Cutaneous histoplasmosis in nine patients with AIDS

In AIDS patients the diagnosis of systemic mycosis is a clinical challenge. When cutaneous affection occurs, the diagnosis is difficult because of the non-specific clinical findings. We describe nine patients with AIDS and cutaneous histoplasmosis as the initial clinical manifestation. These patients were diagnosed from 1987 to 1998. In all the diagnosis of histoplasmosis was done by skin biopsy and fungal isolation. The main skin lesions were papules combined with pustules or nodules in 6 of 9 patients, ulcers (1/9), erythematous plaques (1/9) and nodules (1/9). Head and trunk were the main anatomical locations of the lesions. All had fever, 7/9 had liver and spleen enlargement and 5/9 had weight loss. At the time of diagnosis all patients had a low CD4+ lymphocyte counts with a mean of 47 cells/mu L. Amphotericin B was the initial treatment followed by itraconazole. Five patients died, one day after diagnosis and four after 5, 8, 11 and 12 months. Four are alive at 3, 3, 19 and 26 months of follow-up. Conclusions. In AIDS patients the skin involvement by histoplasmosis should always be included among the differential diagnoses specially in patients with face and trunk papules and fever and hepatosplenomegaly. Skin and bone marrow cultures were the most reliable diagnostic methods, but skin biopsy was the fastest procedure.