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DERMATOPATHOLOGY ROUND
Year : 2006  |  Volume : 51  |  Issue : 2  |  Page : 137-139
Seven cases of histoplasmosis: Cutaneous and extracutaneous involvements


1 Dermatopathology Clinic, AMRI - Hospitals, Kolkata, India
2 Dept of Internal Medicine, AMRI - Hospitals, Kolkata, India
3 Dept of Microbiology, AMRI - Hospitals, Kolkata, India

Correspondence Address:
Subhra Dhar
Flat 2A2, Block 2, 5, N.S.C. Bose Road, Kolkata - 700040
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.26939

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   Abstract 

Seven cases of histoplasmosis have been reported, 6 males and one female. Their ages ranged from 40 to 78 years. Of 7 patients, 5 had skin lesions, 4 with palatal ulcer, one with papules and nodules. None of the patients were HIV positive. In all patients either cytology, or skin biopsy or both revealed Histoplasma. Culture was positive in two patients.


Keywords: Histoplasmosis, palatal ulcer, nodule


How to cite this article:
Dhar S, Dutta Roy R K, Todi SK, Roy S, Dhar S. Seven cases of histoplasmosis: Cutaneous and extracutaneous involvements. Indian J Dermatol 2006;51:137-9

How to cite this URL:
Dhar S, Dutta Roy R K, Todi SK, Roy S, Dhar S. Seven cases of histoplasmosis: Cutaneous and extracutaneous involvements. Indian J Dermatol [serial online] 2006 [cited 2019 Nov 20];51:137-9. Available from: http://www.e-ijd.org/text.asp?2006/51/2/137/26939



   Introduction Top


Histoplasmasis is a disease involving primarily the reticuloendothelial system and in most cases subclinical or benign involving the respiratory system.[1] However, it can progress and disseminate in some cases and prove fatal.[2] Although the disease occurs worldwide, it is endemic in the east central part of the United States, the Missouri Mississippi and Ohio valleys.[3] Several cases have been reported from India.[4] However, there are only occasional reports of cutaneous involvement in Histoplasmasis in dermatologic literature from India.[5],[6] We have seen seven cases over a period of 2 yrs in our hospital which we hereby report.


   Case Reports Top


Case 1: A 46-year-old female, a housewife presented with fever, weight loss and severe anaemia of 6months duration. She had already received antitubercular treatment with 4 drugs for 2 months without remission of fever. Examination revealed hepatosplenomegaly, cervical lymphadenopathy and a well defined indurated ulcer 2.5 x 2.5 cm at the junction of hard and soft palate [Figure - 1]. Examination of blood revealed haemoglobin to be 9g%, with normal blood sugar levels. HIV 1 and 2 antibodies were negative.

A clinical diagnosis of disseminated histoplasmosis was made. CT scan of abdomen revealed bilateral adrenal mass. Smear from the ulcer stained with Giemsa revealed multiple small yeast cells with budding both inside and outside macrophages [Figure - 2]. Biopsy from the ulcer margin on H and E stain revealed multiple budding yeast cells, both intracellularly and extracellularly [Figure - 3]. PAS and GMS stains were positive [Figure - 4][Figure - 5]. The organism however, could not be cultured in Saboraud's dextrose agar media.

Case 2: A 45 year old male, a rickshaw puller, presented with fever and ulcer over soft palate for 2 months. He was non diabetic and HIV negative (both 1 and 2). Biopsy and histopathological examination from outside carried a report of tuberculosis. However, scrape cytology, stained with Giemsa from the floor of the ulcer revealed, multiple budding yeasts within and outside macrophages. Review of histopathology slides along with fresh sections from the block again revealed PAS and GMS positive yeast forms in intracellular (within macrophages) and extracellular location.

Case 3: A 58-year old male, school teacher, presented with non healing ulcer over soft palate and fever for 4 months. Biopsy from the ulcer was done to rule out malignancy. The patient was diabetic and HIV negative. Histoplasma was demonstrated on cytology, H and E and special stain of mucosal biopsy from the ulcer margin.

Case 4 : A 76-year-old male, retired government employee, chronic, smoker, was admitted with respiratory failure. He was previously diagnosed as bronchogenic carcinoma by CT guided FNAC of lung from outside. Sputum for malignant cells showed numerous yeast cells in cluster and discretely. Culture in SDA media at 30C showed waxy tan cottony colonies after 14 days. Smear examined from the colony revealed both macroconidiae and microconidiae. The patient was nondiabetic and HIV negative

Case 5 : A 40-year-old male a government servant presented with fever, moderate anaemia, weight loss not responding to anti Koch's treatment for 4 months duration. CT abdomen should unilateral adrenal hyperplasia. CT guided FNAC showed numerous histoplasma on smear examination with geimsa and PAS stains. The culture showed growth of the organism.

Case 6 : A 70-year-old male, the editor of a newspaper presented a few erythematous nodules over face. To start with he noticed a single small nodule over the chin which was diagnosed by dermatologists as molluscum contagiosum 4 months later he developed fever and gradual emaciation with more number of nodules erupting over the face in the next 2 months. He was diabetic for 10 years and was on treatment, though not very regular. Chest X-ray showed multiple miliary shadows on both lung fields. CT abdomen revealed a mass on both adrenals. Skin biopsy from nodule over face on histopathology and crushed tissue smear cytology from the same lesions revealed numerours histoplasma. However, the culture did not yield the organism.

Case 7 : A 58-year-old male a businessman presented with ulcer at the junction of hard and soft palate for 6months. He was otherwise totally asymptomatic, nondiabetic, and HIV-ve. He was planned for surgery with diagnosis of squamous cell carcinoma. A review of the old slide and fresh section from the blocks revealed numerous yeast like organisms packed within macrophages and a diagnosis of histoplasma was made.

All these patients responded variably to treatment. While the first patient succumbed to disseminated histoplasmosis inspite of receiving intravenous liposomal Aphotericin -B followed by oral itraconazole for one and a half months. Cases 2-4 however showed excellent result on 400 g day of iatraconazole after 12-16 weeks treatment which was continued for another 8-10 weeks. However, cases 5 and 7 defaulted while on itraconazole 400 mg/day. Case 6 showed excellent results with 400 mg/day and after 8 weeks the cutaneous nodules disappeared and after 12 weeks adrenal masses disappeared. The bigger nodules, however, the persisted because of fibrosis of the nodules.


   Discussion Top


Histoplasmosis is widely distributed throughout the world, occuring in more than 60 temperate and tropical countries in USA, Africa and Australia.[3] In USA itself the number of human infection has been estimated to be 30 million. It is highly endemic in the Mississipi and Ohio valleys of USA where more than 80% of the population has been found to be histoplasmin positive[7] a situation quite akin to tuberculosis in India. However, histoplasmosis is rarely reported by dermatologists in India. The reasons could be lack of awareness about the varied cutaneous manfestations of the disease and more commonly majority of the cases present with palatal ulcers which primarily go to otolaryngologist rather than dermatologists. Of the 25 authentic reported cases between 1968 to 1992, 19 (76%) had lesion confined to oral cavity.[4] In the present series also 4/7 (57%) had presented with palatal ulcers and only one had (case no. 6) classical papulonodular skin lesions over face. The first case of cutaneous histoplasmosis from India was reported by Panja and Sen.[5] Histoplasmosis has been found to be endemic in West Bengal and the organism (H. Capsulatum) has been isolated from the soil in Gangetic plain.[10] Sanyal and Thammaya[11] have evaluated the histoplasmin positivity in people of Calcutta and its neighbourhood. A positive result was seen in 26 of 275 (9.4%) pateints and 38 (13.8%) showed doubtful reactions. However, very few cases of histoplasmosis have been reported by the dermotologists of West Bengal. This could be probably because of non referral of cases of palatal ulcers by the otolaryngologists to the dermatologist colleagues and lack of awareness about the condition amongst them. Only a high degree of suspicion can pick up cases of histoplasmosis. We are afraid that many cases of palatal ulcers are probably being missed out on that front and the mystery is never unravelled.

Although fungal culture is a useful tool to diagnose histoplasmosis, the organism being fastidious, the culture often yields negative results as in our series.

A properly done biopsy and histopathological examination with routine and special stains for fungus can reliably diagnose a case of histoplasmosis. We would like to share our experiences with that of others in the field.

 
   References Top

1.Hay RJ, Moore M. Mycology, In : Champion RH, Burton JL, Burns DA, et al (editors) Text Book of Dermatology, 6th ed, Blackwell Science: Oxford; 1998. p. 1363-6.   Back to cited text no. 1    
2.Venugopal PV, Venugopal TV. Deep fungal infections In: Valia RG, valia A (editors), IADVL Text bok and atlas of Dermatology Vol 1, Bhalani Publishing House: Mumbai; 2001. p. 259-84.   Back to cited text no. 2    
3.Schwartz J. Histoplasmosis. Praeger: New York; 1981. p 352.  Back to cited text no. 3    
4.Padhye AA, Pathak AA, Katkar VJ, Hazare VK, Kaufman L. Oral histoplasmosis in India: A case report and an overview of cases reported during 1968-92. J Med Vet Mycol 1994;32:93-103.   Back to cited text no. 4  [PUBMED]  
5.Thankappan TP, Vijayalekshmy A. Ramchandran Nair P. Chronic Progressive disseminated mucocutaneous histoplasmosis. Indian J Dermatol Venereol Leprol 1983;49:26-8.   Back to cited text no. 5    
6.Panja G, Sen S. A unique case of histoplasmosis. J Indian Med Assoc 1959;23:257-8.   Back to cited text no. 6    
7.Edwards LB, Acquaviva FA, Livesay VT, Cross FW, Palmer CE. An atlas of sensitivity to tuberculin, PPD-B and histoplasmin in the United States. Am Rev Respir Dis 1969;99:1-132.   Back to cited text no. 7  [PUBMED]  
8.Nair PS, Vijayadharan M, Vincent M. Primary cutaneous histoplasmosis. Indian J Dermatol Venereol Leprol 2000;66:151-3.   Back to cited text no. 8    
9.Singhi MK, Gupta L, Kacchawa D, Gupta D. Disseminated primary cutaneous histoplasmosis successfully treated with intraconazole. Indian J Dermatol Venereol Leprol 2003;69:405-7.   Back to cited text no. 9    
10.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. 10    
11.Sannyal M, Thamnaya A. Skin sensitivity to histoplasmin in calcutta and its neighbourhood. Indian J Dermatol Venereol Leprol 1980;46:94-8.   Back to cited text no. 11    


    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

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