Disseminated histoplasmosis with unusual cutaneous lesions in a patient from the Philippines

The incidence and prevalence of histoplasmosis in Southeast Asia has not been extensively described. The first microbiologically documented case of disseminated histoplasmosis with cutaneous papulonodules in a 56-year-old woman from the Philippines is reported. She presented with fever and generalized papulonodular lesions in various stages, which evolved into vesicles with central necrosis that resembled molluscum contagiosum with an indurated erythematous halo. Biopsies revealed a granulomatous mass of lymphohistiocytic and epithelioid cells with intracellular budding yeast cells and dark nuclei. Cultures were positive for Histoplasma capsulatum. The patient was treated with amphotericin B (3 g) and 5-fluorocytosine (50 mg/kg/day), followed by ketoconazole (400 mg/day). Her clinical course was complicated by intractable hemolytic anemia that was initially treated with corticosteroids. A splenectomy was subsequently performed. Pneumonia and a brain abscess caused by Nocardia asteroides were secondary complications. Nine months after her admission, repeat testing was diagnostic for systemic lupus erythematosus. This patient serves to re-emphasize that cutaneous lesions in an immunocompromised patient must be evaluated by biopsy and culture analysis. Disseminated histoplasmosis in the immunocompromised host may present with unusual cutaneous lesions, and must be considered even in a nonendemic area.