Nasal cartilage destruction associated to cutaneous histoplasmosis in AIDS

Systemic histoplasmosis is a disease of high morbidity and mortality in immunocompromised patients. Patients with AIDS get the infection through inhalation of spores, triggering a primary lung infection with a subsequent hematogenous spread to multiple organs, including the skin. Tissue necrosis have been documented in cutaneous histoplasmosis with multiple clinical manifestations that mimic other diseases.

We report the case of nasal cartilage destruction associated to cutaneous histoplasmosis in AIDS. A 24-year-old man, resident in Ecuadorian coast, with a history of HIV for 7 years without any treatment. In the last 3 months, he has been presenting a molluscum-like lesions on his nasal bridge with subsequent dissemination to the trunk and extremities. He was admitted to the emergency department for dyspnoea, cough, and malaise. Due to his respiratory failure, he was admitted to the intensive care unit (ICU) with mechanical ventilation. Physical examination reveals a crusted surface ulcer that involves the nose and cheeks, associated with erythematous papules, some with a crusted surface which are spread to the face, trunk, and upper limbs. The patient has a specific skin involvement with a butterfly-like ulcer appearance and destruction of the upper and lower lateral cartilage of the nose. At admission CD4 cell count was 11/mm³ with a HIV viral load of 322,908 copies. Mycological cultures identified Histoplasma capsulatum. A treatment with highly active antiretroviral therapy (HAART) was stablished, associated with liposomal amphotericin B at a dose of 3 mg/kg/day and itraconazole 200 mg twice a day for 12 months.

Cutaneous histoplasmosis is a rare manifestation of pulmonary histoplasmosis in patients with AIDS. The cutaneous manifestations included papules, nodules, plaques, and ulcers. A histology examination is required to rule out other fungal or parasitic infections. Treatment includes highly active antiretroviral therapy (HAART), amphotericin B liposomal and itraconazole, the latest for at least 12 months.