Cutaneous Findings as a Harbinger of Disseminated Fungal Infection

Histoplasma capsulatum is a dimorphic fungus that causes pulmonary, disseminated, or, rarely, primary cutaneous disease. Primary cutaneous histoplasmosis presents with non-specific skin lesions, which can lead to poor patient outcomes due to diagnostic challenges and delays in diagnosis. A 62-year-old male on immunosuppressive medications for lupus nephritis presented to the emergency department with 24 hours of altered mental status. He had a three-month history of non-healing, ulcerated plaques with hemorrhagic discharge on the left side of his face. Although multiple urine antigen tests were negative, the patient was ultimately diagnosed with disseminated histoplasmosis and histoplasma meningitis based on skin biopsy and lumbar puncture findings. Given the longstanding nature of the patient's skin lesions prior to systemic symptoms, this likely represents a rare case of disseminated histoplasmosis secondary to primary cutaneous infection, highlighting the importance of including H. capsulatum in the differential diagnosis when an immunocompromised patient presents with nonspecific skin lesions.