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A 66-year-old male presented with oral pain during eating and a 30 lb weight loss over 2 months. He resided in California but grew up near New Orleans and the Mississippi River. He last visited New Orleans 9 months before the onset of symptoms. A workup and history were negative for immunodeficiency. Exam revealed tenderness over the gingiva, base of the tongue and ulcers on the soft palate (Fig. 1). Chest x-ray was unremarkable. Biopsy of the tongue base demonstrated non-caseating granulomas. Stainings of the tissue showed encapsulated intracellular organisms, including budding yeast forms, within histiocytes (Fig. 2) consistent with histoplasmosis. Based on the time course of his weight loss and fatigue, the patient was presumptively diagnosed with chronic disseminated histoplasmosis. He was successfully treated with liposomal amphotericin B, followed by itraconazole.
Common risk factors for disseminated histoplasmosis include AIDS, primary immunodeficiency disorders, extremes of age and those taking immunosuppressive medications (glucocorticoids, TNF-alpha inhibitors, antirejection medications). However a smaller subset of patients without known risk factors are susceptible. In patients without known immunodeficiency presenting with oral ulcers, a diagnosis of histoplasmosis should be entertained.