Cutaneous Manifestation of Underlying Disseminated Histoplasmosis in an Immunocompetent Host of Nonendemic Area with Reversible CD4 Cell Depletion and its Recovery on Antifungal Therapy

Abstract

We present the case of an 18-year-old male patient admitted with complaints of fever and rapid weight loss since 3 months. Patient had multiple umbilicated papular to nodular lesions over chin and forehead region. Complete blood count revealed bicytopenia. An excisional biopsy of the skin lesions had revealed cutaneous histoplasmosis. On further investigations for bicytopenia, histoplasmosis had been diagnosed on bone marrow trephine biopsy. For the immune status, patient's serology against HIV was negative and his CD4 lymphocyte counts were low at 161. Patient received antifungal therapy including amphotericin B and itraconazole. He showed remarkable improvement in his general condition and blood counts. A repeat CD4 count showed normal counts, and idiopathic CD4 lymphocytopenia was excluded. Disseminated histoplasmosis presenting as cutaneous lesions in an immunocompetent host is very rare, and we are not aware of any case report in the literature where there is reversible depletion of CD4 counts following antifungal treatment in an immunocompetent host of nonendemic area.

Disseminated Cutaneous Histoplasmosis and Its Recurrence in an Apparently Immunocompetent Patient

“…Nevertheless, there is a possibility that we were dealing with a case of idiopathic CD4+ T lymphocytopenia, as there are several reports of patients presenting with histoplasmosis as the initial manifestation. Although this was not demonstrable in our patient, it is noteworthy that he presented with lymphocytopenia at the onset of the condition [12,13].…”

“…An intriguing observation was made in a case of cutaneous histoplasmosis, where a patient initially presented with transient depletion of CD4+ T lymphocytes, with a count of 161 cells/μL [ 12 ]. Following antifungal treatment, the lymphocyte levels returned to normal.…”

Disseminated Histoplasmosis Involving Soft Palate, Duodenum, Sigmoid Colon and Bone Marrow in a Patient With Isolated CD4+ T-Lymphocytopenia

“…Previously reported cases of histoplasmosis in the setting of ICL mentioned the involvement of skin [ 11 , 12 ], soft palate, lung [ 12 , 13 ], liver, spleen, bone marrow [ 12 , 14 ], and olecranon bursa [ 11 ]. All previously reported cases had normal or decreased levels of immunoglobulins [ 14 ].…”

Endoscopic ultrasound-guided cytodiagnosis of adrenal histoplasmosis with reversible cd4 t-lymphocytopenia and jejunal lymphangiectasia

“…Posttreatment reversal of CD4 lymphocytopenia has been described in tuberculosis, but only in two earlier reports of disseminated histoplasmosis. [ 4 5 ] Pooling of CD4 T-lymphocytes at the sites of active infection or granulomatous response resulting in relative peripheral CD4 lymphocytopenia, or a cytokine-mediated suppressive effect, as described for tuberculosis,[ 6 ] may also apply for another similar macrophage, CD4 T-lymphocyte, and interferon γ-mediated granulomatous infection such as histoplasmosis. Therapeutic regimes resulting in elimination of the microbes and clearing of granulomatous inflammation may correct the CD4 lymphocytopenia by redistribution of the peripheral blood CD4 T-lymphocytes [ Figure 3 ].…”