Perforation of the Nasal Septum as the First Sign of Histoplasmosis Associated with AIDS and Review of Published Literature

Abstract

Disseminated histoplasmosis in South America is associated with AIDS in 70-90 % of cases. It is visceral and cutaneous, compromising the oral, pharynx, and laryngeal mucous membranes. The involvement of the nasal mucosa is unusual. Two patients with perforation of the nasal septum as the only sign of their disease were clinically and histopathologically diagnosed as leishmaniasis. The revision of the biopsies and the culture of nasal discharge secretions showed that the pathogens seen were not amastigotes but Histoplasma capsulatum. Other mycotic lesions were not detected, nor there was history of cutaneous leishmaniasis. The leishmanin skin test, available only for the male patient, was negative. The PCR and immunofluorescence antibody titers for Leishmania were negative in both patients. They were HIV positive; in the male, his CD4+ T cell count was 60/mm(3) and in the female 133/mm(3). The nasal ulcer was the only manifestation of histoplasmosis and the first of AIDS in both patients. The male patient recovered with amphotericin B and itraconazole treatment. The female has improved with itraconazole. Both patients received antiretroviral treatment. Nasal mucous membrane ulcers should include histoplasmosis among the differential diagnosis. In conclusion, two patients had perforation of their nasal septum as the only manifestation of histoplasmosis, a diagnosis confirmed by nasal mucosa biopsy and by culture of H. capsulatum, findings which demonstrated that both patients had AIDS.

Case of disseminated histoplasmosis in a HIV-infected patient revealed by nasal involvement with maxillary osteolysis

“…The issue is that histoplasmosis can be confused with leishmaniosis for the following reasons: first of all Histoplasma yeasts could be interpreted as Leishmania amastigotes in direct examination; second, leishmaniosis frequently affects nasal mucosa [11, 12]. …”

“…Generally speaking, diagnosis of histoplasmosis can be difficult because of its low frequency, its non-specific clinical presentation and some histological similarities with others causes of nasal damage [5, 11]. …”

Oral Manifestations Associated to Paracoccidioidomicosis and Histoplasmosis

“…In this study it was found 10.34% of prevalence; in contrast, some researchers do not report any case of HIV/AIDS coinfection [6]. Therefore, the dentist should always suspect immunosuppression in patients with PCM or histoplasmosis oral manifestations, due to the fact that these mycoses can be AIDS/HIV-defining illnesses [1,5,10,11,17,19].…”

“…Histoplasmosis has long been recognized as an important opportunistic infection in patients with HIV/AIDS living in endemic regions all over the world [13][14][15][16][17]. In Venezuela, it is the most common mycosis among those with CD4 counts below 200 cell/mm3 [1,8,11,16,18].…”

“…As in PCM, we also reported macrochelia in histoplasmosis. Mucocotaneous lesions of both mycoses can be observed in any oral structure and may be polymorphic [13,17,29,30]. For this reason, they can be misdiagnosed as tuberculosis, SCC, leishmaniasis, among others.…”