Cutaneous histoplasmosis associated with acquired immunodeficiency syndrome (AIDS)

A 30-year-old man, who had originally been admitted to the Centro Dermatolo gico Pascua for medical attention and was later transferred to the Hospital General de Mexico, presented with a 2-month history of progressive dermato sis affecting the head (face, ear lobes, oral cavity), trunk (all faces), u pper and lower limbs (including the palms and soles), external genitalia, a nd the perianal region. The patient had no history of homosexuality, but di d have a long history of sexual intercourse with prostitutes in the city of Ciudad del Carmen (island in southeastern Mexico), where he was born and l ives. The dermatosis consisted of multiple nodules and ulcerative lesions, some of them isolated and others with junctions between them, forming verru cous plaques. He complained of mild pruritus and pain. The lesions had firs t appeared on the face and, over the course of 2 months, had increased in s ize and number and were accompanied by malaise, fever, and loss of 6 kg of body weight (Fig. 1). The presumptive clinical diagnosis was leishmaniasis, an endemic disease in the area where he lives. Laboratory parameters at pr esentation included the following. hemoglobin 11.5 g/dL; hematocrit 34%; wh ite blood cells (WBC) total 7900 cells/mm(3); lymphocytes total 1414 cells/ mm(3); platelets 449,000/mm(3); CD4+ lymphocytes 1.5% and CD8+ lymphocytes 81.0%, with a CD4/CD8 ratio of 0.18 cells/mm(3). Blood chemistry, hepatic f unction tests, and serum electrolyte determinations were all within normal ranges. A chest roentgenogram was also normal. Human immunodeficiency virus (HIV) seropositivity was tested by enzyme-linked immunosorbent assay (ELIS A) and confirmed by Western blot. Histologic evaluation showed a dense infiltration of lymphocytes and histio cytes, many of which were markedly vacuolated. A number of intracellular ye ast-like cells that were easily stained with hematoxylin and eosin and peri odic acid-Schiff (PAS) were evident inside the histiocytes (Fig. 2). We con cluded that the granulomatous process was suggestive of histoplasmosis. Histoplasma capsulatum was eventually cultured from the skin biopsy specime ns. A histoplasmin skin test was negative; precipitin and complement fixati on tests using the same antigen were both positive, the latter with an init ial titer of 1 : 320. The confirmatory diagnosis of acquired immunodeficiency syndrome (AIDS)-ass ociated cutaneous histoplasmosis prompted us to begin treatment with amphot ericin B 1 mg/kg/day, heparin 5 IU/day, hydrocortisone 500 mg/day, and itra conazole 400 mg/day. Also, the main laboratory tests were repeated. When an accumulated dose of 535 mg of amphotericin B had been reached, an elevatio n of serum creatinine to 1.48 mg/dL occurred, and a glomerular filtration r ate of 57.8%, a urinary volume of 1350 mL/24 h, and a potassium (K) of 2.3 mEq/L were found. For this reason, the amphotericin B dose was reduced to 0 .50 mg/kg/day, and potassium replacement was started. The reduced amphoteri cin B dose resulted in an improvement in the serum creatinine to 0.9 mg/dL, a glomerular filtration rate of 92.5%, a urinary Volume of 2900 mL/24 h, a nd a potassium; level of 4.3 mEq/L. Despite the abnormalities detected in t he laboratory tests. the patient showed a clear clinical improvement and hi s complement fixation ratio to histoplasmin decreased from 1 : 320 to 1 : 6 4. Currently, the patient is being maintained with a 300-mg/day dose of itr aconazole, and is being periodically re-evaluated by laboratory testing. He shows good clinical progress and resolution of most lesions (Fig. 3).