|Year : 2000 | Volume
| Issue : 3 | Page : 151-153
Primaty Cutaneous Histoplasmosis
S Pradeep Nair, M Vijayadharan, Maya Vincent
S Pradeep Nair
Source of Support: None, Conflict of Interest: None
A 29-year old woman presented with diffuse swelling of the base of the right thumb along with ulceration. X-ray indicated bony damage. Histopathology showed PAS positive intracellular organisms suggestive of histoplasmosis. We are reporting a very rare case of primary cutaneous histoplasmosis from this part of the country.
Keywords: Lichen planus, Clinico- histopathological
|How to cite this article:|
Nair S P, Vijayadharan M, Vincent M. Primaty Cutaneous Histoplasmosis. Indian J Dermatol Venereol Leprol 2000;66:151-3
| Introduction|| |
Histoplasmosis is a deep mycotic infection caused by two species, Histoplasma capsulatum found in America and the Tropics and Histoplasma dubosii found in Africa. The spores of these organisms are found in soil, thorns and bird droppings. Inhalation of these spores causes a lung disease resembling tuberculosis. Histoplasmosis causes a wide spectrum of clinical disease ranging from acute and chronic pulmonary disease, acute and chronic desseminated disease and primary cutaneous disease.  Pulmonary histoplasmosis and desseminated disease are very common in AIDS patients and are a great cause of morbidity and mortality in these patients.  Primary cutaneous histoplasmosis is very rare and occurs due to penetrating injuries.
| Case Report|| |
A-29-year-old woman presented with a diffuse swelling of the base of the right thumb of 3months duration. The history indicated that the patient had sustained multiple thorn pricks of the hand as she was in them habit of collecting firewood from a forest area near her house. Initially there was a pricking type of pain followed by progressive diffuse swelling of the base of the right thumb. There were no constitutional symptoms. During the course of the disease there was spontaneous rupture in one area of the swelling followed by purulent discharge, leaving behind a chronic non healing ulcer.
On examination there was an illdefined tender erythematous firm to hard diffuse swelling of the base of the right thumb extending to the first metacarpal joint and the thenar eminence [Figure - 1]. There was an illdefined ulcer with oozing and crusting just above the first interdigital space with the floor being lined by granulation tissue. There was restriction of the movements of the thumb in all directions. The right axillary lymph nodes were enlarged with slight tenderness. There was no clinical evidence of systemic involvement.
Investigations showed a normal blood hemogram with ESR of 35mm. Liver and renal function tests and blood sugar levels were within normal limits. Blood VDRL and TPHA were non reactive and ELISA test for HIV was repeatedly negative. Pus culture from the lesion was sterile. The Mantoux test was negative. X-ray of chest,and ultrasound of abdomen were within normal limits. X-ray of the right thumb showed osteolysis, osteoporosis, destruction and dislocation of the middle and proximal phalanges and the first metacarpophalangal joints [Figure - 2]. Histopathology of the lesion showed chronic granulomatous infiltrate with abscesses containing numerous intracellular PAS positve round to oval organisms with a clear halo suggestive of histoplasmosis [Figure - 3]. However an initial fungal culture did not yield any organisms. The patient showed prompt response to itraconazole in a dose of 200 mg bid.
| Discussion|| |
Our patient had given history of multiple thorn pricks in a forest area. This history along with presentation of a diffuse swelling of the right thumb with bony involvement, histopathology showing PAS positive intracellular organisms with a clear halo, the absence of systemic involvement and HIV infection and the prompt response to itraconazole enabled us to make a diagnosis of primary cutaneous histoplasmosis. Histoplasmosis usually responds to itraconazole, fluconazole or amphotericin B. Localised histoplasmosis can cause osseous involvement which explains the bony lesions in our patient.  Histoplasma capsulatom is considered to be endemic in certain North Indian states like West Bengal where a previous study showed a skin positivity to histoplasmin antigen in 9.4% of the persons studied.  Our case report indicates that histoplasmosis is present in South India also. There has also been reports of desseminated mucocutaneous histoplasmosis in South India.
Primary cutaneous histoplasmosis is very rare and occurs by local trauma or innoculation and can present with nodules, ulcers, abscesses or molluscum contagiosum - like lesions. Desseminated histoplasmosis can present with maculopapular rash. The interesting feature in our patient is that in spite of numerous organisms in the histopathological specimen there was no evidence of systemic involvement. Cutaneous histoplasmosis should be included in the differential diagnosis of localised cutaneous swelling with bony involvement. We are reporting this case because of its extreme rarity.
| References|| |
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[Figure - 1], [Figure - 2], [Figure - 3]