Disseminated histoplasmosis presenting as pyoderma gangrenosum-like lesions in a patient with acquired immunodeficiency syndrome

A 33-year-old Hispanic woman with newly diagnosed human immunodeficiency vi rus (HIV) infection, a CD4 T-lymphocyte count of 2, viral load of 730,000 c opies/mL, candidal esophagitis, seizure disorder, a history of bacterial pn eumonia, and recent weight loss was admitted with tonic clonic seizure. On admission, her vital signs were: pulse of 88, respiration rate of 18, tempe rature of 37.7 degreesC, and blood pressure of 126/76. Her only medication was phenytoin. On examination, the patient was found to have multiple umbil icated papules on her face, as well as painful, erythematous, large, punche d-out ulcers on the nose, face, trunk, and extremities of 3 months' duratio n (Fig. 1). The borders of the ulcers were irregular, raised, boggy, and un dermined, while the base contained hemorrhagic exudate partially covered wi th necrotic eschar. The largest ulcer on the left mandible was 4 cm in diam eter. The oral cavity was clear. Because of her subtherapeutic phenytoin le vel, the medication dose was adjusted, and she was empirically treated with Unasyn for presumptive bacterial infection. Chest radiograph and head comp uted tomography (CT) scan were within normal limits. Sputum for acid-fast b acilli (AFB) smear was negative. Serologic studies, including Histoplasma a ntibodies, toxoplasmosis immunoglobulin M (IgM), rapid plasma reagin (RPR), hepatitis C virus (HCV), and hepatitis B virus (HBV) antibodies were all n egative. Examination of the cerebrospinal fluid was within normal limits wi thout the presence of cryptococcal antigen. Blood and cerebrospinal culture s for bacteria, mycobacteria, and fungi were all negative. Viral culture fr om one of the lesions was also negative. The analysis of her complete blood count showed: white blood count, 2300/muL; hemoglobin, 8.5 g/dL; hematocri t, 25.7%; and platelets, 114,000/muL. Two days after admission, the dermatology service was asked to evaluate the patient. Although the umbilicated papules on the patient's face resembled lesions of molluscum contagiosum, other infectious processes considered in the differential diagnosis included histoplasmosis, cryptococcosis, and Pen icillium marnefei. In addition, the morphology of the ulcers, particularly that on the left mandible, resembled lesions of pyoderma gangrenosum. A ski n biopsy was performed on an ulcer on the chest. Histopathologic examinatio n revealed granulomatous dermatitis with multiple budding yeast forms, pred ominantly within histiocytes, with few organisms residing extracellularly. Methenamine silver stain confirmed the presence of 2-4 mum fungal spores su ggestive of Histoplasma capsulatum (Fig. 2). Because of the patient's deter iorating condition, intravenous amphotericin B was initiated after tissue c ulture was obtained. Within the first week of treatment, the skin lesions s tarted to resolve. Histoplasma capsulatum was later isolated by culture, co nfirming the diagnosis, The patient was continued on amphotericin B for a t otal of 10 weeks, and was started on lamivudine, stavudine, and nelfinavir for her HIV infection during hospitalization. After amphotericin B therapy, the patient was placed on life-long suppressive therapy with itraconazole. Follow-up at 9 months after the initial presentation revealed no evidence of relapse of histoplasmosis.