A Relapsed Case of Disseminated Histoplasmosis – A Case Report from Sri Lanka

Abstract

Histoplasma capsulatum is a soil saprophyte which is now considered to be endemic in Southeast Asia and Southern Europe. It is a thermally dimorphic fungus seen in damp soil contaminated with bat guano and bird excreta. Here we present a case of disseminated histoplasmosis, which is rarely encountered in the Sri Lankan clinical setting. 57-year-old farmer presented to Army hospital Colombo 05 with painful, pus discharging multiple nodular lesions on face, upper limbs, and trunk for one month. He had oral mucosal lesions with oral swelling and he complained of dysphagia, loss of appetite and loss of weight. He had been treated for Histoplasma capsulatum infection four years ago in a different hospital but had defaulted treatment. This patient had been exposed to caves with bats in their village which can be considered as the source of his infection. In this admission histopathology of forehead nodular lesion was compatible with Histoplasma infection. KOH direct smear of biopsy samples from R/axillary nodules showed numerous budding yeast cells and culture isolated Histoplasma capsulatum at the Mycology Reference Laboratory. CECT revealed numerous foci of calcification in the pancreatic head, body, and tail region with a large amorphous calcification (32mm x 22mm x 16mm) in the tail region. No other organs were involved. He was managed as disseminated histoplasmosis, with IV amphotericin B and oral itraconazole to which he achieved an adequate clinical response. Histoplasmosis should be suspected in patients with granulomatous skin lesions, and prompt diagnosis and prolonged antifungal treatment with close follow up will result in favourable outcomes in these patients.