Sporotrichosis in the acquired immunodeficiency syndrome

Osteoarticular Mycoses

Osteoarticular mycoses are chronic debilitating infections that require extended courses of antifungal therapy and may warrant expert surgical intervention. As there has been no comprehensive review of these diseases, the International Consortium for Osteoarticular Mycoses prepared a definitive treatise for this important class of infections. Among the etiologies of osteoarticular mycoses are Candida spp., Aspergillus spp., Mucorales, dematiaceous fungi, non-Aspergillus hyaline molds, and endemic mycoses, including those caused by Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides species. This review analyzes the history, epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, inflammatory biomarkers, diagnostic imaging modalities, treatments, and outcomes of osteomyelitis and septic arthritis caused by these organisms. Candida osteomyelitis and Candida arthritis are associated with greater events of hematogenous dissemination than those of most other osteoarticular mycoses. Traumatic inoculation is more commonly associated with osteoarticular mycoses caused by Aspergillus and non-Aspergillus molds. Synovial fluid cultures are highly sensitive in the detection of Candida and Aspergillus arthritis. Relapsed infection, particularly in Candida arthritis, may develop in relation to an inadequate duration of therapy. Overall mortality reflects survival from disseminated infection and underlying host factors.

Sporothrix schenckii Immunization, but Not Infection, Induces Protective Th17 Responses Mediated by Circulating Memory CD4+ T Cells

Sporotrichosis is a chronic subcutaneous mycosis caused by the Sporothrix schenckii species complex and it is considered an emerging opportunistic infection in countries with tropical and subtropical climates. The host’s immune response has a main role in the development of this disease. However, it is unknown the features of the memory cellular immune response that could protect against the infection. Our results show that i.d. immunization in the ears of mice with inactivated S. schenckii conidia (iC) combined with the cholera toxin (CT) induces a cellular immune response mediated by circulating memory CD4⁺ T cells, which mainly produce interleukin 17 (IL-17). These cells mediate a strong delayed-type hypersensitivity (DTH) reaction. Systemic and local protection against S. schenckii was mediated by circulating CD4⁺ T cells. In contrast, the infection induces a potent immune response in the skin mediated by CD4⁺ T cells, which have an effector phenotype that preferentially produce interferon gamma (IFN-γ) and mediate a transitory DTH reaction. Our findings prove the potential value of the CT as a potent skin adjuvant when combined with fungal antigens, and they also have important implications for our better understanding of the differences between the memory immune response induced by the skin immunization and those induced by the infection; this knowledge enhances our understanding of how a protective immune response against a S. schenckii infection is developed.

Molecular Components of the Sporothrix schenckii Complex that Induce Immune Response

Sporotrichosis is a fungal disease caused by the Sporothrix schenckii complex that includes species such as S. brasiliensis, S. schenckii sensu stricto, S. globosa, S. luriei, S. mexicana, and S. pallida, which exhibit different potentially antigenic molecular components. The immune response of susceptible hosts to control infection and disease caused by these fungi has been little studied. Besides, the fungus-host interaction induces the activation of different types of immune response. This mini-review analyzes and discusses existing reports on the identification and functional characterization of molecules from species of the S. schenckii complex with clinical relevance, and the mechanisms that mediate the type and magnitude of the immune response in experimental models in vivo and in vitro. This knowledge is expected to contribute to the development of protective and therapeutic strategies against sporotrichosis and other mycoses.

The impact of sporotrichosis in HIV-infected patients: a systematic review

Sporotrichosis is a fungal infection of man and animals caused by Sporothrix complex. It usually presents as a lymphocutaneous form, but disseminated disease may occur. Given the paucity of data about HIV/AIDS and sporotrichosis co-infection, a systematic review of reported cases of HIV-associated sporotrichosis found via Pubmed (1984-2013) was done. A total of 39 papers were included, and 58 patients' data analyzed. Thirty-three (56.9 %) cases were from Brazil and 18 (31 %) from the USA. Patients' mean age was 37.8 ± 10.4 years; males predominated (84.5 %). The median CD4(+) cell count was 97 cells/mm(3). The most common clinical forms were disseminated and disseminated cutaneous with 33 (56.9 %) and 10 (17.5 %) patients, respectively. There was a correlation between CD4(+) count and clinical categories (p = 0.002). Mortality was 30 % and there was a correlation between central nervous system involvement and death (p < 0.001).

Sporotrichosis: a forgotten disease in the drug research agenda

Potassium iodide was discovered in the 19th century and still remains as one of the more effective and most prescribed treatments for sporotrichosis. No new drugs have been evaluated in large randomized clinical trials in comparison with standard or alternative treatments for sporotrichosis during the last decades. The emergence of disseminated sporotrichosis in AIDS patients has uncovered the need for more effective treatments. Sporotrichosis is only a public health problem in a few geographical areas, mostly located in developing countries; and its usually harmless history could explain the limited investment in sporotrichosis treatment research. Better understanding of the virulence factors, such as the melanization process, could reveal new potential drug targets.

Characterization of virulence profile, protein secretion and immunogenicity of different Sporothrix schenckii sensu stricto isolates compared with S. globosa and S. brasiliensis species

A comparative study about protein secretion, immunogenicity and virulence was performed in order to characterize and to compare eight Sporothrix schenckii sensu stricto isolates. For virulence characterization, a murine model, based on survival assay and CFU counting was used. S. brasiliensis and S. globosa, a highly virulent and a non-virulent isolates, respectively were used as external controls. Exoantigen profiles showed different secreted molecules; the 46- and 60-kDa molecules were commonly secreted by all three species. The S. schenckii s. str. isolates could be classified as non-virulent or presenting low, medium or high virulence, based on survival times after infection and recovery of viable fungi. The humoral response profiles of mice infected with S. schenckii s. str., S. globosa and S. brasiliensis were heterogeneous; five virulent isolates (S. schenckii s. str., n = 4 and S. brasiliensis, n = 1) had in common the recognition of the 60-kDa molecule by their respective antisera, suggesting that this antigen may be involved in virulence. Furthermore, the 110-kDa molecule was secreted and recognized by antisera from four virulent isolates (S. schenckii s. str., n = 3 and S. brasiliensis, n = 1), so there is a possibility that this molecule is also related to virulence. Our findings reveal different degrees of virulence in S. schenckii s. str. isolates and suggest the correlation of protein secretion and immunogenicity with virulence of S. schenckii complex. These findings provide new insights into the pathogenesis of S. schenckii s. str. and improve the knowledge about immunogenicity and protein profiles in S. schenckii complex.

Disseminated Sporothrix brasiliensis infection with endocardial and ocular involvement in an HIV-infected patient

Disseminated sporotrichosis occurs in individuals with impaired cellular immunity, such as in cases of neoplasia, transplantation, diabetes, and especially, acquired immunodeficiency syndrome. This report presents a 32-year-old Brazilian human immunodeficiency virus (HIV)-infected patient who developed a protracted condition of disseminated sporotrichosis with endocarditis, bilateral endophthalmitis, and lymphatic involvement. He needed cardiac surgery to replace the mitral valve. Sporothrix brasiliensis isolates were recovered from cultures of subcutaneous nodules and mitral valve fragments. Species identification was based on classical and molecular methods. The patient received amphotericin B for 52 days and subsequently, oral itraconazole. He remains asymptomatic, and he is on maintenance therapy with itraconazole. Despite his positive clinical outcome, he developed bilateral blindness. To our knowledge, this case is the first report of endocarditis and endophthalmitis caused by S. brasiliensis.

Sporotrichosis in HIV-infected patients: report of 21 cases of endemic sporotrichosis in Rio de Janeiro, Brazil

Sporotrichosis is endemic in Rio de Janeiro, Brazil, and cases have been reported to be associated with HIV. This article describes the clinical manifestations and evolution of sporotrichosis in HIV-positive patients and constitutes the largest case series reported to date. There were 21 HIV-positive patients with sporotrichosis diagnosed by the recovery of the etiologic agent from 1999-2009. Sixteen patients (76.2%) were men and five (23.8%) were women, with a mean age of 41.2 years. Seven of these individuals were previously unaware of their HIV infection. Mean CD4 count was 346.4 cells/μl. The most frequent clinical presentations of sporotrichosis in these patients were the lymphocutaneous and disseminated form (seven patients each, 33.3%), followed by the widespread cutaneous form in five (23.8%), and fixed form in the remaining two (9.5%). In patients with the disseminated forms, clinical manifestations involved the skin in six, mucosa (nasal, oral, or conjunctival) in four, bone in two, and meninges in two. Eleven (52.4%) patients received itraconazole and eight (38.1%) amphotericin B contributing to an overall cure rate of 81%. Spontaneous cure was observed in one patient. The clinical forms of sporotrichosis varied according to the patients' immune status. The results demonstrate the importance of sporotrichosis as an opportunistic infection associated with AIDS in countries where the mycosis occurs.

Cutaneous and meningeal sporotrichosis in a HIV patient

A male patient with HIV and past history of tuberculosis and suspected neurotoxoplasmosis was admitted to the hospital with vomiting and small nodules through all his body. Few of the nodules were found forming chains of enlarged lymphatic vessels, especially on lesions located on the limbs. Some of the nodules were ulcerated with a serosanguineous discharge. Collected samples from ulcerated and the nodular lesions showed the presence of Sporothrix schenckii in culture. Although all hemocultures were negative, a spinal fluid collected from this patient and cultures from the cutaneous lesions were both positive for S. schenckii. The patient showed improvement after treatment with Amphotericin B. Sadly, he later died of complications not related to the S. schenckii infection. This case of disseminated sporotrichosis is a remainder that in patients with immunological disorders exotic forms of this fungal clinical entity could be expected.

Sporothrix schenckii and sporotrichosis

For a long time sporotrichosis has been regarded to have a low incidence in Brazil; however, recent studies demonstrate that not only the number of reported cases but also the incidence of more severe or atypical clinical forms of the disease are increasing. Recent data indicate that these more severe forms occur in about 10% of patients with confirmed diagnosis. The less frequent forms, mainly osteoarticular sporotrichosis, might be associated both with patient immunodepression and zoonotic transmission of the disease. The extracutaneous form and the atypical forms are a challenge to a newly developed serological test, introduced as an auxiliary tool for the diagnosis of unusual clinical forms of sporotrichosis.

Therapeutic approaches to subcutaneous mycoses

Subcutaneous mycoses, which are much less common than superficial fungal infections, are characterized by a heterogeneous group of infections that often result from direct penetration of the fungus into the dermis and subcutaneous tissue through traumatic injury. The fungus spreads by local deep tissue invasion from the inoculation site. The disease usually remains localized and then slowly spreads to adjacent tissue and eventually to the lymphatics. More rarely, hematogenous dissemination is observed. There are usually various clinical features and thus a broad range of differential diagnoses. The common subcutaneous mycoses are sporotrichosis, chromoblastomycosis, phaeohyphomycosis, eumycotic mycetoma, and hyalohyphomycosis. Many subcutaneous mycoses are confined to the tropical and subtropical regions, but some, such as sporotrichosis, are also prevalent in temperate regions. Subcutaneous mycoses can occur in healthy individuals. In immunocompromised individuals, these infections can disseminate widely. Treatment usually involves use of antifungal agents and/or surgical excision. Treatment of some serious subcutaneous mycoses remains unresolved, and there have been reports of relapses or progression during therapy and problems with lack of tolerability of antifungal drugs. Identification of the etiologic agent by culture is essential for prognostic and management considerations, since some fungi are more frequently associated with dissemination. Results of antifungal susceptibility tests may provide valuable information for deciding the appropriate method of treatment. Development of new antifungal agents and combination therapies may result in improvement in the management of subcutaneous mycoses in the future.

Identifying and treating mycotic skin infections

PURPOSE

To provide physicians and nurses with an overview of mycotic infections and related cutaneous manifestations.

TARGET AUDIENCE

This continuing-education activity is intended for physicians and nurses with an interest in learning how to recognize and treat mycotic skin infections.

OBJECTIVES

After reading the article and taking the test, the participant will be able to:1. Identify the cause and clinical presentation of mycotic skin infections.2. Identify diagnostic tests used in evaluating patients with mycotic skin infections.3. Identify appropriate treatment options in patients with mycotic skin infections.

Sporothrix schenckii lipid inhibits macrophage phagocytosis: involvement of nitric oxide and tumour necrosis factor-alpha

The role of cell-wall compounds in the immune response to sporotrichosis is unknown. The effect of cell-wall compounds and exoantigen obtained from Sporothrix schenckii in macrophage/fungus interaction was analysed with respect to nitric oxide (NO) and tumour necrosis factor-alpha (TNF-alpha). The lipid compound of the cell wall plays an important role in the pathogenesis of this mycosis and was found to inhibit the phagocytic process and to induce high liberation of NO and TNF-alpha in macrophage cultures in the present study. This is a very interesting result because it is the first report about one compound of the fungus S. schenckii that presents this activity.

Successful treatment of AIDS-related disseminated cutaneous sporotrichosis with itraconazole

Sporotrichosis is a chronic granulomatous mycosis caused by a dimorphic fungus, Sporothrix schenckii. The most common manifestations of infection are lymphocutaneous and fixed-cutaneous types. In the case of immunosuppressed patients, and particularly in patients with acquired immune deficiency syndrome (AIDS), it occurs as disseminated cutaneous disease. This is a report of a 28-year-old male patient who presented with disseminated cutaneous and hematogenous sporotrichosis involving multiple ulcerative, nodular lesions in various body areas. Treatment consisted of 300 mg/d of itraconazole, which resulted in clinical and mycological cure.

Mycetoma in an HIV-infected patient

Although opportunistic fungal infections occur commonly in immunocompromised hosts, mycetoma has never been reported in association with HIV infection. The authors present a case that to their knowledge is the first reported case of mycetoma associated with HIV infection. Diagnosis was confirmed by direct examination of grains and histologic examination. Precise identification of the agent, an actinomycete, was not possible. The unusual site of infection may probably be related to the use of contaminated needless and syringes for HIV drug injection.

Host organism defense by a peptide-polysaccharide extracted from the fungus Sporothrix schenckii

A peptide-polysaccharide, a peptide-rhamnomannan, was isolated from the pathogenic yeast form of the fungus Sporothrix schenckii. This substance, which may play a role in fungal virulence, was tested in an animal model of systemic disease, and depression of the immune response was observed in the animals between the 4th and 6th week of infection. Concomitantly, this compound showed mitogenic activity when challenged with normal lymphocytes and was also found to be involved in the inflammatory response. These results provide further information for the understanding of fungal implantation in tissues and of the pathogenicity of this systemic mycosis.

Update on the cutaneous manifestations of HIV infection. Clinical and pathologic features

Skin is the most commonly affected organ in patients with HIV. As such, cutaneous manifestations of HIV infection have been the subject of intense scrutiny as well as the topic of many articles. A broad range of infectious and noninfectious skin lesions may develop during the course of the disease. This article discusses the clinical and pathological cutaneous manifestations of HIV infection.

Disseminated sporotrichosis with extensive cutaneous involvement in a patient with AIDS

Sporotrichosis most commonly presents as a localized, lymphocutaneous infection that follows trauma, such as an injury from a rose thorn. In patients infected with HIV, it may be widespread and disseminated. We describe a patient with AIDS who developed disseminated sporotrichosis, a rare opportunistic fungal infection that may affect these patients. The condition remained undiagnosed because of failure to recognize characteristic histopathologic findings and failure of clinicians to interface closely with the microbiology laboratory. The condition was difficult to treat, requiring systemic administration of amphotericin. While localized sporotrichosis is an innocuous disorder that responds well to therapy, in immunocompromised hosts, it is potentially life-threatening and may require prolonged therapy with potentially toxic medications such as amphotericin B. It is important that clinicians be aware of the presentation of this unusual opportunistic infection and that they maintain close communication with pathology and clinical microbiology laboratories to ensure that proper stains and cultures are performed to avoid potential misdiagnosis.

Esporotricose cutânea disseminada como manifestação inicial da síndrome da imunodeficiência adquirida - relato de caso

Os autores relatam caso de infecção cutânea disseminada pelo Sporothrix schenckii em paciente de 30 anos, previamente assintomático e portador de infecção pelo HIV. Observou-se comprometimento cutâneo extenso com coleções supurativas e ulcerações. O agente foi isolado em cultura de abscesso. O tratamento com anfotericina B forma lipossomal mostrou-se eficaz.

Update on cutaneous manifestations of HIV infection

The skin is affected in virtually all patients with HIV infection. Many articles and several books have been published that deal with these disorders for a number of reasons. First, cutaneous disease may serve as the initial or only problem that the patient suffers for much of the course of the HIV infection. Second, serious opportunistic infections may present for the first time in the skin, so that a skin lesion may be a harbinger of the patient's having a life-threatening illness. Third, skin disorders in these patients may appear unusual and hence may not be accurately diagnosed by clinical inspection alone. Furthermore, response to treatment may be poorer than expected. Thus, skin diseases in the HIV-infected patient are important and, in some cases, may be the most debilitating element of the patient's condition.

Diagnosis and treatment of infectious diseases in HIV-infected hosts

Treatment of infectious diseases in patients with HIV infection is of primary importance in patient care. Viral, bacterial, parasitic, and fungal pathogens all may affect these patients. It is essential that accurate diagnoses be made and appropriate therapy be administered as early as possible.

Fungal disease in the immunocompromised host

A variety of superficial and deep mycoses may affect the immunocompromised patient. Among the superficial mycoses, candidal infections are common in all groups, but dermatophyte and pityrosporum infections may also be found. Although not primarily dangerous, they may lead to secondary bacterial infections and morbidity. Of the systemic mycoses, candidiasis, aspergillosis, and mucor-mycosis are frequently lethal and require early diagnosis and aggressive antifungal treatment. Endemic mycoses, such as histoplasmosis and coccidioidomycosis, may result in severe and often fatal infections in those patients with cellular immune alterations. The identification and prophylaxis of high-risk patients and the development of more effective antifungal therapies are beginning to have an impact on the control of fungal disease in this population.

Treatment of tropical mycoses

Several subcutaneous and deep-seated mycoses are either observed more frequently in the tropical areas or are restricted to certain regions within the tropics. These mycoses include sporotichosis, chromoblastomycosis, entomophthoromycosis, eumycetoma, lobomycosis, and paracoccidioidomycosis. In sporotrichosis and paracoccidioidomycosis, therapy often results in either complete resolution or marked improvement. For decades sporotrichosis has been treated successfully with potassium iodide, but recently the triazole compounds, especially itraconazole, have proved effective and free of major side effects. The usual therapy for paracoccidioidomycosis is sulfonamides or amphotericin B; the former requires prolonged treatment, whereas the latter causes a significant degree of toxicity. Various azole derivatives (ketoconazole, fluconazole, saperconazole, and itraconazole) allow shorter treatment courses, can be given orally, and are more effective. Presently, itraconazole is the drug of choice. Chromoblastomycosis is a difficult condition to treat, especially if it is caused by Fonsecaea pedrosoi. Several therapeutic approaches have been used, including heat, surgery, cryotherapy, thiabendazole, amphotericin B combined with flucytosine, and azole derivatives, but their success has been modest. A 65% response rate has been obtained with itraconazole given for periods of 6 to 19 months; in limited trials, saperconazole appears to be more effective and requires shorter treatment courses. Only a few patients with eumycetoma respond to therapy; 70% of patients with Madurella mycetomatis respond to prolonged treatment with ketoconazole. Griseofulvin has been tried in nonresponders with partial success. Limited data in patients with Fusarium species eumycetoma indicate good responses to itraconazole. Eumycetoma caused by Pseudallescheria boydii or Acremonium species has been refractory to therapy. Therapy of entomophthoromycosis is also difficult because the diagnosis is usually established late and not all patients respond to therapy; this situation applies to infection caused by either Basidiobolus haptosporus or Conidiobolus coronatus. Although there is no consensus, African physicians prefer to use potassium iodide or trimethoprim-sulfamethoxazole. Isolated reports indicate that the azole derivatives, including the triazoles, may be effective. As for lobomycosis, all attempts at medical treatment have failed. Surgery is successful only when the lesion is small and can be fully resected; repeated cryotherapy appears to be more successful.

Efficacy of acute phase and maintenance therapy with itraconazole in an AIDS patient with sporotrichosis

An AIDS patient with sporotrichosis who improved with itraconazole therapy after consecutive failure of ketoconazole, saturated solution of potassium iodide, fluconazole and amphotericin B is presented. In addition, long-term therapy with high doses of itraconazole was well tolerated and effective in avoiding relapse. Itraconazole may be suitable for use in HIV-infected patients with sporotrichosis, who probably require chronic suppressive therapy to prevent relapse of symptomatic disease.

Disseminated cutaneous and meningeal sporotrichosis in an AIDS patient

We report the first proven case of Sporothrix meningoencephalitis in an AIDS patient. The patient had dramatic, wide-spread ulcerative and infiltrative disease with progressive meningoencephalitis in spite of amphotericin and itraconazole therapy. Sporothrix was cultured from premortem cerebrospinal fluid and seen in the meninges and in brain vessels at autopsy.

Sporotrichosis presenting as arthritis and subcutaneous nodules

Arthritis is a rare manifestation of systemic sporotrichosis. A patient who had sporotrichal arthritis of both wrists and elbows is described. Predisposing factors included alcoholism, rose gardening, and antecedent trauma. The onset of the arthritis was insidious, and the diagnosis was made 2 1/2 years after his first symptoms were noted. Treatment with surgical debridement and a 23-week course of ketoconazole was unsuccessful. A review of the literature suggests that some combination of intravenous or intraarticular amphotericin B and potassium iodide, ketoconazole, or surgery is necessary for effective treatment.

Uncommon invasive fungal pathogens in the acquired immunodeficiency syndrome

This communication lists fungi reported to cause invasive infection in patients with AIDS. It excludes the well known and common fungi that infect these patients such as Candida, Cryptococcus, Histoplasma, Coccidioides and Aspergillus. It is likely that these less common fungal pathogens will be seen more frequently in the enlarging AIDS population as it is continuously exposed to many of these potentially opportunistic fungi.

Dermatologic manifestations of human immunodeficiency virus infection

Human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS) have become major health problems in the United States, and patients with manifestations of these diseases are seen by physicians in all areas of medicine. Cutaneous manifestations develop in as many as 92% of HIV-positive persons. Familiarity with these manifestations facilitates early diagnosis and enhances the care of HIV-infected patients. The spectrum of mucocutaneous disorders in these patients includes an acute exanthem, multiple infections, neoplastic processes, and miscellaneous disorders. Herein we review the most common and the most specific dermatologic manifestations associated with HIV infection, which often are atypical, more severe, or less responsive to treatment than the corresponding diseases encountered in non-HIV-infected persons.

Treatment of cutaneous sporotrichosis with terbinafine

Terbinafine, an allylamine antifungal agent, has been shown to have excellent in-vitro activity against dermatophytes. Several other fungi of importance also show in-vitro sensitivity. Because terbinafine is fungicidal rather than fungistatic in action, its efficacy in treating such fungal infections requires evaluation. Five patients with cutaneous sporotrichosis were treated with 250 mg of terbinafine twice daily. All of the patients were cured. Overall, the clinical response was rapid. In three patients, negative culture was achieved within 8 weeks; in the other two, negative culture was obtained at 12 and 32 weeks, respectively. Terbinafine was well tolerated, although one patient developed erectile dysfunction while receiving treatment. This was completely resolved on stopping the treatment. The treatment of sporotrichosis is also reviewed in this article.

Medical management of AIDS patients. Bacterial and fungal infections

The rapid and thus far generally inexorable rise in HIV infections has led to a series of opportunistic infection that includes those caused by bacteria, yeasts, and members of the Eumycetes. The infections range in prevalence from occasional to highly prevalent, in severity from trivial to fatal, and in anatomic areas involved from local to disseminated. They occur as isolated, concurrent, or sequential infections with regard to other opportunistic diseases. Some vary in their geographic distribution. They may be newly acquired or reactivated and occur early or late in the course of HIV infection. Bacterial infections are usually easily treated, although they frequently disseminate and often recur after seemingly appropriate treatment. In contrast, all but the mildest fungal infections are difficult to treat and even more difficult or impossible to eradicate. The diagnosis of bacterial and fungal infections begins with clinical suspicion and involves relatively standard methodology. Treatment of the systemic mycoses and some bacterial infections in HIV infected patients is punctuated by exaggerated side effects of therapy, frequent relapses, and the need for maintenance suppressive therapy.

Mucocutaneous disease in pediatric human immunodeficiency virus infection

Children with HIV infection may develop a wide variety of infectious and inflammatory diseases of the skin. These disorders are often more severe and more difficult to treat than in the healthy child. In some cases, disorders of the skin or mucous membranes may provide an early clue to the presence of pediatric HIV infection.

Disseminated histoplasmosis presenting as an ulcerated verrucous plaque in a human immunodeficiency virus-infected man. Report of a case possibly involving human-to-human transmission of histoplasmosis

A 46-year-old homosexual man with disseminated histoplasmosis and human immunodeficiency virus (HIV) infection had a histoplasmosis-related ulcerated verrucous plaque above his left upper lip; systemic and cutaneous disease manifestations of histoplasmosis resolved with daily ketoconazole therapy. Disseminated histoplasmosis, with similar cutaneous features, also was present in his HIV-seropositive male sexual partner. The possibility of human-to-human transmission of histoplasmosis between these patients is considered and the skin lesions of systemic fungal infections in HIV-infected patients are reviewed.

Pyoderma gangrenosum in pediatric acquired immunodeficiency syndrome

We describe two children with human immunodeficiency virus infection in whom pyoderma gangrenosum developed. Although pyoderma gangrenosum most commonly occurs in children with inflammatory bowel disease, it has also been described in patients with a variety of immunodeficiencies. In such patients a vigorous search to exclude a treatable infection should be made before the lesions are treated as pyoderma gangrenosum.