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 Table of Contents 
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 1287-1289  

A rare cause of nodular skin lesions with fever in an immunocompetent individual


1 Department of Medicine, PGIMER, Dr. RML Hospital, New Delhi, India
2 Department of Medicine, Smt. Sucheta Kriplani Hospital and LHMC, New Delhi, India

Date of Web Publication27-Mar-2019

Correspondence Address:
Dr. Subodh Kumar Mahto
C/O: Anandi Prakash Hospital, Sitamarhi, Bihar - 843 316
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_26_19

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  Abstract 


Histoplasmosis is a fungal disease caused by the dimorphic fungus Histoplasma capsulatum. It is endemic to many parts of the world but is rarely seen in India. The fungus usually affects the immunocompromised patients and is rarely reported in immunocompetent hosts. We hereby report a case of the nodular skin lesion with fever lesion that finally turned out to have cutaneous histoplasmosis, from a non-endemic region of northern India and that too in an immunocompetent.

Keywords: Fever, immunocompetent, nodular skin lesion, skin biopsy


How to cite this article:
Mahto SK, Jamal A, Gupta PK, Majumdar P, Grewal V, Agarwal N. A rare cause of nodular skin lesions with fever in an immunocompetent individual. J Family Med Prim Care 2019;8:1287-9

How to cite this URL:
Mahto SK, Jamal A, Gupta PK, Majumdar P, Grewal V, Agarwal N. A rare cause of nodular skin lesions with fever in an immunocompetent individual. J Family Med Prim Care [serial online] 2019 [cited 2019 Oct 22];8:1287-9. Available from: http://www.jfmpc.com/text.asp?2019/8/3/1287/254870




  Introduction Top


Histoplasmosis is a worldwide systemic mycosis caused by Histoplasma capsulatum and Histoplasma duboisii, which occurs endemically in many parts of the world, but is rare in India.[1] The primarymode of infection has been postulated as inhalation of conidia (spores) present in soil orsuspended in the atmosphere. After inhalation, these fungal elements convert into yeast forms, which may disseminate systemically.[2]


  Case Report Top


A 62-year-old male who is a native of northern India, skilled laborer (carpenter) by profession, was admitted to our hospital with complaints of high-grade fever (103°F) of 1-month duration. Twenty days after the onset of fever, he developed nodular skin lesions all over the body, which first involved the face then chest and abdomen and then the extremities, sparing the palm and the soles. Along with these predominant nodular lesions, he also had multiple non-blanchable, non-indurated, and hyperpigmented papules [Figure 1]. The patient had a history of 12 kg weight loss over the past 4 months. His general physical examination showed multiple hyperpigmented papular and nodular lesions covering the face, chest, abdomen, and extremities [Figure 2]. Rest of the general physical and systemic examination was normal.
Figure 1: Showing multiple hyperpigmented papules over the face

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Figure 2: Multiple hyperpigmented patches on the abdomen

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Blood counts were within normal limits. Serology for viral hepatitis, malaria, rK-39, and HIV was negative. Mantoux test and antinuclear antibody were also negative. No abnormality was detected on imaging (chest X-ray/contrast-enhanced computed tomography of thorax and abdomen). Skin biopsy was done, which showed ulcerated epithelium covered with exudates. The dermis shows dense inflammatory infiltrate with many foam cells and many intracellular yeast forms of Histoplasma were noted [Figure 3] and [Figure 4]. No abnormality was detected on bone marrow aspiration and biopsy. To rule out any other causes for immunocompromised state, his immunological profile was done, CD4 count was 722 cells/mm 3 (normal 500–1200 cells/mm 3) and the levels of IgA (86 mg/dL), IgM (211 mg/dL), and IgG (861 mg/dL) were all normal.
Figure 3: Low power photomicrograph of skin biopsy showing ulcerated epithelium covered with exudates. The dermis shows dense inflammatory infiltrate with many foam cells [H and E, ×100]

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Figure 4: High power under oil emersion lens shows many intracellular spores of Histoplasma (arrows) [H and E, ×1000]

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Serum antigen for Histoplasma was positive. Isolation of the fungus was achieved on special media (Sabouraud agar) and growth of H. capsulatum was detected after 4 weeks. The patient was started on liposomal amphotericin-B at a dose of 3 mg/kg/day, intravenous for 4 weeks, and then oral itraconazole at a dose of 200 mg twice a day orally, which was continued for 6 months. There was a marked improvement in his symptoms without any adverse effects of amphotericin-B and he was discharged on oral itraconazole after 5 weeks of hospital stay.


  Discussion Top


H. capsulatum is found in the North and Central America mainly in Mississippi and Ohio River valleys.[1] H. duboisii is prevalent in Africa.[3] The common presentation can be with fever, abdomen pain, weight loss, mucocutaneous lesions, such as oral ulcers, erythematous, or vegetativenodules, growth resembling warts, hepatosplenomegaly, lymphadenopathy, cytopenias, such asanemia, and/or thrombocytopenia.[4] The occurrence of disseminated histoplasmosis is mostcommonly seen even in immunosuppressed individuals, rarely seen in immunocompetentindividuals.[5]

Isolation of H. capsulatum from clinical specimens remains the gold standard for the diagnosis of histoplasmosis with a sensitivity of 74%.[6] Treatment of cutaneous histoplasmosis is the administration of liposomal amphotericin-B (3–5 mg/kg/day) for 2 weeks followed by maintenance therapy with oral itraconazole 200 mg twice a day for 6 months with regular monitoring of Histoplasma antigen level in serum or urine.[6]


  Conclusion Top


The notable feature of this case was the variable presentation in an immunocompetent individual from a non-endemic area, highlighting the possibility of repeated misdiagnosis and inadequate treatment if there is no high index of suspicion. Early diagnosis and treatment of the disease can decrease further complications, morbidity, and mortality and turn out as a favorable outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kauffman CA. Histoplasmosis: A clinical and laboratory update. Clin Microbiol Rev 2007;20:115-32.  Back to cited text no. 1
    
2.
Harnalikar M, Kharkar V, Khopkar U. Disseminated cutaneous histoplasmosis in an immunocompetent adult. Indian J Dermatol 2012;57:206-9.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Gugnani HC. Histoplasmosis in Africa. Indian J Chest Dis Allied Sci 2000;42:271-7.  Back to cited text no. 3
    
4.
Fortaleza SC, Lopes SK, Bandeira TJ, Nogueira TN, Holanda MA. Acute disseminated histoplasmosis in an immunocompetent patient. J Bras Pneumol 2004;30:1-6.  Back to cited text no. 4
    
5.
Sayal SK, Prasad PS, Sanghi S. Disseminated histoplasmosis: Cutaneous presentation. Indian J Dermatol Venereol Leprol 2003;69:90-1.  Back to cited text no. 5
  [Full text]  
6.
Hage CA, Azar MM, Bahr N, Loyd J, Wheat LJ. Histoplasmosis: Up-to-date evidence-based approach to diagnosis and management. Semin Respir Crit Care Med 2015;36:729-45.  Back to cited text no. 6
    


    Figures

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



 

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