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BMJ Case Rep. 2010; 2010: bcr.06.2010.3120.
Published online 2010 November 5. doi:  10.1136/bcr.06.2010.3120
PMCID: PMC3029345
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Disseminated histoplasmosis presenting with chronic ulcerative tongue lesions in a patient with diabetes

Description

We describe a case of chronic tongue ulceration with systemic symptoms in a patient with poorly controlled diabetes. A biopsy of a lesion from the posterior third of the tongue showed features typical of histoplasmosis (figure 1). A CT of the thorax and abdomen revealed a diffuse reticulonodular pattern bilaterally (figure 2A). The intra-abdominal organs were normal. A diagnosis of disseminated histoplasmosis was made. The patient was started on intravenous amphotericin B for 3 weeks followed by oral itraconazole 100 mg twice a day for 1 month. A repeat CT thorax 6 weeks after antifungal treatment revealed resolution of the lesions (figure 2B).

Figure 1
Tissue biopsy taken from the tongue lesion shows multinucleated giant cells containing encapsulated fungal organism.
Figure 2
(A) CT of the thorax showing a diffuse reticulonodular pattern bilaterally which was more evident in the upper and middle zones. (B) CT of the thorax showing resolution of the reticulonodular shadowing 6 weeks after treatment.

Disseminated histoplasmosis refers to a process of severe fungus colonisation in the lungs and other organs and body sites 1 The first ever case of disseminated histoplasmosis in a patient with diabetes living in a non-endemic area was reported in 1977.2 Since the AIDS epidemic, disseminated histoplasmosis is more commonly seen. Chronic infection often presents with pancytopenia, hepatosplenomegaly, hepatitis and oropharyngeal or gastrointestinal lesions.3 A definitive diagnosis requires a positive blood culture or histological demonstration in involved tissue.3

Learning points

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Despite no obvious immunocompromise except for diabetes, a high suspicious of index is required to diagnose disseminated histoplasmosis.
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Recognition of the typical fungal infection is essential for a correct diagnosis.
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The finding of a diffuse reticulonodular pattern on CT of the thorax should be correlated with clinical presentation for accurate diagnosis and treatment.

Footnotes

Competing interests None.

Patient consent Obtained.

References

1. Deepe GS. Histoplasma capsulatum. In: Mandell GL, Bennet JE, Dolin R, eds. Principles and Practice of Infectious Diseases. Sixth edition Philadelphia: Churchill; Livingstone 2005:2718–33.
2. Jariwalla A, Tulloch BR, Fox H, et al. Disseminated histoplasmosis in an English patient with diabetes mellitus. Br Med J 1977;1:1002–4. [PMC free article] [PubMed]
3. Goodwin RA, Jr, Shapiro JL, Thurman GH, et al. Disseminated histoplasmosis: clinical and pathologic correlations. Medicine (Baltimore) 1980;59:1–33. [PubMed]

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