African histoplasmosis: the first report of an indigenous case in India

African histoplasmosis, caused by Histoplasma capsulatum var. duboisii, is an invasive fungal infection endemic in Central and West Africa. Cases seen outside Africa are generally imported. We report a disseminated purely cutaneous form of this infection in an otherwise healthy person from Kerala, in southern India.

A 59-year-old farmer presented with asymptomatic, generalized, reddish skin lesions of five months in duration. Dermatologic examination revealed multiple erythematous papules and plaques of varying sizes, predominantly over the trunk and upper limbs. The patient was otherwise in good health. Systemic examination including the pulmonary and musculoskeletal systems revealed no abnormalities.

Skin biopsy was performed from a lesion on the thigh. Histopathologic examination revealed epithelioid and suppurative granulomas in the upper dermis, with lymphocytes, neutrophils, and plenty of giant cells. Fite-Faraco staining for Mycobacterium leprae was negative. Fungus cultured from the specimen was identified as H. capsulatum var. duboisii, the rarer variant of H. capsulatum. The patient was treated with ketoconazole 200 mg/day for four months and attained complete clearance. No relapse has been detected over two years of follow-up.

To the best of our knowledge, this case represents the first instance of African histoplasmosis to be reported from India. The occurrence of such a rare infection in an immunocompetent individual, who had not travelled elsewhere, raises the possibility of the indigenous existence of H. capsulatum var. duboisii in Kerala. Further studies of the ecology and epidemiology of this rare infection are essential.