Skin lesions in histoplasmosis

Histoplasmosis around the world: A global perspective on the presentation, virulence factors, and treatment of histoplasmosis

Histoplasmosis is a systemic infection caused by an endemic dimorphic fungus, Histoplasma capsulatum. Though prevalent in the eastern United States of America, near the Ohio and Mississippi River Valleys, the evidence underlying the global prevalence of histoplasmosis, especially in immunocompromised populations, is underappreciated. This article highlights the global epidemiology, risk factors, microbiology and pathophysiological characteristics, pulmonary and extrapulmonary manifestations, prevention measures, radiographic patterns, diagnostic techniques, and antifungal treatment approaches for Histoplasma capsulatum.

Diagnosing disseminated histoplasmosis in advanced HIV/AIDS disease in Cameroon using a point of care lateral flow assay

Histoplasmosis is an AIDS-defining opportunistic infection. Disseminated histoplasmosis (DH) can be fatal without early diagnosis and treatment initiation. We present one confirmed and three probable cases of DH in advanced HIV/AIDS disease patients diagnosed using OIDx Histoplasma LFA in Yaoundé, Cameroon. Four women with HIV but unknown CD4 count presented with asthenia, weight loss, productive cough, and fever (39°C) as common symptoms for at least 3 weeks. Two of the patients had skin lesions. These included facial papules, macules, and umbilicated vesicles scattered over the trunk and limbs. These were diffuse lesions which were purulent, itching, and papillomatous lesions with a necrotic centre, and one patient had a right forearm ulcer. We performed the Histoplasma antigen tests using the OIDx Histo LFA, and they were strongly positive in all four patients. Histopathology in skin biopsy allowed identification of the species as Histoplasma capsulatum var capsulatum in one patient. In this same patient, Pseudomonas aeruginosa and Proteus mirabilis were cultured from the forearm ulcer. This patient later commenced antibiotics (Levofloxacin 500 mg) and oral itraconazole (800 mg/day) with immediate improvement. Unfortunately, the other three patients could not access itraconazole, were discharged and lost to follow-up. Early diagnosis and treatment are essential for the management of DH. LFA is a test that can be set up in any setting with limited resource. Access to this can be a major advance in the diagnosis of histoplasmosis in resource-limited settings.

Cutaneous eccrine inflammation and necrosis: review of inflammatory disorders affecting the eccrine apparatus including new associations

Despite being frequently overlooked during the examination of histopathological sections, eccrine sweat glands can offer clues for diagnosing various skin conditions. They provide important functions and can lead to several diseases when inflamed or injured. This review article provides information regarding eccrine physiology as well as well-established and novel entities that occur in association with eccrine gland pathology.

Deep mycoses and pseudomycoses of the foot: a single-center retrospective study of 160 cases, in a tertiary-care center in Mexico

BACKGROUND

Deep mycoses and pseudomycoses (DMP) may cause significant disability and even death; however, the reports regarding these diseases, mainly affecting the foot, are scarce.

OBJECTIVE

To describe the epidemiological, clinical, and diagnostic characteristics of DMP of the foot in 160 patients.

METHODS

A retrospective and observational study of DMP affecting the foot was carried out in a tertiary-care center in Mexico for 20 years (from January 2000 to December 2019). Cases with confirmatory microbiological studies were included; the identification of the isolated fungi was based on the forms of reproduction. For actinomycetes, morphological analysis in an automated system ATB Vitek® 1574 (Biomèrieux) was used. The fungi were identified by PCR, using several primers from the ITS regions and for actinomycetes in the 16S rRNA region. Data from histopathological studies were also collected.

RESULTS

One hundred and sixty proven cases of DMP of the foot were included. The cases were categorized into nine types of infections including mycetoma (actinomycetoma and eumycetoma) in 102 cases (63.7%); sporotrichosis in 21 cases (13.1%); chromoblastomycosis, 18 cases (11.2%); phaeohyphomycosis, 3 cases (1.8%); histoplasmosis, 12 cases (7.5%); coccidioidomycosis 2 cases (1.2%) and botryomycosis and nocardiosis with one case respectively (0.6%). Most cases developed after traumatic implantation (147 cases, 91.8%). One hundred fifteen cases (71.8%) were men. The evolution was chronic in 125 cases (78.2%); bone involvement was observed in 64 cases (40%). Parasitic forms were observed In 139 cases (86.8%). The isolation and identification of the etiological agents were confirmed in all cases.

CONCLUSION

The main DMP affecting the foot were infections due to traumatic implantation; most were endemic mycoses. The clinical characteristics and the evolution of the diseases are easily misdiagnosed, and thus, diagnostic tests are usually required.

Disseminated Histoplasmosis Diagnosed by "Touch Prep"

Disseminated histoplasmosis is a rare but serious complication of infection with the dimorphic fungus Histoplasma capsulatum. We report a case of disseminated histoplasmosis with cutaneous involvement diagnosed by touch wet preparation and confirmed with histopathology and culture. "Touch prep" performed from a lesional punch biopsy, prepared with Wright-Giemsa followed by chlorazol black containing KOH, revealed abundant yeast organisms localized within multinucleated giant cells, and a rapid diagnosis of disseminated histoplasmosis with cutaneous involvement was achieved. This report demonstrates the utility of wet prep techniques as an invaluable and rapid beside diagnostic tool in the setting of cutaneous histoplasmosis. In addition, we compare the distinguishing histopathologic features of the infectious organisms within the differential diagnosis of parasitized histiocytes.

An unusual presentation of cutaneous histoplasmosis as a recurrent solitary and spontaneously healing lesion in an immunocompetent patient

Infection with Histoplasma capsulatum typically manifests as a self-limiting pulmonary disease in immunocompetent patients. Systemic symptoms such as cutaneous lesions are associated with immunodeficient states. Our patient was an immunocompetent 68-year-old male who presented with a plaque on his left infraorbital area that was concerning for malignancy. Histological examination of the lesion revealed granulomatous inflammation and small yeast forms suggestive of H. capsulatum. The lesion resolved spontaneously and recurred 1 year later. On recurrence, histological examination again revealed yeast forms consistent with H. capsulatum. Serum and urine testing for H. capsulatum antigen were negative. Next-generation sequencing detected H. capsulatum, which supported the diagnosis of a cutaneous infection. The patient was prescribed and started treatment with itraconazole for 1 year after recurrence of the lesion, and he has not reported further disease recurrence to date. This case is unique because of the presentation of a primary cutaneous recurrent H. capsulatum lesion, and it demonstrated the utility of laboratory testing in its diagnosis.

Cutaneous Histoplasmosis: An Unusual Presentation with Nasal Obstruction

Histoplasmosis is a systemic fungal disease that may be presented with a variety of clinical manifestations, usually as an opportunistic infection in immunocompromised individuals. We present an HIV seropositive patient with a large fleshy growth causing left-sided nasal obstruction, as an unusual presentation. The lesions shrunk dramatically and almost completely on intravenous amphotericin-B lipid complex (ABLC) given for 2 weeks followed by long-term oral itraconazole.

An Italian Case of Disseminated Histoplasmosis Associated with HIV

Histoplasma capsulatum is a dimorphic fungus, endemic in the Americas, Africa (var. duboisii), India, and Southeast Asia. H. capsulatum infection is rarely diagnosed in Italy, while in Latin America, progressive disseminated histoplasmosis (PDH) is one of the most frequent AIDS-defining illnesses and causes of AIDS-related deaths. We report a case of PDH and new HIV infection diagnosis in a Cuban patient, who has been living in Italy for the past 10 years. Bone marrow aspirate and peripheral blood smear microscopy suggested H. capsulatum infection. The diagnosis was confirmed with the culture method identifying its thermal dimorphism. Liposomal amphotericin B was administered alone for 10 days and then for another 2 days, accompanied with voriconazole; the former was stopped for probable side effects (persistent fever and worsening thrombocytopenia), and voriconazole was continued to complete 4 weeks. PDH maintenance treatment consisted of itraconazole for one year. Antiretroviral therapy (ART) was started on the third week of antifungal treatment. At the 3-year follow-up, the patient is adherent on ART, the virus was suppressed, and she has an optimal immune recovery. This case highlights the need to suspect histoplasmosis in the differential diagnosis of opportunistic infections in immunocompromised persons, native to or who have traveled to endemic countries.

Disseminated histoplasmosis in immunocompetent patients from an arid zone in Western India: A case series

Histoplasmosis is a systemic fungal disease caused by dimorphic fungus Histoplasma capsulatum and is more common in immunocompromised patients. We report two cases of disseminated histoplasmosis in immunocompetent individuals from a non-endemic zone in Western India. Rapid diagnostic tests like urinary antigen detection and molecular assays comprise the need of the hour as early initiation of antifungal therapy can be life-saving. Clinicians need to be aware of this entity to prevent misdiagnosis and initiate prompt effective management.

An immigrant with acquired immunodeficiency syndrome presenting with a rash: A case report

A 58-year-old woman from Zimbabwe, with a history of untreated human immunodeficiency virus, presented with leonine facies and a diffuse rash. The rash occurred in the context of a 1-year history of constitutional symptoms and cognitive decline. Laboratory investigations confirmed that her human immunodeficiency virus had progressed to acquired immunodeficiency syndrome. Through imaging, tissue biopsies, and polymerase chain reaction, a diagnosis of disseminated histoplasmosis was made. Since there was no history of travel and histoplasmosis is not locally endemic, the patient likely contracted this fungal infection more than 7 years ago, while living in Africa. We speculate that the histoplasmosis remained latent until her immune system began to decline. The work-up and management of this rare cutaneous presentation of a systemic disease, which should be added to the list of “great mimickers” in dermatology, are discussed.

Histoplasma panniculitis in a patient with systemic lupus erythematosus

Histoplasmosis usually presents primarily as lung infection. Occasionally, mainly in immunocompromised hosts, it can spread and cause systemic manifestations. Skin lesions have been reported in 10 to 15 percent of cases of disseminated histoplasmosis, and panniculitis has been described as an unusual form of presentation in affected patients. We present the case of a patient with systemic lupus erythematosus who presented cellulitis due to disseminated histoplasmosis.

Skin Infections

Cutaneous infections are common in immunocompromised patients. Neutropenia predisposes patients to fungal, bacterial and viral infections. Antibacterial antifungal and antiviral prophylaxis have caused a significant reduction in some of these infections.

There are two main types of cutaneous infections : primary cutaneous infections and cutaneous manifestations of a disseminated infection. In the latter, skin lesions may be the window to disseminated bloodstream infection and the first and only evidence of a disseminated life threatening infection.

The diagnosis may be at your fingertips; therefore a thorough skin exam is the clue. However, it’s also important to know the characteristic lesions associated with different infections. It will help expedite diagnosis so appropriate treatment is initiated promptly in neutropenic patients, which can be lifesaving.

In a retrospective study of 43 neutropenic febrile patients with cutaneous lesions, fungal infections were the most frequent, and nodular lesions on the lower extremities were the most prevalent (Naorungroj and Aiempanakit, J Am Acad Dermatol 74:AB166, 2016).

Skin biopsy for pathological study and culture remains the gold standard and should be obtained early to confirm the suspected diagnosis. In these immunocompromised patients the inflammatory response is altered by either the primary disease or its treatment. Therefore, routine pathogens may present in an atypical fashion, with diminished or absent induration, erythema, or pustulation in response to bacterial resulting cutaneous infection without typical cellulitis (Urabe, Clin Infect Dis 39:S53–S55, 2004). Skin lesions are evaluated not only by morphology, but also in the context of the clinical setting and biopsy result. The skin biopsy is inexpensive, relatively noninvasive and without contraindication, and may avoid the need for more invasive procedures such an open lung biopsy (Grossman, et al., Cutaneous manifestations of infection in the immunocompromised host. Springer Science+Business Media, LLC, New York, 2012).

In addition to antimicrobial therapy, surgery should not be postponed in the face of progressive skin and soft tissue infection in this population (Brzozowski and Ross, J Hand Surg Br 22:679–680, 1997).

Disseminated histoplasmosis: case report and review of the literature

Case report We report the case of a young Cameroonian woman who presented with cough, hyperthermia, weight loss, pancytopenia, and hepatosplenomegaly. A positive HIV serology was discovered and a chest radiography revealed a 'miliary pattern'. Bone marrow aspiration pointed out yeast inclusions within macrophages. Given the morphological aspect, the clinical presentation and immunosuppression, histoplasmosis was retained as a working hypothesis. Antiretroviral and amphotericin B treatments were promptly initiated. Review Given the immigration wave that Europe is currently experiencing, we think it is important to share experience and knowledge, especially in non-endemic areas such as Europe, where clinicians are not used to face this disease. Histoplasmosis is due to Histoplasma capsulatum var. capsulatum, a dimorphic fungus. Infection occurs by inhaling spores contained in soils contaminated by bat or bird droppings. The clinical presentation depends on the immune status of the host and the importance of inoculum, varying from asymptomatic to disseminated forms. AIDS patients are particularly susceptible to develop a severe disease. Antigen detection, molecular biology techniques, and microscopic examination are used to make a rapid diagnosis. However, antigen detection is not available in Europe and diagnosis needs a strong clinical suspicion in non-endemic areas. Because of suggestive imagery, clinicians might focus on tuberculosis. Our case illustrates the need for clinicians to take histoplasmosis in the differential diagnosis, depending on the context and the patient's past history.

Treatment of disseminated histoplasmosis in advanced HIV using itraconazole with increased bioavailability

Disseminated histoplasmosis (DH), an endemic mycosis caused by the dimorphic fungus Histoplasma capsulatum, is a life-threatening infection in immunocompromised hosts. A patient with newly-diagnosed human immunodeficiency virus (HIV) infection presented with a violaceous, raised, indurated, pruritic rash over the face, arms and trunk on a background of significant weight loss, fevers with sweats, diarrhoea and worsening shortness of breath. His CD4+ T cell count was 14 cells/µl (12%). Histoplasmosis was diagnosed from histology, fungal stain and culture of skin biopsy. In addition to DH, he was found to have Pneumocystis jiroveci pneumonia and multi-resistant Salmonella choleraesuis bacteraemia. He improved with treatment with antibiotics and was commenced on conventional itraconazole, orally. Antiretroviral therapy was commenced soon after. He was unable to achieve therapeutic levels with the conventional formulation due to gastrointestinal side effects and had ongoing fevers. A newer formulation of oral itraconazole with improved bioavailability was commenced. He achieved therapeutic drug levels and had no further intolerance. His fevers settled and the rash improved. He has now completed one year of treatment and is well. To our knowledge this is the first case of moderate DH in an advanced HIV patient treated successfully with oral itraconazole with improved bioavailability.

Approach to skin and soft tissue infections in non-HIV immunocompromised hosts

PURPOSE OF REVIEW

Skin and soft tissue infections are frequent contributors to morbidity and mortality in the immunocompromised host. This article reviews the changing epidemiology and clinical manifestations of the most common cutaneous pathogens in non-HIV immunocompromised hosts, including patients with solid organ transplants, stem cell transplants, solid tumors, hematologic malignancies, and receiving chronic immunosuppressive therapy for inflammatory disorders.

RECENT FINDINGS

Defects in the innate or adaptive immune response can predispose the immunocompromised host to certain cutaneous infections in a predictive fashion. Cutaneous lesions in patients with neutrophil defects are commonly due to bacteria, Candida, or invasive molds. Skin lesions in patients with cellular or humoral immunodeficiencies can be due to encapsulated bacteria, Nocardia, mycobacteria, endemic fungal infections, herpesviruses, or parasites. Skin lesions may reflect primary inoculation or, more commonly, disseminated infection. Tissue samples for microscopy, culture, and histopathology are critical to making an accurate diagnosis given the nonspecific and heterogeneous appearance of these skin lesions due to a blunted immune response.

SUMMARY

As the population of non-HIV immunosuppressed hosts expands with advances in medical therapies, the frequency and variety of cutaneous diseases in these hosts will increase.

Common Child and Adolescent Cutaneous Infestations and Fungal Infections

Cutaneous infections and infestations are common among children and adolescents. Ectoparasitic infestations affect individuals across the globe. Head lice, body lice, scabies, and infestations with bed bugs are seen in individuals who reside in both resource poor areas and in developed countries. Superficial cutaneous and mucosal candida infections occur throughout the life cycle. Dermatophyte infections of keratin-containing skin and skin structures result in tinea capitis (scalp), tinea corporis (body), tinea pedis (foot), and tinea unguium (nails). Less frequent endemic fungal infections such as blastomycosis, coccidiodomycosis, and histoplasmosis may present with skin findings. This article will describe the epidemiology and transmission of these conditions as well as their clinical manifestations. The approach to diagnosis will be addressed as well as primary prevention and current therapies.

The Changing Epidemiology of Invasive Fungal Infections

Invasive fungal infections (IFI) are an emerging problem worldwide with invasive candidiasis and candidemia responsible for the majority of cases. This is predominantly driven by the widespread adoption of aggressive immunosuppressive therapy among certain patient populations (e.g., chemotherapy, transplants) and the increasing use of invasive devices such as central venous catheters (CVCs). The use of new immune modifying drugs has also opened up an entirely new spectrum of patients at risk of IFIs. While the epidemiology of candida infections has changed in the last decade, with a gradual shift from C. albicans to non-albicans candida (NAC) strains which may be less susceptible to azoles, these changes vary between hospitals and regions depending on the type of population risk factors and antifungal use. In certain parts of the world, the incidence of IFI is strongly linked to the prevalence of other disease conditions and the ecological niche for the organism; for instance cryptococcal and pneumocystis infections are particularly common in areas with a high prevalence of HIV disease. Poorly controlled diabetes is a major risk factor for invasive mould infections. Environmental factors and trauma also play a unique role in the epidemiology of mould infections, with well-described hospital outbreaks linked to the use of contaminated instruments and devices. Blastomycosis is associated with occupational exposure (e.g., forest rangers) and recreational activities (e.g., camping and fishing).The true burden of IFI is probably an underestimate because of the absence of reliable diagnostics and lack of universal application. For example, the sensitivity of most blood culture systems for detecting candida is typically 50 %. The advent of new technology including molecular techniques such as 18S ribosomal RNA PCR and genome sequencing is leading to an improved understanding of the epidemiology of the less common mould and dimorphic fungal infections. Molecular techniques are also providing a platform for improved diagnosis and management of IFI.Many factors affect mortality in IFI, not least the underlying medical condition, choice of therapy, and the ability to achieve early source control. For instance, mortality due to pneumocystis pneumonia in HIV-seronegative individuals is now higher than in seropositive patients. Of significant concern is the progressive increase in resistance to azoles and echinocandins among candida isolates, which appears to worsen the already significant mortality associated with invasive candidiasis. Mortality with mould infections approaches 50 % in most studies and varies depending on the site, underlying disease and the use of antifungal agents such as echinocandins and voriconazole. Nevertheless, mortality for most IFIs has generally fallen with advances in medical technology, improved care of CVCs, improved diagnostics, and more effective preemptive therapy and prophylaxis.

Deep Fungal Infections, Blastomycosis-Like Pyoderma, and Granulomatous Sexually Transmitted Infections

Granulomatous diseases are caused by multiple infectious and noninfectious causes. Deep fungal infections can present in the skin or extracutaneously, most commonly with lung manifestations. An Azole or amphotericin B is the universal treatment. Blastomycosis-like pyoderma is a clinically similar condition, which is caused by a combination of hypersensitivity and immunosuppression. Successful treatment has been reported with antibiotics and, more recently, the vitamin A analog, acitretin. Granuloma inguinale and lymphogranuloma venereum cause ulcerative genital lesions with a granulomatous appearance on histology. The Centers for Disease Control and Prevention recommens treatment of these genital infections with doxycycline.

Cutaneous histoplasmosis as a complication after anti-TNF use--Case report

Anti-TNF agents are effective in the treatment of psoriasis. However, they render individuals more susceptible to infections. We report an atypical case of histoplasmosis in an immunosuppressed patient due to anti- TNF therapy. A patient who used anti-TNF for the treatment of psoriasis had had a lesion on the right eyebrow since discontinuation of the medication. The diagnostic hypothesis was basal cell carcinoma, but the histopathological examination was compatible with histoplasmosis.

Disseminated cutaneous histoplasmosis in newly diagnosed HIV

We present a woman with a widespread severe papulopustular eruption, fever, and fatigue of 5 weeks' duration. HIV infection was diagnosed, with an absolute CD4(+) count of 3 cells/µL. The eruption was consistent with disseminated cutaneous histoplasmosis. The clinical manifestations and management of cutaneous histoplasmosis are reviewed.

Disseminated histoplasmosis partially mimicking a dermatomyositis in a patient with rheumatoid arthritis

Histoplasma capsulatum var. capsulatum is a dimorphic fungus endemic to America and subtropical regions. Several cases of this opportunist mycosis have been reported in immunocompromised patients. We report the case of a patient treated with methotrexate and corticosteroid therapy for rheumatoid arthritis and who presented with disseminated histoplasmosis that partially mimicked a dermatomyositis.

Cutaneous manifestations of endemic mycoses

All of the endemic mycoses have cutaneous and mucocutaneous manifestations that are most commonly seen when patients have disseminated infection. Biopsy of skin lesions is simple and safe and can assist in making a timely diagnosis of disseminated infection. Primary cutaneous inoculation infection has been reported with all of the endemic mycoses, but is rare. In this situation, a nodule or ulcer occurs at the inoculation site, is often accompanied by lymphangitis and regional lymphadenopathy, and systemic symptoms and signs as almost always absent. Mucosal lesions are common with disseminated histoplasmosis, but also have been described in patients who have disseminated blastomycosis and coccidioidomycosis. Biopsy is essential to rule out cancer and allows a rapid diagnosis of the endemic fungal infection.

The mycoarray as an aid for the diagnosis of an imported case of histoplasmosis in an Italian traveler returning from Brazil

We describe an imported case of histoplasmosis, whose serological profile was established by means of a protein-based microarray platform, the recently described mycoarray. Because of its peculiarities, such a novel tool greatly facilitates the rapid and multiparametric assessment of patients' serological status and lends itself to be employed as an aid in the diagnosis of primary mycoses, especially in nonendemic countries.