Case of disseminated histoplasmosis in a HIV-infected patient revealed by nasal involvement with maxillary osteolysis

Abstract

Background: Disseminated Histoplasmosis (DH) is a rare manifestation of Acquired Immune Deficiency Syndrome (AIDS) in European countries. Naso-maxillar osteolysis due to Histoplasma capsulatum var. capsulatum (Hcc) is unusual in endemic countries and has never been reported in European countries. Differential diagnoses such as malignant tumors, cocaine use, granulomatosis, vasculitis and infections are more frequently observed and could delay and/or bias the final diagnosis.

Case presentation: We report the case of an immunocompromised patient infected by Human Immunodeficiency Virus (HIV) with naso-maxillar histoplasmosis in a non-endemic country. Our aim is to describe the clinical presentation, the diagnostic and therapeutic issues. A 53-year-old woman, originated from Haiti, was admitted in 2016 for nasal deformation with alteration of general condition evolving for at least 6 months. HIV infection was diagnosed in 2006 and classified at AIDS stage in 2008 due to cytomegalovirus infection associated with pulmonary histoplasmosis. At admission, CD4 cell count was 9/mm³. Surgical biopsies were performed and ruled out differential or associated diagnoses. Mycological cultures identified Hcc and Blood Polymerase Chain Reaction (PCR) for Hcc was positive. The patient was given daily Amphothericin B liposomal infusion during 1 month. Hcc PCR became negative in the blood under treatment, and then oral switch by itraconazole was introduced. Antiretroviral treatment was reintroduced after a 3-week histoplasmosis treatment. Normalization of naso-maxillar mucosa enabled a palatal prosthesis.

Conclusion: Naso-maxillar histoplasmosis is extremely rare; this is the first case ever reported in a non-endemic country. Differential diagnoses must be ruled out by conducting microbiologic tools and histological examinations on surgical biopsies. Early antifungal treatment should be initiated in order to prevent DH severe outcomes.

Keywords: Case report; HIV; Histoplasmosis; Immunocompromized; Maxillary osteolysis.

Fig. 1

Clinical presentation of the case. a: Three-quarter picture of the face; b: Profile picture of the face; c: Face picture of the face showing lack of teeth 11, 21 and 22 which fall spontaneously; d: Bottom view of the face: nasal tip collapse, hard palate lysis and remaining nasal septum through the hole

Fig. 2

Imaging exploration. a: Sinus CT-scan showing bony nasal septum lysis and bilateral maxillary sinus opacities; b and c: Gadolinium-enhanced T1 weighted MRI (b: axial section; c: frontal section) showing bony nasal septum lysis and maxillar lysis without enhanced tumor mass

Fig. 3

Histological analysis of naso-maxillar biopsy. a and c: Grocott staining; b: Gram Wegert staining; d: PAS staining