A 37-year-old male farmer, hailing from Puttur, Karnataka, a known case of AIDS on antiretroviral treatment, presented with high-grade fever, cough with expectoration of 6 weeks duration and multiple papulonodular lesions on the face, neck and chest of 2 weeks duration. The lesions were sudden in onset and were gradually progressive.
On examination, he had multiple, discrete, mildly tender, hyperpigmented, papulonodular lesions, distributed over the face [Figure 1], neck, chest, back and oral cavity. Some of them showed ulcerations and crusting. A bright red, elevated, non-mobile, bulbar conjunctival nodule with congestion was present in the right eye [Figure 2]. He had generalized lymphadenopathy and non-tender hepatomegaly. Examination of the respiratory system revealed bilateral coarse crackles. Other systemic examination and fundus examination were unremarkable.
On investigation, his hemoglobin was 6.5 gm/dL, total count was 2220/mm3, differential count was neutrophils 81, lymphocytes 15, monocytes 2 and eosinophils 2 and his platelet count was 1.69 lakhs. Peripheral smear showed microcytic hypochromic red blood cells, anisopoikilocytosis, polychromasia and reduced leucocyte count and toxic granules with no evidence of hemolysis. The erythrocyte sedimentation rate was 140 mm/h. The CD4 count was 150/mL. Serum lactate dehydrogenase (LDH) was 842 IU/L. The Venereal Disease Research Laboratory (VDRL) test was non-reactive. Urine and stool examinations were within normal limits. Liver and renal function tests were normal. Blood culture was negative. Chest roentgenogram showed reticulonodular pattern with hilar lymphadenopathy. Sputum examination for Mycobacterium tuberculosis was negative.
Leishman-stained bone marrow aspirate smears showed a reactive marrow with few extracellular and intracellular H. capsulatum within macrophages [Figure 3].
Skin biopsy specimen showed dermis with aggregates of numerous macrophages containing rounded to oval organisms surrounded by a clear space within the cytoplasm. The organisms were positive for Periodic Acid Schiff (PAS) stain, confirming H. capsulatum infection. There was minimal inflammatory response around the macrophages.
Histopathological examination of the conjunctival specimen showed numerous macrophage aggregates with 2-4 mm PAS-positive yeast-like forms of H. capsulatum [Figure 4].
The patient was started on IV Amphotericin B at a dose of 1 mg/kg/day. Antiretroviral therapy with zidovudine, lamivudine and efavirenz was continued. He became afebrile within 48 h after starting treatment. The skin lesions and the conjunctival lesion healed within 10 days. He was then switched over to oral itraconazole 200 mg twice daily and discharged with an advice to continue the drug for his lifetime.