A case of oral localized histoplasmosis in an immunocompetent patient

Endemic Systemic Mycoses in Italy: A Systematic Review of Literature and a Practical Update

Endemic systemic mycoses such as blastomycosis, coccidioidomycosis, histoplasmosis, talaromycosis, paracoccidioidomycosis are emerging as an important cause of morbidity and mortality worldwide. We conducted a systematic review on endemic systemic mycoses reported in Italy from 1914 to nowadays. We found out: 105 cases of histoplasmosis, 15 of paracoccidioidomycosis, 10 of coccidioidomycosis, 10 of blastomycosis and 3 of talaromycosis. Most cases have been reported in returning travelers and expatriates or immigrants. Thirtytwo patients did not have a story of traveling to an endemic area. Fortysix subjects had HIV/AIDS. Immunosuppression was the major risk factor for getting these infections and for severe outcomes. We provided an overview on microbiological characteristics and clinical management principles of systemic endemic mycoses with a focus on the cases reported in Italy.

Histoplasmosis of the External Auditory Canal

This report describes the diagnosis and treatment of a patient with a rare fungal infection of the external ear, as well as a review of the literature. A 76-year-old Caucasian gentleman from rural southern United States with diabetes and hypertension was referred to our clinic for intractable left otalgia, otorrhea, headaches, and an exophytic lesion in the left external ear since five months. There was no pertinent travel history. Biopsy by an outside otolaryngologist was inconclusive. Repeat biopsy under anesthesia revealed morphological characteristics consistent with histoplasmosis. Intravenous amphotericin B and later oral antifungal agent voriconazole led to improvement in symptoms. The clinical presentation resembled a malignancy. A high index of clinical suspicion, histologic confirmation with deep tissue biopsy, and culture are essential for diagnostic confirmation followed by treatment with systemic antifungals. A multidisciplinary team approach is necessary to manage this rare condition.

Oral Localized Lesion on the Tongue in an Immunocompetent Individual: A Report of a Rare Case With a Comprehensive Review of the Literature

Histoplasmosis (HP) is a sporadic deep fungal disease that rarely shows oral lesions in various clinical forms. It is usually associated with immunocompromised states, but oral HP has also been reported in many immunocompetent individuals. An unusual case of focal oral HP in a 65-year-old immunocompetent male is reported from New Delhi, India (non-endemic region) presenting with oral ulcerative lesions on the floor of the mouth and lateral surface of the tongue. This case report highlights the importance of prompt diagnosis for the success of the treatment of oral HP along with a thorough review of the literature on HP in immunocompetent patients with oral manifestations. The average age of immunocompetent patients with oral HP is 49.65 years with a marked male predilection. The most common intraoral site is the tongue, followed by the gingiva. Also, five intraosseous cases of HP in immunocompetent patients are reported, among which four are seen in patients from Africa and in a much younger age group (mean: 17.25 years).

Oral manifestation of histoplasmosis on the palate

This case report describes an uncommon manifestation of histoplasmosis on the soft palate. The importance of appropriate treatment and follow-up in complex cases is emphasized, especially in patients with chronic diseases. Oral lesions may occur as multiple, granular and painful ulcers, as well as verrucous growths. Lesions may also be deep, with infiltrative edges and erythematous or with white areas, accompanied by local lymphadenopathy, resembling a carcinoma on clinical examination. In this sense, a fast and accurate diagnosis is essential to the success of treatment of oral histoplasmosis.

Typical Facial Lesions: A Window of Suspicion for Progressive Disseminated Histoplasmosis-A Case of Asian Prototype

Histoplasmosis is caused by a dimorphic fungus Histoplasma capsulatum in endemic areas, mainly America, Africa, and Asia. In India, it is being reported from most states; however, it is endemic along the Ganges belt. We report a case of an apparently immunocompetent male who presented with 3-month history of fever, cough, and weight loss with recent onset odynophagia and had hepatosplenomegaly and mucocutaneous lesions over the face. The differential diagnosis of leishmaniasis, tuberculosis, leprosy, fungal infection, lymphoproliferative malignancy, and other granulomatous disorders was considered, but he succumbed to his illness. Antemortem skin biopsy and bone marrow aspiration along with postmortem liver, lung, and spleen biopsy showed disseminated histoplasmosis. This case highlights the need for an early suspicion of progressive disseminated histoplasmosis in the presence of classical mucocutaneous lesions even in an immunocompetent patient suffering from a febrile illness. Cure rate approaches almost 100% with early treatment, whereas it is universally fatal if left untreated.

Cutaneous manifestations of endemic mycoses

All of the endemic mycoses have cutaneous and mucocutaneous manifestations that are most commonly seen when patients have disseminated infection. Biopsy of skin lesions is simple and safe and can assist in making a timely diagnosis of disseminated infection. Primary cutaneous inoculation infection has been reported with all of the endemic mycoses, but is rare. In this situation, a nodule or ulcer occurs at the inoculation site, is often accompanied by lymphangitis and regional lymphadenopathy, and systemic symptoms and signs as almost always absent. Mucosal lesions are common with disseminated histoplasmosis, but also have been described in patients who have disseminated blastomycosis and coccidioidomycosis. Biopsy is essential to rule out cancer and allows a rapid diagnosis of the endemic fungal infection.

Disseminated histoplasmosis with oral and cutaneous manifestations

Histoplasmosis is a systemic mycotic infection caused by the dimorphic fungus, Histoplasma capsulatum. Systemic histoplasmosis has emerged as an important opportunistic infection in human immunodeficiency virus (HIV) patients and those in endemic areas. Reported cases of histoplasmosis have been low in India with less than 50 cases being reported. We are reporting a case of disseminated histoplasmosis with oral and cutaneous involvement in an HIV seronegative patient.

Disseminated cutaneous histoplasmosis in an immunocompetent adult

Histoplasmosis, a systemic mycosis caused by the dimorphic fungus Histoplasma capsulatum var capsulatum and Histoplasma capsulatum var duboisii is endemic to many parts of the world. The clinical manifestations range from acute or chronic pulmonary infection to a progressive disseminated disease. After initial exposure to the fungus, the infection is self-limited and restricted to the lungs in 99% of healthy individuals. The remaining 1%, however, progress to either disseminated or chronic disease involving the lungs, liver, spleen, lymph nodes, bone marrow or rarely, the skin and mucous membranes. Mucocutaneous histoplasmosis is frequently reported in patients with acquired immune deficiency syndrome (AIDS), but it is rare in immunocompetent hosts. A 60-year-old male presented with asymptomatic swelling of the hard palate and crusted papules and nodules over the extremities, face and trunk. Clinically, the diagnoses of cutaneous cryptococcosis versus histoplasmosis was considered in this patient. A chest X-ray revealed hilar lymphadenopathy. Enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) was nonreactive. Skin biopsy revealed multiple tiny intracellular round yeast forms with a halo in the mid-dermis. Culture of the skin biopsy in Sabouraud's dextrose agar showed colonies of Histoplasma capsulatum. Despite an investigation including no evidence of underlying immunosuppression was found, he was started on IV amphotericin-B (0.5 mg/kg/day). However, the patient succumbed to his disease 2 days after presentation. We report a rare case of disseminated cutaneous histoplasmosis in an immunocompetent individual.

Histoplasmosis among hospitalized febrile patients in northern Tanzania

Histoplasmosis may be common in East Africa but the diagnosis is rarely confirmed. We report 9 (0.9%) cases of probable histoplasmosis retrospectively identified among 970 febrile inpatients studied in northern Tanzania. Median (range) age was 31 (6, 44) years, 6 (67%) were female, 6 (67%) HIV-infected; 7 (78%) were clinically diagnosed with tuberculosis or bacterial pneumonia. Histoplasmosis is an important cause of febrile illness in Tanzania but is rarely considered in the differential diagnosis. Increased clinician awareness and availability of reliable diagnostic tests may improve patient outcomes.

Primary localized histoplasmosis with lesions restricted to the mouth in a Chinese HIV-negative patient

Histoplasmosis is a deep mycosis caused by Histoplasma capsulatum, which is endemic in many areas of the world but is relatively rare in China. Although the majority of cases present as a mild to moderate flu-like disease requiring only supportive therapy, approximately 1% of patients experience more serious pulmonary and extrapulmonary disease, which can be life-threatening if diagnosis is delayed or the treatment is not initiated rapidly. Definitive diagnosis is usually made by a combination of culture, detection of the organism in tissues, measurement of antibodies, and detection of antigen. We present the case of a 51-year-old patient who presented with histoplasmosis only, with several ulcerated lesions in the oral cavity and without HIV infection, who did not show any detectable signs and symptoms of systemic disease or extra-oral manifestations. Histopathological analysis indicated a chronic inflammatory process with granulomas with yeast-like organisms. Isolation of H. capsulatum and molecular identification provided the definitive diagnosis. Treatment with oral itraconazole led to remission of the oral lesions. This is the first Chinese case report of localized histoplasmosis with lesions restricted to the mouth in an HIV-negative patient.

Treating oral histoplasmosis in an immunocompetent patient

BACKGROUND

Histoplasmosis is a deep fungus infection that occurs worldwide and is caused by Histoplasma capsulatum. Oral histoplasmosis has been of considerable importance in recent years because it occurs frequently in immunosuppressed patients, more often in those who test positive for the human immunodeficiency virus (HIV). However, the literature contains reports of histoplasmosis in immunocompetent patients, especially in endemic areas.

CASE DESCRIPTION

The authors describe a case of an HIV-negative, immunocompetent 60-year-old man with ulcerative and painful oral lesions. The clinician included squamous cell carcinoma and systemic mycosis in the differential diagnosis. After the patient underwent a biopsy and a definitive diagnosis was reached, his initial treatment regimen included itraconazole (200 milligrams per day for one month), nystatin and chlorhexidine mouthrinse (0.12 percent, 10 milliliters, two times a day). The itraconazole treatment was continued for three more months (100 mg daily) until the lesions had resolved completely.

CLINICAL IMPLICATIONS

Clinicians need to conduct a careful clinical evaluation and make an accurate diagnosis of ulcerated oral lesions. Knowledge of the oral manifestations of histoplasmosis may enable clinicians to reach a diagnosis earlier and initiate therapy more quickly.

Rare mycoses of the oral cavity: a literature epidemiologic review

Stomatologic fungal infections display different etiologies, pathogenesis, and clinical presentations. The incidence of rare mycoses of oral cavity is very low. These infections can involve both immunocompromised and immmunocompetent patients with common predisposing factors, such as diabetes or suffering from diseases causing immune system impairment. Oral mycoses can cause acute, chronic, and mucocutaneous lesions. Candidiasis is the most common mouth mycosis. Although occasionally primary mouth pathogens, Cryptococcus spp. or filamentous fungi (Aspergillus spp. and zygomycetes) can cause oral mycoses, with the oral localization more commonly secondary to a more serious systemic infection. The diagnosis of oral mycoses is based on clinical examination; for yeasts, culture is necessary to identify the etiologic agents; for filamentous fungi, in particular for zygomycetes and dimorphic, a definitive diagnosis can be made by histologic examination and pertinent stains with or without isolation of the fungus from the same site.

Tracheal and endobronchial involvement in disseminated histoplasmosis: a case report

Histoplasmosis is an endemic fungal infection that can involve any organ when disseminated. Although oral, pharyngeal, laryngeal, and endobronchial involvement have been described, direct tracheal involvement has not been reported. We describe the first case of disseminated histoplasmosis with direct involvement of the trachea. The endobronchial manifestations of histoplasmosis are reviewed.

Head and neck histoplasmosis--a nightmare for clinicians and pathologists! Experience at a tertiary referral cancer centre

Histoplasmosis is a rarely reported deep mycotic infection in the Indian context. Oral or oropharyngeal manifestation can occur as an isolated symptom or as part of a disseminated process associated with immunosuppression especially with HIV and diabetes. Five cases of head and neck histoplasmosis accrued over 6 years in a tertiary referral cancer institute were reviewed. All these patients presented clinically as cancer. In three patients, the marked pseudoepitheliomatous hyperplasia led to a mistaken biopsy diagnosis of malignancy following which definitive surgical treatment was performed. The subsequent excision revealed typical features of histoplasmosis. Isolated oral presentation of histoplasmosis can mimic malignancy both clinically as well as pathologically, leading to potentially disastrous consequences. A high index of suspicion in those with overt or hidden immunosuppression and a deep wedge biopsy to demonstrate the organisms in the subepithelial tissue is recommended.

Oral histoplasmosis after radiation therapy for laryngeal squamous cell carcinoma

Histoplasmosis is a usually asymptomatic deep fungal infection of tropical origin with respiratory entry and possible oral, pharyngeal, or metastatic localization. The condition represents an important imported systemic mycosis with oral involvement. We report the case of a patient who developed an oropharyngeal reactivation of a latent Histoplasma infection after receiving local antitumoral radiation therapy of the neck. H capsulatum was shown to be present in the lesion by both histopathology and staining, and was deduced to be the causative organism of the disease.

Histoplasmosis: a clinical and laboratory update

Infection with Histoplasma capsulatum occurs commonly in areas in the Midwestern United States and Central America, but symptomatic disease requiring medical care is manifest in very few patients. The extent of disease depends on the number of conidia inhaled and the function of the host's cellular immune system. Pulmonary infection is the primary manifestation of histoplasmosis, varying from mild pneumonitis to severe acute respiratory distress syndrome. In those with emphysema, a chronic progressive form of histoplasmosis can ensue. Dissemination of H. capsulatum within macrophages is common and becomes symptomatic primarily in patients with defects in cellular immunity. The spectrum of disseminated infection includes acute, severe, life-threatening sepsis and chronic, slowly progressive infection. Diagnostic accuracy has improved greatly with the use of an assay for Histoplasma antigen in the urine; serology remains useful for certain forms of histoplasmosis, and culture is the ultimate confirming diagnostic test. Classically, histoplasmosis has been treated with long courses of amphotericin B. Today, amphotericin B is rarely used except for severe infection and then only for a few weeks, followed by azole therapy. Itraconazole is the azole of choice following initial amphotericin B treatment and for primary treatment of mild to moderate histoplasmosis.

Chronic disseminated histoplasmosis with lesions restricted to the mouth: case report

We report a rare case of chronic disseminated histoplasmosis with several ulcerated lesions in the oral cavity in an alcoholic patient without human immunodeficiency virus infection, with no detectable signs and symptoms of systemic disease or extraoral manifestations. Histopathological analysis revealed chronic inflammatory process with granulomas containing Histoplasma-like organisms. The isolation of Histoplasma capsulatum provided the definitive diagnosis. Treatment with itraconazole resulted in complete remission of oral lesions. As far we aware, this is the second case report of oral histoplasmosis in an HIV negative patient described in Brazil.

Imported and autochthonous histoplasmosis in Italy: new cases and old problems

In the past the Italian soil was considered as a low-endemic pabulum for H. capsulatum var. capsulatum and only few autochthonous cases of histoplasmosis were reported in Italy, especially in the Po valley. The aim of the paper was to evaluate this possibility by reviewing the literature and providing our own personal data. Four additional cases of histoplasmosis were observed during 1999-2003 in AIDS immigrant or in Italian citizens, and in travellers to endemic areas. One of the AIDS patients was an autochthonous case of histoplasmosis. The Italian literature was reviewed. Recent cases and literature data confirm the possible autochthonous presence of histoplasmosis in Italy, especially in the Northern regions.

Oral histoplasmosis in an HIV-negative patient

Histoplasmosis is a deep mycosis caused by Histoplasma capsulatum, which has been found in soil with accumulated excreta of bats and birds. This disease has variable clinical findings with only pulmonary or systemic involvement. Upper aerodigestive lesions are found mainly associated with systemic disease, affecting particularly patients with immunosuppression conditions mainly caused by HIV. However, it is uncommon in immunocompetent patients. This report describes a case of oro-laryngeal-esophageal histoplasmosis in a HIV-seronegative patient without detectable systemic involvement.

[Histoplasmosis of the oral cavity]

Histoplasmosis is an endemic mycosis. Histoplasma capsulatum, and duboisiï are the pathogenic agents in humans. The disease is reported as endemic in more than 30 countries. Three clinical forms are distinguished; acute, chronic and disseminated. Oral lesions may take on different clinical aspects which are often associated with disseminated histoplasmosis. Disseminated histoplasmosis is frequently diagnosed in immunocompromised hosts. High risk of mortality dictates rapid diagnosis and treatment.

Histoplasmosis in Australia: A report of a case with a review of the literature

Histoplasmosis is a rare but serious fungal infection commonly presenting as mucosal ulceration of the oral cavity. It is increasingly recognized in Australia but the source of infection remains obscure and it is likely to be under-diagnosed. We report a case of chronic mucosal ulceration which failed to fully respond to periodontal therapy. Histology and culture of a gingival biopsy was consistent with histoplasmosis, and the patient responded favourably to treatment with oral itraconazole. Histoplasmosis may present to general dental practitioners as chronic mucosal ulceration and should be considered in the differential diagnosis of such lesions. Diagnosis is best made by culture and histology of biopsy specimens.