A 46-year-old man was attended in the dental clinic complaining of symptomatic oral lesions with two months in duration. The intraoral physical examination revealed diffuse, friable, vegetative areas on the right upper alveolar ridge, hard palate, and left inferior alveolar ridge (Figures 1(a) and 1(b)). His medical history revealed a diagnosis of tuberculosis about a month ago in which the expectorated sputum smears were positive for bacteria and acid-fast bacilli. In addition, at the time of diagnosis of tuberculosis, the patient had a significant weight loss and asthenia. The patient was under antibacterial therapy (oral isoniazid (INH) 225 mg/day, rifampicin (RFP) 450 mg/day, pyrazinamide 1,200 mg/day, and ethambutol (EB) 825 mg/day). Testing for human immunodeficiency virus (HIV) infection was negative. Furthermore, the patient confirmed smoking and chronic alcoholism. He worked as a night flow controller on the side of a highway and lived very close to the countryside. After knowing the patient's medical history, the main hypothesis for oral lesions was tuberculosis.
An incisional biopsy of the right upper alveolar ridge showed connective tissue with intense inflammatory infiltrate with a granulomatous pattern, consisting of giant multinucleated inflammatory cells and vacuolated macrophages, with innumerable fungi suggestive of H. capsulatum (Figures 2(a) and 2(b)). Staining slides with periodic acid-Schiff (PAS) (Figures 2(c) and 2(d)) and Grocott-Gomori methenamine silver were positive for the morphological characteristics of H. capsulatum. In addition, the immunohistochemical reactivity to Histoplasma using polyclonal antibody was positive; for polyclonal P. brasiliensis, Leishmania spp. and Calmette-Guerin bacillus were negative. The diagnosis of oral histoplasmosis was established. We did not search for fungi in other biological samples.
Initially, the drug was maintained for tuberculosis and prescribed fluconazol (400 mg/day) for seven months for treatment of oral histoplasmosis. During the follow-up, when a gradual increase in body weight was noted, fluconazole was substituted for itraconazole 200 mg/day for eight months with the resolution of oral histoplasmosis lesions. The clinical control one year after initiation of itraconazole treatment can be seen in Figures 3(a) and 3(b). One year after the initial treatment of tuberculosis, the patient was cured.