With cefaclor and then with ciprofloxacin Rolipram ZK 62711 and doxycycline was initiated, again with minimal improvement. A 4 3 cm wide, 1.5 cm thick cutaneous ellipse containing a 1.9 cm large, ulcerated tumor was received at the Department of Pathology. Histology showed the tumor to consist of a diffuse, granulomatous inflammation of the dermis, with a prominent multinucleate giant cell component, both of Langhans and foreign body type. Many oval fungi, around 10 mm in diameter were identified, both within giant cells and outside, some formed budding pairs, with a narrow connection. Fungi were highlighted by means of both periodic acid Schiff and Grocott stains. The overlying epidermis was focally ulcerated. The diagnosis of African histoplasmosis was suggested, after which the patient was admitted to the Department of Internal Medicine for a further workup. Material from the paraffin block was sent to an international reference center for mycology, where the diagnosis was confirmed by means of an in house real time polymerase chain reaction, according to a previously described protocol.4 This method detects both Histoplasma spp. varieties and targets the ITS2 region of the ribosomal DNA. The PCR results were confirmed by sequencing the amplicon and comparing the sequence with the nucleotide sequence database available in the Mycology Laboratory and with the GenBank database. The sequence matched that of H. capsulatum var. duboisii. The percentage of identity with both databases was 99%. Upon admission, the patient had a past medical history of type II diabetes mellitus for the last 10 years, in addition to persistent lumbago and right sciatica pain. He was on metformin, carvedilol, clopidogrel, and enteric coated aspirin. No risk factors for human immunodeficiency virus infection or exposure to pets or soil were disclosed.
Physical examination disclosed a systolic heart murmur consistent with aortic stenosis with normal S1 and S2 and hepatosplenomegaly without concomitant lymphadenopathy. No spinal tenderness was found, neurologic Linifanib assessment was unremarkable. Complete blood count, serum protein electrophoresis, and biochemical examinations were within normal limits. Serologic evaluation for hepatitis B virus, hepatitis C virus, or HIV, as well as specific PCR for Plasmodium spp. performed in a blood specimen were negative. Fungal blood cultures were negative. Chest computer tomography was unremarkable, whereas abdominal computer tomography disclosed hepatosplenomegaly with no enlarged lymph nodes. Bone scan showed increased gallium citrate concentration at the L4 and S1 vertebrae, right sternoclavicular joint and both knees, interpreted as of a degenerative origin. The patient was initiated on itraconazole capsules at a dose of 200 mg tid for 3 days, followed by 200 mg bid for the following 6 months. The surgical wound gradually healed with no recurrence of the original skin lesion. He has since returned to DRC, where repeat ultrasound examinations showed a significant reduction of both liver and spleen size with no evidence of punctuate calcifications. Complete blood count during followup was normal. He is still under treatment and fares well. DISCUSSION First described in 1952 by Dubois and others,5 African histoplasmosis is a rare deep mycosis.