AIDS-Related Endemic Mycoses in Western Cape, South Africa, and Clinical Mimics: A Cross-Sectional Study of Adults With Advanced HIV and Recent-Onset, Widespread Skin Lesions

Abstract

Background: Skin lesions are common in advanced HIV infection and are sometimes caused by serious diseases like systemic mycoses (SM). AIDS-related SM endemic to Western Cape, South Africa, include emergomycosis (formerly disseminated emmonsiosis), histoplasmosis, and sporotrichosis. We previously reported that 95% of patients with AIDS-related emergomycosis had skin lesions, although these were frequently overlooked or misdiagnosed clinically. Prospective studies are needed to characterize skin lesions of SM in South Africa and to help distinguish these from common HIV-related dermatoses.

Methods: We prospectively enrolled HIV-infected adult patients living in Western Cape, South Africa, with CD4 counts ≤100 cells/μL and widespread skin lesions present ≤6 months that were deemed clinically compatible with SM. We obtained skin biopsies for histopathology and fungal culture and collected epidemiological and clinical data.

Results: Of 34 patients enrolled and in whom a diagnosis could be made, 25 had proven SM: 14 had emergomycosis, and 3 each had histoplasmosis and sporotrichosis; for 5 additional patients, the fungal species could not be identified. Antiretroviral therapy (ART) had been initiated in the preceding 4 weeks for 11/25 (44%) patients with SM (vs no patients without SM). Plaques and scale crust occurred more frequently in patients with SM (96% vs 25%, P = .0002; and 67% vs 13%, P = .01, respectively).

Conclusions: Recent ART initiation and presence of plaques or scale crust should make clinicians consider SM in patients with advanced HIV infection in this geographic area. Clinical overlap between SM and other dermatoses makes early skin biopsy critical for timely diagnosis and treatment.

Keywords: Emergomyces africanus; emergomycosis; emmonsiosis; histoplasmosis; sporotrichosis.

Figure 1.

Histopathology of skin biopsies from patients with systemic mycoses. (A) Sporothrix schenckii. Ovoid yeast-like forms that measure 2–8 μm in size (long arrows), as well as elongated “cigar bodies” that vary in diameter from 2–4 and in length from 4–10 μm (short arrows). The larger size of the yeast-like forms and the presence of elongated forms are helpful to distinguish S. schenkii from Histoplasma capsulatum and Emergomyces africanus (Periodic Acid Schiff [PAS], ×1000). (B) H. capsulatum. Round to ovoid yeasts that vary in size from 2–3 to 3–5 μm with single budding nuclei and thin walls. Intra- and extracelluar oragnisms are present (arrows; PAS, ×1000). (C and D) E. africanus. Morphological features of fungal elements in tissue sections simulate the yeasts of H. capsulatum in particular (arrows; PAS, ×1000).

Figure 2.

Selected cutaneous lesions of persons with advanced HIV infection and generalized, recent-onset skin lesions suspicious for systemic mycoses. Lesions shown are from patients with proven systemic mycoses caused by Emergomyces africanus (A–E), Sporothrix schenckii (F–H), and Histoplasma capsulatum (I–K).

Figure 3.

Chest x-rays from 2 HIV-infected patients with E. africanus infection diagnosed by skin biopsy and in whom pulmonary tuberculosis was excluded. (A) Diffuse, bilateral reticulonodular infiltrates. (B) Bilateral reticulonodular infiltrates with multifocal airspace disease and bilateral hilar involvement.