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Primary cutaneous histoplasmosis.

An 80-year-old farmer with arthritis, anemia, chronic kidney disease, and a history of shingles presented with a 3-month history of a painful, nonhealing, ulcerative pinna lesion refractory to antibiotics and local wound care (figure 1). He reported a subsequent development of similar ulcerative lesions involving the oral tongue and floor of his mouth.

Biopsy of the pinna and oral cavity revealed diffuse, mixed inflammatory infiltrate and numerous epithelioid histiocytes containing small, circular yeast cells compatible with Histoplasma capsulatum (figure 2). Special stains for fungal organisms, including Gomori methenamine silver (GMS) and periodic acid-Schiff (PAS) were strongly positive (figure 3).

The patient had no clinical or laboratory findings to suggest systemic fungal infection, so oral itraconazole was initiated for treatment of primary cutaneous histoplasmosis with dissemination to the oral cavity. Despite a promising initial clinical response, the medication was withdrawn several weeks into therapy because of the patient's worsening renal function. Hemodialysis was initiated; however, the patient's health progressively deteriorated, and he passed away a few months later from renal-, heart-, and liver-associated complications.

H capsulatum is a soil saprophyte endemic to the Ohio and Mississippi River valleys, often found in chicken habitats or caves inhabited by bats and birds. Infection by inhalation of aerosolized H capsulatum microconidia primarily affects the lungs of immuno-suppressed individuals, although a variety of clinical presentations exist. (1) Histoplasmosis of the skin, a less common presentation, occurs either secondarily via systemic infection that disseminates to the skin, or primarily via direct inoculation of H capsulatum during injury to the skin. (1,2) The latter disease process, termed primary cutaneous histoplasmosis (PCH),rarely presents in the head and neck and is poorly described in the otolaryngologic literature. (3)

Patients with PCH present with nonspecific skin lesions including papules, plaques, ulcers, purpura, abscesses, impetigo, or dermatitis. (4) Diagnosis hinges on evidence of fungus in the wound and absence of systemic disease. Tissue biopsy of the cutaneous lesion should be performed promptly. Microscopy may reveal fungal elements and granuloma formation, but histopathology showing any distinctive 2- to 4-[micro]m, oval, narrow-based budding yeasts secures the diagnosis (figure 2).

GMS and PAS stains (figure 3) help identify H capsulatum in macrophages and within the tissue. Cultures showing small, oval, budding yeast can be used to confirm the diagnosis, but their results often take several weeks. Antigen detection is a sensitive method used for ruling out disseminated disease. (1-3)

Treatment of PCH depends on the extent and severity of the disease. Topical amphotericin B and nystatin can be used for limited disease, while systemic amphotericin B and itraconazole often are reserved for more widespread lesions. (5) Incision and drainage maybe necessary for lesions refractory to medical therapy. (6)

Blake Raggio, MD

From the Department of Otolaryngology, Tulane University Medical Center; and the Department of Otolaryngology, Ochsner Health System, New Orleans. The case described in this article occurred at the University of Florida Medical Center, Gainesville. This article has been edited and adapted from its presentation as a poster at the American Academy of Otolarayngology-Head and Neck Surgery Annual Meeting; Sept. 10-13, 2017; Chicago.

References

(1.) Wheat LJ, Azar MM, Bahr NC, et al. Histoplasmosis. Infect Dis Clin North Am 2016;30(1):207-27.

(2.) Tesh RB, Schneidau JD Jr. Primary cutaneous histoplasmosis. N Engl J Med 1966;275(11):597-9.

(3.) Kollipara R, Hans A, Hall J, Watson K. A case report of primary cutaneous histoplasmosis requiring deep tissue sampling for diagnosis. Dermatol Online J 2014;20(11). pii: 13030/ qt/11b53041.

(4.) Chang P, Rodas C. Skin lesions in histoplasmosis. Clin Dermatol 2012;30(6):592-8.

(5.) Wheat LJ, Freifeld AG, Kleiman MB, et al. Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis 2007;45(7):807-25.

(6.) Buitrago MJ, Gonzalo-Jimenez N, Navarro M, et al. A case of primary cutaneous histoplasmosis acquired in the laboratory. Mycoses 2011;54(6):e859-61.

Caption: Figure 1. Photo shows the erosive, ulceronodular lesion of the left pinna and preauricular skin.

Caption: Figure 2. Hematoxylin and eosin (H & E)-stained sections demonstrate numerous vacuolated areas (arrows) surrounded by a diffuse, mixed inflammatory infiltrate (A; original magnification x20) and numerous epithelioid histiocytes with small, circular yeast cells (arrows), characteristic of H capsulatum (B; original magnification x 40).

Caption: Figure 3. GMS (A) and PAS (B) stains highlight numerous aggregates and randomly distributed organisms of H capsulatum (original magnification x40).
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Title Annotation:PATHOLOGY CLINIC
Author:Raggio, Blake
Publication:Ear, Nose and Throat Journal
Article Type:Clinical report
Date:Oct 1, 2018
Words:739
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