A 43-year-old man was referred to the Department of Stomatology at the Heliopolis Hospital by a private dentistry complaining oral lesions. The lesions were asymptomatic and oral examination revealed ulcerative areas with granulomatous bed affecting the gingival papillae between lower central incisors, partially covered by a pseudomembranous material [Figure 1]. On physical examination, no regional and extra-regional lymphadenopathy or organomegaly was detected.
His medical history includes episodes of dry cough, costal pain, and weight loss under medical investigations. The chest radiography [Figure 2a] and computed tomography scan [Figure 2b] of the thorax have revealed a diffuse infiltrate of nodular and linear/irregular coalescent opacities, distributed throughout both lungs [Figure 2]. The hypothesis of tuberculosis has been discussed at that moment in spite of negative results for acid-fast bacilli from sputum and culture. The CD4/CD8 lymphocyte count and rate were normal. Tests for human immunodeficiency virus (HIV) were negative. Among the requested serological exams, it has been found antibodies against H. capsulatum on immunodiffusion test. However, culture and histology of the specimens obtained by bronchoalveolar lavage failed to confirm the presence of fungi. Thus, the patient remained under this medical investigation without any specific treatment plain at that moment, in which the patient was evaluated by a private dentist complaining the gingival lesions described previously.
We conducted the case performing an incisional biopsy of the oral lesion. Routine sections show fragments of squamous mucosa with a marked granulomatous infiltrate composed by Langhans-type multinucleated giant cells interspersed with extensive macrophagic infiltrate with variable amounts of lymphocytes and neutrophils [Figure 3a]. Staining slides with Grocott-Gomori methenamine silver, scarce oval structures with apparent single budding, measuring 3-5 mm in diameter were found suggesting histoplasmosis [Figure 3b]. A specimen was collected with a swab from the base of lesion and sent to culture. In slide culture preparations, hyaline and septated hyphae producing numerous thick-walled and tuberculated macroconidia were also consistent with histoplasmosis [Figure 3c]. The incubation of this material on Sabouraud Dextrose Agar at room temperature by 3 weeks was sufficient to reveal the typical growth pattern of H. capsulatum, which consists of white to brownish filamentous colonies on the slants [Figure 3d]. The patient was treated with Itraconazol 200 mg, given 6 times/day, reducing to two tablets per day after the 3rd day until the condition improves [Figure 4]. After 6 months of control the patient was referred again to his private dentist for periodontal and restorative treatment plain.