Case Report: Histoplasmosis in Himachal Pradesh (India): An Emerging Endemic Focus

Abstract

We describe four cases of histoplasmosis indigenous to Himachal Pradesh (India) that will be of considerable public health interest. A 48-year-old human immunodeficiency virus (HIV)-negative man with cervical and mediastinal lymphadenopathy, hepatosplenomegaly, adrenal mass, and bone marrow involvement was treated as disseminated tuberculosis without benefit. Progressive disseminated histoplasmosis was diagnosed from the fungus in smears from adrenal mass. Another 37-year-old HIV-positive man was on treatment of suspected pulmonary tuberculosis. He developed numerous erythema nodosum leprosum-like mucocutanous lesions accompanied by fever, generalized lymphadenopathy, and weight loss. Pulmonary histoplasmosis with cutaneous dissemination was diagnosed when skin lesions showed the fungus in smears, histopathology, and mycologic culture. Both were successfully treated with amphotericin B/itraconazole. Third patient, a 46-year-old HIV-negative man, had oropharyngeal lesions, cervical lymphadenopathy, intermittent fever, hepatosplenomegaly, and deteriorating general health. Progressive disseminated oropharyngeal histoplasmosis was diagnosed from the fungus in smears and mycologic cultures from oropharyngeal lesions and cervical lymph node aspirates. He died despite initiating treatment with oral itraconazole. Another 32-year-old man 3 months after roadside trauma developed a large ulcer with exuberant granulation tissue over left thigh without evidence of immunosuppression/systemic involvement. He was treated successfully with surgical excision of ulcer under amphotericin B/itraconazole coverage as primary cutaneous histoplasmosis confirmed pathologically and mycologically. A clinical suspicion remains paramount for early diagnosis of histoplasmosis particularly in a nonendemic area. Most importantly, with such diverse clinical presentation and therapeutic outcome selection of an appropriate and customized treatment schedule is a discretion the treating clinicians need to make.

Figure 1.

Geographic distribution of histoplasmosis cases in India. This figure appears in color at www.ajtmh.org.

Figure 2.

Case 2. Wide spread papules and nodules over face. Similar lesions were present over trunk and extremities. This figure appears in color at www.ajtmh.org.

Figure 3.

Case 2. Histologic section of skin lesion showing sheets of macrophages with numerous yeast cells of Histoplasma capsulatum (A) H&E, ×40; (B) periodic acid Schiff, ×40. This figure appears in color at www.ajtmh.org.

Figure 4.

Characteristic cottony white colonies with yellowish tinge of Histoplasma capsulatum on Sabouraud’s dextrose agar at 25–30°C. This figure appears in color at www.ajtmh.org.

Figure 5.

Characteristic mycelia and large, rounded, unicellular, tuberculate macroconidia of Histoplasma capsulatum on short, hyaline, and undifferentiated conidiophores in lactophenol cotton blue mounts (×40). This figure appears in color at www.ajtmh.org.

Figure 6.

Case 3. Numerous coalescing macerated papules in the orophayrnx, and over palate. This figure appears in color at www.ajtmh.org.

Figure 7.

Case 3. Fine needle aspiration cytology from submandibular lymph node showing intra- and extracellular yeasts of Histoplasma capsulatum. This figure appears in color at www.ajtmh.org.

Figure 8.

Case 4. Single punched-out ulcer over left thigh with exuberant granulation tissue, sclerotic, and hyperpigmented margins and indurated ill-defined borders. This figure appears in color at www.ajtmh.org.