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| CASE REPORT |
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| Year : 2015 | Volume
: 1
| Issue : 1 | Page : 33-34 |
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Cutaneous histoplasmosis successfully treated with oral itraconazole monotherapy in a human immunodeficiency virus positive female
Girish Ambade1, Bhushan Madke2, Sushil Pande3
1 Department of Medicine, Antiretroviral Therapy Centre, Indira Gandhi Government Medical College, Nagpur, Maharashtra, India
2 Department of Dermatology, Venereology and Leprosy, Jawaharlal Nehru Medical College, AVBR Hospital, Wardha, Maharashtra, India
3 Department of Dermatology, NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Nagpur, Maharashtra, India
| Date of Web Publication | 1-Dec-2015 |
Correspondence Address:
Girish Ambade
Department of Medicine, Antiretroviral Therapy Centre, Indira Gandhi Government Medical College, Nagpur, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/WKMP-0110.170763
Histoplasmosis is a deep fungal infection with a worldwide distribution that can affect both immunocompromised and immunocompetant individuals. The majority of cases with cutaneous involvement also have systemic disease. Intravenous amphotericin is commonly employed for its treatment which is associated with significant side effects. We hereby report a of case cutaneous histoplasmosis in a human immunodeficiency virus (HIV) positive female who was treated successfully with oral itraconazole monotherapy along with anti-retroviral therapy. A 38-year-old HIV-positive female presented with multiple asymptomatic skin colored umbilicated papular eruptions over face, neck, trunk, and upper extremities of two and half months duration. She did not have any systemic complaints. Histopathology of the lesion showed a diffuse dermal granulomatous inflammation with 2–4 µ sized round organisms in macrophages with a clear halo suggestive of histoplasmosis. Her CD4 cell count was 38 cells/mm3. She was started on highly active antiretroviral therapy (tenofovir 300 mg OD, lamivudine 300 mg OD, and nevirapine 200 mg BID) along with cotrimoxazole prophylaxis. The patient was also prescribed oral itraconazole 100 mg twice daily. After 20 weeks of therapy, the patient showed complete resolution of lesions with minimal scarring. Histoplasmosis in retrovirus positive patient is frequently treated with intravenous amphotericin. Our patient responded to long-term itraconazole monotherapy.
Keywords: Acquired immunodeficiency syndrome, antifungal, disseminated histoplasmosis, efficacy, human immunodeficiency virus, Itraconazole
How to cite this article:
Ambade G, Madke B, Pande S. Cutaneous histoplasmosis successfully treated with oral itraconazole monotherapy in a human immunodeficiency virus positive female. Indian J Drugs Dermatol 2015;1:33-4 |
How to cite this URL:
Ambade G, Madke B, Pande S. Cutaneous histoplasmosis successfully treated with oral itraconazole monotherapy in a human immunodeficiency virus positive female. Indian J Drugs Dermatol [serial online] 2015 [cited 2023 Jun 1];1:33-4. Available from: https://www.ijdd.in/text.asp?2015/1/1/33/170763 |
| Introduction | |  |
Histoplasmosis is a thermal dimorphic intracellular fungal infection that can affect both immunocompromised and imunocompetent individuals.[1],[2] Histoplasmosis may occur in three forms: (i) Primary acute pulmonary form, (ii) chronic pulmonary and (iii) disseminated form. Disseminated form presenting with molluscum-like skin lesions is a characteristic feature of cutaneous histoplasmosis and is an acquired immunodeficiency syndrome (AIDS) defining illness.[3] Though amphotericin B is considered as a drug of choice, itraconazole is an effective alternate therapy which must be tried as a first line drug.
| Case Report | | |
A 38-year-old widow presented with multiple asymptomatic skin colored umbilicated papular eruptions over face, neck, trunk, and upper extremities since two and half months duration. She had a history of pulmonary tuberculosis 10 years back and was adequately treated with standard anti-tubercular drugs. She did not have any systemic complaints.
On cutaneous examination, there were multiple discrete, skin colored umbilicated papules over face, neck, trunk, and both upper limbs [Figure 1]. Few of the lesions showed crusts. Mucosae were spared, and systemic examination revealed no abnormality. A differential diagnosis of Molluscum contagiosum, cutaneous cryptococcosis, cutaneous histoplasmosis, and penicilliosis was considered.
Complete hemogram revealed anemia and leukopenia with erythrocyte sedimentation rate of 55 at the end of 1 h. Liver and renal functions tests were normal. Serologies for venereal disease research laboratory test and Australia antigen were negative. Rapid test for human immunodeficiency virus-1 was reactive. Chest X-ray chest and abdominal ultrasound revealed no abnormality. Histopathology of the lesion showed a diffuse granulomatous inflammation occupying the entire dermis with parasitized macrophages containing 2–4 µ sized round organisms with a clear halo suggestive of histoplasmosis. Her CD4 cell count was 38 cells/mm 3. She was diagnosed to have AIDS and was started on highly active antiretroviral therapy (tenofovir 300 mg OD, lamivudine 300 mg OD, and nevirapine 200 mg BID) along with cotrimoxazole prophylaxis. The patient was also prescribed oral itraconazole 100 mg twice daily. After 20 weeks of therapy, the patient showed complete resolution of lesions with minimal scarring [Figure 2]. | Figure 2: Subsidence of cutaneous histoplasmosis after 5 months of oral itraconazole therapy
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| Discussion | | |
Amphotericin B has been considered as the treatment of choice for disseminated histoplasmosis in patients with AIDS. Prohibitive cost and nephrotoxicity are the major drawbacks of amphotericin B therapy. Oral antifungal agents would be welcome alternatives to standard treatment of disseminated histoplasmosis in less severe cases. In an open-label study of 59 patients done by Wheat et al., 50 patients with disseminated histoplasmosis responded to 12 weeks course of oral itraconazole.[4] Though oral itraconazole is not as a rapid acting agent as amphotericin B, it is well tolerated and lacks nephrotoxicity.[5]
Singhi et al. treated a case of disseminated primary cutaneous histoplasmosis in an imunocompetent female with itraconazole showing excellent results.[6] Itraconazole in oral capsule formulation needs gastric acid for absorption, and so are usually taken with food or acidic beverages. Immunocompromised patients with moderate disease can be treated with itraconazole monotherapy. An expert group recommended itraconazole 200 mg three times daily for 3 days followed by 200 mg twice daily for 12 months for immunocompromised hosts with pulmonary histoplasmosis or with the progressive or disseminated disease.[7]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Pal N, Adhikary M. Cutaneous histoplasmosis in a HIV seronegative patient. J Nat Sci Biol Med 2013;4:477-9. |
| 3. | Rosenberg JD, Scheinfeld NS. Cutaneous histoplasmosis in patients with acquired immunodeficiency syndrome. Cutis 2003;72:439-45. |
| 4. | Wheat J, Hafner R, Korzun AH, Limjoco MT, Spencer P, Larsen RA, et al. Itraconazole treatment of disseminated histoplasmosis in patients with the acquired immunodeficiency syndrome. AIDS Clinical Trial Group. Am J Med 1995;98:336-42. |
| 5. | Kurowski R, Ostapchuk M. Overview of histoplasmosis. Am Fam Physician 2002;66:2247-52. |
| 6. | Singhi MK, Gupta L, Kacchawa D, Gupta D. Disseminated primary cutaneous histoplasmosis successfully treated with itraconazole. Indian J Dermatol Venereol Leprol 2003;69:405-7. [ PUBMED]  |
| 7. | Limper AH, Knox KS, Sarosi GA, Ampel NM, Bennett JE, Catanzaro A, et al. An official American Thoracic Society statement: Treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med 2011;183:96-128. [ PUBMED] |
[Figure 1], [Figure 2]
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