based on histological and mycological examination. Systemic involvement was not found. The lesions healed after 2 months of therapy with 100 mg day -1 fluconazole, confirmed at follow-up 1 year later.

A patient presented with multiple nodulo-ulcerative lesions over neck and chest. Lymphadenopathy and systemic involvement were absent. Patient was seronegative for HIV. There was no history of local injury and no history of travel. Histopathological findings were consistent with histoplasmosis. Diagnosis of primary cutaneous histoplasmosis was made. We highlight this case owing to its rare and atypical presentation, in an attempt to promote clinical and micro-pathological awareness regarding such occurrences.

Histoplasmosis refers to an infection caused by histoplasma capsulatum, a dimorphic fungus. We report a rare case of cutaneous histoplasmosis in an immunocompromised patient. The diagnosis was made by the cytopathologic examination of skin scraping smear, which showed numerous intracellular and extracellular periodic acid-schiff positive rounded yeast cells. The patient showed dramatic response with itraconazole and amphotericin B. We opine that skin scrape cytology can be useful in establishing the diagnosis of the disease, specially when the other facilities are not readily available.

To define the clinical presentation of histoplasmosis among hospitalized children, we reviewed the charts of patients treated for histoplasmosis at Vanderbilt University Children's Hospital during the years 1968 through 1988. Thirty-five patients with histoplasmosis diagnosed by culture, pathologic examination, or serologic testing were identified, including 29 patients (83%) with pulmonary/mediastinal infection, 5 (14%) with disseminated disease, and 1 (3%) with primary cutaneous histoplasmosis. The most common symptoms included fever, present in 26 patients (74%), and cough, present in 20 (57%). Of 26 patients with fever, 18 (69%) had fever of > 2 weeks' duration and 7 (27%) had temperatures > or = 40.5 degrees C (> or = 105 degrees F). Abnormal physical findings were few, but 19 patients (54%) had wheezing. Chest radiographs were obtained in all cases except one; 31 (91%) showed abnormalities, including adenopathy in 25 cases (74%) and infiltrates in 19 (56%). Histoplasmin skin tests were positive for 22 (96%) of the 23 patients tested. No cases of classic disseminated histoplasmosis of infancy were identified. Histoplasmosis should be considered in the differential diagnosis when children living in endemic areas are evaluated for persistent fever, cough, and/or wheezing, particularly if adenopathy is seen on the chest radiograph.

A 31-year-old human immunodeficiency virus-positive male who presented to the Dermatology Outpatient Department with complaints of red, raised lesions on the face of 2 weeks duration was, on examination, found to have multiple papulonodular lesions on the face with associated cervical and axillary lymphadenopathy. There was history of local injury on the face 6 months prior to the development of symptoms. Skin biopsy revealed multiple round to oval spores with surrounding halo intracellularly, confirming the diagnosis of cutaneous histoplasmosis. No systemic involvement was detected on further investigations. The patient responded to oral antifungals in a short duration, confirming the local nature of the presentation. This is probably the first time in the literature that a primary cutaneous manifestation of histoplasmosis is being described in an immunocompromised individual.

Summary Two patients with primary disseminated mucocutaneous histoplasmosis are reported. As there was no focus of infection, active or healed, in the lung or other internal organs, it is assumed that a primary cutaneous site was the source for dissemination to the skin and mucous membrane. The organism could be cultured from the skin and mucous membrane only. No immune suppression was detected. Infection cleared with amphotericin B.

After subcutaneous injection of Histoplasma capsulatum into hamsters, a primary complex (cutaneous lesion plus involvement of regional lymphnodes) developed with regularity. The ensuing hematogenous spread was governed primarily by the invasiveness of the individual strains. Primary cutaneous histoplasmosis provided only partial protection to challenge with the same organism. Human cutaneous infections with fungi are acceptable as primary only if a chancre with regional lymphnodes is demonstrated in conjunction with traumatic inoculation.

THE criteria suggested by several investigators1 , 2 as necessary to establish a diagnosis of primary cutaneous infection with a fungus capable of causing pulmonary mycosis are as follows: history of traumatic inoculation, with subsequent development of a chancriform lesion within three or four weeks at the point of trauma; evidence that the wound was contaminated with the causative fungus; development of lymphangitis and regional lymphadenopathy; no history or clinical or laboratory evidence of previous pulmonary or systemic mycosis; and conversion of the skin test from negative to positive and rising serologic titer (where applicable). This sequence of events, which Wilson3 calls . . .

HISTOPLASMA CAPSULATUM may cause several types of cutaneous manifestations. Disseminated histoplasmosis has been most commonly associated with oral mucocutaneous ulcers, 1-3 which may persist longer than three months. The progressive cutaneous form of disseminated histoplasmosis may appear as granulomas, ulcerations, or papulonecrotic lesions. Differentiation of these lesions from other cutaneous ulcers on clinical grounds alone is difficult if not impossible. Etiologic confirmation is determined by isolating H capsulatum , usually from a biopsy specimen. Primary cutaneous histoplasmosis, in which the organism is confined to the skin, is uncommon. To our knowledge, only three verified cases have been reported. 4-6 Furcolow 7 has reviewed previous possible cases. In each of the three verified cases, the infection was self-limited without systemic therapy. The purpose of this report is to present a fourth case of apparent primary cutaneous histoplasmosis. The disease in this immunosuppressed patient differed from previously reported cases of primary cutaneous histoplasmosis in being

Histoplasmosis was considered a rare and always fatal disease for many years after it was first described by Darling in 1906. However, recent epidemiological studies in the United States have revealed that in some states in the endemic area 60% to 70% of males aged 17 through 21 years have been infected with Histoplasma capsulatum . 1 The respiratory tract is the usual portal of entry of the fungus with the primary lesion occurring in the lungs. 2 Cases of histoplasmosis having skin lesions have been reported, but the skin lesions were usually the result of dissemination of the infection. 3,4 The purpose of this paper is to report a case of primary cutaneous histoplasmosis which resulted from direct inoculation of the fungus through the skin. Report of Case On Jan 12, 1959, a 32-year-old white male who had recently moved into the endemic area for histoplasmosis assisted with an autopsy