Case 2 was a 31-year-old HIV-positive male referred for evaluation of multiple cutaneous ulcers. The patient was under anti-retroviral therapy (efavirenz, stavudine and lamivudine), with CD4 count of 114 cells/mm3 and viral load of 76,023 copies/ml. He also reported use of tobacco and alcohol. Upon physical examination, multiple cutaneous ulcers with elevated margins and crust formation were observed on the face, chest, and upper limbs. Intra-oral examination showed diffuse superficial granular ulcers of moriform surface and variable size, located in the hard/soft palate, gingivae, buccal mucosa and tongue (Fig. 2). White patchy lesions were also noted in both lateral borders the tongue, as well as white removable plaques with erythematous background in the dorsum of the tongue, buccal mucosa, palate, and labial mucosa. Ulcerative lesions were also identified on the esophagus.
In both cases, incisional biopsies of cutaneous and oral lesions were performed. Histological evaluation showed ulcerated fragments containing diffuse chronic granulomatous inflammation located deeply in the connective tissue. Periodic acid Schiff and Grocott-Gomori methenamine-silver stains highlighted round yeast-like fungal structures, which showed spherical, oval, or elongated (cigar-shaped) morphology by exfoliative cytology evaluation (Fig. 3). Yeast culture showed at first, white-creamy membranous colonies which later turned to black-leathery color. Microscopic evaluation of the colonies showed septate hyphae of pyriform conidia with typical "daisy-like" arrangement at the end of the conidiophores (Fig. 3). The microscopic diagnosis was of sporotrichosis in both cases. The correlation between clinical and microscopic findings of both cases lead to the final diagnosis of disseminated sporotrichosis. The second patient was then diagnosed with acquired immunodeficiency syndrome (AIDS) due to CD4 count and viral load associated with deep fungal infection.
The first patient was submitted to amphotericin B treatment for 15 days (1 mg/kg daily), which was subsequently changed to 400 mg of itraconazole, daily, for 2 weeks. As cutaneous lesions persisted, patient was submitted to itraconazole 800mg daily for 6 months. Therapy for tuberculosis followed with ethambutol and isoniazid. Clinical improvement was observed for both cutaneous and oral lesions after 6 months, but the patient did not attend the following appointments. The second patient received 1.5 mg/kg of amphotericin B for 2 weeks, followed by 400 mg of itraconazole, daily, for the next 2 weeks. A good response was observed, with complete remission of cutaneous and oral lesions; the patient missed long-term follow up appointments.