histoplasmosis , also known as darling 's disease , is a systemic fungal infection caused by the dimorphic fungus , histoplasma capsulatum .
infection is acquired by inhalation of conidia from soil contaminated by bird or bat excreta .
histoplasmosis can manifest in a bewildering array of clinical types and variation and has been called the syphilis of fungal world .
we report a case of chronic disseminated cutaneous histoplasmosis with varied skin lesions in an immunocompetent host .
presence of cutaneous ulcers , linear erythematous plaques , skin coloured atrophic plaques and recurrent self - limiting oral ulcers in a single patient has not been documented in literature so far .
a 74-year - old male , woodcutter by occupation , residing in a non - endemic area in south india , presented with multiple painful ulcers over face and oral mucosa and asymptomatic reddish raised lesions over neck and trunk of 5 days duration . there was history of recurrent episodes of self - healing ulcers over lower lip and soft palate for the past 10 years , and multiple asymptomatic skin coloured lesions over forearm and trunk for these years , which were not preceded by any other type of skin lesions .
on examination , multiple ulcers of varying size with well - defined , irregular margin were seen on forehead , periorbital area , chin and left anterior axillary fold .
multiple skin coloured atrophic plaques were present over forearm , trunk and thighs [ figure 1 ] .
leishman stained tissue smears from ulcers and erythematous crusted plaques revealed budding organism with peripheral halo [ figure 2 ] .
biopsies from these lesions and the skin coloured atrophic plaques showed parasitized macrophages , containing small round yeast - like organisms with a surrounding halo suggestive of histoplasma capsulatum , which was confirmed by gomori methenamine silver ( gms ) stain [ figure 3 ] .
patient was diagnosed with chronic disseminated cutaneous histoplasmosis and started on itraconazole 200 mg twice in a day .
varied morphological lesions : ( a ) ulcerated plaques of varying size over forehead , periorbital area and cheeks ; ( b ) linear erythematous plaques over upper chest and crusted lesions over anterior axillary fold ; ( c ) atrophic plaques over thigh ; ( d ) linear atrophic plaque forearm tissue smears from ulcers and erythematous crusted plaques showing budding organism with peripheral halo .
( leishman stain , 400 ) histology showing ( a ) heavy dermal inflammatory infiltrate containing poorly formed granulomas and many giant cells , hematoxylin and eosin stain , original magnification 40 ; ( b ) intracellular and extracellular yeast - like organisms with a surrounding halo , gms stain , original magnification 100 healed lesions after 6 weeks of antifungal therapy
there are 2 varieties of histoplasma capsulatum that are pathogenic to man : h. capsulatum var .
capsulatum occurs worldwide with endemic foci in central and north america , whereas h. capsulatum var .
panja and sen reported the first case of disseminated histoplasmosis from india in 1954 . among the forms of histoplasmosis reported from india , disseminated
infection is acquired by inhalation of conidia from soil contaminated by bird or bat excreta .
the risk factors for acquiring the infection include occupational and recreational activities in old buildings , bridges and caves .
being a woodcutter , our patient had occupational exposure to multitude of trees inhabited by birds .
though any person can acquire infection through inhalation , disseminated infection occurs in patients with defective cellular immunity .
a myriad of lesions such as macules , papules , plaques , pustules , ulcers , abscesses and purpuric lesions have been described in histoplasmosis .
molluscum contagiosum - like , erysipelas - like , pyoderma gangrenosum - like , ecthyma - like , rosacea - like and exfoliative forms are the rare manifestations reported .
our patient , who was an immunocompetent elderly male , presented with diverse skin lesions including well defined irregular ulcers , linear erythematous crusted plaques , and skin coloured atrophic plaques .
verma s.b . reported the first case of chronic disseminated cutaneous histoplasmosis presenting as linear erythematous plaques with central ulceration over the neck and upper chest in an immunocompetent host .
we suspect this could be a specific manifestation of chronic disseminated cutaneous histoplasmosis in immunocompetent host
. another unique feature in our patient was the presence of skin coloured atrophic plaques , from which we demonstrated the organism .
our patient gave history of recurrent self - healing oral ulcers for about 10 years .
most skin lesions of histoplasmosis arise following dissemination from a pulmonary focus and the only evidence of lung involvement could be calcification , which is indistinguishable on x - ray from tuberculosis . in our patient , history of chronic cough and chest x - ray finding of pulmonary calcification
could have been due to pulmonary histoplasmosis , which might have been erroneously treated as tuberculosis .
diagnosis of histoplasmosis was established by identifying small intracellular yeast - like cells of histoplasma in tissue smear and skin biopsy . in our case ,
the choice of therapy depends on the severity of illness . for patients with localized or few disseminated lesions , oral itraconazole of 200 - 400 mg daily
intravenous amphotericin b up to 1 mg / kg daily is recommended for patients with widespread and severe infections .
presence of cutaneous ulcers , linear erythematous plaques , skin coloured atrophic plaques and recurrent self - limiting oral ulcers in a single patient is reported .
skin coloured atrophic plaques , from which we demonstrated the organism in our patient is a type of lesion that has not so far been documented in literature .
 a case of chronic disseminated cutaneous histoplasmosis with unusual skin manifestations in an immunocompetent host is reported . 
 presence of cutaneous ulcers , linear erythematous plaques , skin coloured atrophic plaques and recurrent self - limiting oral ulcers in a single patient has not been documented in literature so far . 
 diagnosis was established by identifying small intracellular yeast - like cells of histoplasma in tissue smear and skin biopsy . 
 leishman stained tissue smear proves to be an easy and simple procedure for diagnosis of histoplasmosis . 
Introduction
Case Report
Discussion