Unmasking histoplasmosis immune reconstitution inflammatory syndrome in a patient recently started on antiretroviral therapy

Abstract

Histoplasmosis is the most common endemic mycoses among HIV-infected people. Patients with suppressed cell immunity mainly due to HIV are at increased risk of disseminated disease. Dermatological manifestations of immune reconstitution inflammatory syndrome (IRIS) and cutaneous manifestations of histoplasmosis similar to an IRIS event have been previously described. We report the case of a 43-year-old male who presented with cutaneous disseminated histoplasmosis due to Histoplasma capsulatum var. capsulatum 4 months after the onset of the antiretroviral therapy and some improvement in the immune reconstitution. After 2 weeks of amphotericin B and itraconazole therapy, the scheduled treatment involved fluconazole maintenance therapy, which resulted in an improvement of his skin lesions.

Keywords: Antiretroviral Therapy, Highly Active, Fluconazole; Histoplasmosis; Immune Reconstitution Inflammatory Syndrome.

Figure 1. Cutaneous lesions throughout on the face before the antifungal treatment.

Figure 2. Photomicrography of the skin biopsy. A - Normal epidermis and infiltrated dermis (H&E, 100X); B, C, and D - Small, oval, narrow based yeasts consistent with Histopolasma capsulatum (H&E, 400X).

Figure 3. Photomicrography of the skin biopsy showing in A - multiple oval-shaped structures consistent with Histoplasma sp (Grocott, 1000X); in B - PAS staining spores appearing as round or oval structures within the cytoplasm of the macrophages (PAS, 1000X).

Figure 4. Skin examination after 6 months of treatment.