Journal of Indian Society of Periodontology
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CASE REPORT
Year : 2009  |  Volume : 13  |  Issue : 3  |  Page : 157-159 Table of Contents   

Oral histoplasmosis


Department of Oral Medicine and Radiology, JSS Dental College and Hospital, JSS University, Mysore - 15, India

Date of Submission05-Mar-2009
Date of Acceptance12-Aug-2009
Date of Web Publication3-Mar-2010

Correspondence Address:
Karthikeya Patil
Professor and Head, Department of Oral Medicine and Radiology, JSS Dental College and Hospital, JSS University, Mysore - 15
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-124X.60230

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   Abstract 

Histoplasmosis is a systemic fungal disease that takes various clinical forms, among which oral lesions are rare. The disseminated form of the disease that usually occurs in association with Human Immunodeficiency Virus (HIV) is one of the AIDS-defining diseases. Isolated oral histoplasmosis, without systemic involvement, with underlying immunosuppression due to AIDS is very rare. We report one such case of isolated oral histoplasmosis in a HIV-infected patient.

Keywords: Oral histoplasmosis, oral ulcer, AIDS


How to cite this article:
Patil K, Mahima V G, Prathibha Rani R M. Oral histoplasmosis. J Indian Soc Periodontol 2009;13:157-9

How to cite this URL:
Patil K, Mahima V G, Prathibha Rani R M. Oral histoplasmosis. J Indian Soc Periodontol [serial online] 2009 [cited 2020 Sep 19];13:157-9. Available from: http://www.jisponline.com/text.asp?2009/13/3/157/60230


   Introduction Top


Histoplasmosis is a granulomatous systemic mycosis caused by the dimorphic fungus Histoplasma Capsulatum, the clinical disease of which was first described by Samuel Darling in 1905. Oral histoplasmosis usually occurs in association with the chronic disseminated form of the disease. Sometimes they may present as the initial or the only mucocutaneous manifestation of the disease.


   Case Report Top


A 45-year-old male patient reported with a chief complaint of painful ulcer on the left side of his tongue since two months. The patient gave no history of trauma prior to the onset of the ulcer. There was a history of associated pain and bleeding from the ulcer with difficulty in speech, mastication, and deglutition, with no history of pus discharge, paresthesia or numbness. Also, there were no systemic symptoms. The medical and personal histories were noncontributory.

An extraoral examination revealed left submandibular lymphadenopathy, and intraoral examination revealed a solitary, large, deep ulcer on the left dorsum of the tongue, which was roughly rhomboidal in shape and measured 1.0 × 2.5 cm. The borders of the ulcer were edematous and raised, the floor appeared granular, and was covered with slough [Figure 1]. The ulcer was tender and indurated on palpation. Diffuse granular enlargement of marginal, interdental, and attached gingiva of the maxilla and mandible was conspicuous, with focal areas of necrosis [Figure 2] and [Figure 3].

A panoramic radiograph revealed generalized, moderate, horizontal bone loss. A chest radiograph did not reveal any abnormality. The patient was reactive for HIV 1 and 2 using Western blot assay. The fungal culture of the tissue from the tongue and left maxillary palatal gingiva showed the presence of normal oral flora and no evidence of mycobacterium tuberculi. The histopathologic sections revealed an ulcerated, stratified, squamous epithelium in relation to the tongue and an intact epithelium in relation to the gingiva, with dense chronic inflammation, numerous epitheloid cell granulomas, few Langhans-type giant cells, and foamy macrophages [Figure 4]. The foamy macrophages showed numerous small fungal spores surrounded by a clear halo. There was no evidence of caseous necrosis or malignancy in the tissue sections.[Figure 5]. The histological features were suggestive of histoplasmosis. Based on the clinical features and investigatory findings, a final diagnosis of localized oral histoplasmosis in a HIV seropostive patient was made. Further, the patient was referred to a general physician for complete systemic evaluation, where systemic involvement of histoplasmosis was ruled out.

After counseling the patient, anti-retroviral therapy was instituted as a part of the general management. T. Itraconozole 200 mg TID for three days followed by T. Itraconozole 200 mg BD for 12 weeks was instituted, as a part of a specific therapy. The lesions completely healed after a complete course of medication [Figure 6] and [Figure 7]. The patient, however, is under regular follow-up and no recurrence is noted.


   Discussion Top


Histoplasma Capsulatum is a dimorphic fungus that assumes a yeast form, about 1-4 microns in diameter, in the host tissue. It is found chiefly in warm, humid environment that contains bird and bat excreta, and soil high in nitrogen content. [1],[2],[3] Although Histoplasma Capsulatum is endemic, sporadic cases have been reported throughout the world. Humidity and soil characters [2],[3] have been attributed for its endemic distribution. Padhye et al., suggested that histoplasmosis in Indians tends to occur primarily in the extrapulmonary sites, particularly in the oral cavity. [2] Clinically it can take an acute pulmonary, a chronic pulmonary or a disseminated form. [4]

Oral lesions of the disease manifests rarely. When present, they occur in association with the disseminated form or sometimes as a localized lesion, which could be the initial [2],[5] or the only manifestation of the disease. [2],[3],[4],[5],[6] They are common in men, with a male to female ratio of 9:1. [1],[2],[3],[4],[5],[6],[7],[8] The mean age of occurrence is 39 years, with an average ranging from 26 to 65 years. The commonly involved sites in the oral cavity are tongue, hard and soft palate, buccal mucosa, gingiva, and lips. [1],[2],[3],[4],[5] According to Goodwin et al., the oropharyngeal lesions are frequently the initial presentation of the disease, especially in the disseminated form. [2] Reddy et al. (1970), reported that all the patients who presented initially with oral lesions, subsequently developed disseminated disease, [2] suggesting the need for a periodic evaluation of patients with localized oral histoplasmosis, for any systemic involvement. Oral lesions can manifest as papular, ulcerative, nodular, vegetative, furunculoid, granulomatous, or plaque-like lesions, with the most common presentation being a shallow or deep infiltrated ulceration with a pseudomembrane. [1],[2],[3],[4],[5],[9],[10] Gingival manifestations include ulcerative and painful granulomatous lesions. [8] Sore throat, hoarseness of voice, and dysphagia can also manifest. [3]

Histoplasmosis can be diagnosed based on clinical signs and symptoms, histopathology, cultures, serologic test, including compliment fixation test, immunodiffusion, and histoplasmin skin test. Diagnosis by fungal culture provides the strongest evidence of infection, but that is useful in progressive, disseminated, or chronic pulmonary histoplasmosis, rather than in the initial cases. Care should be taken not to exclude the diagnosis in false negative cases. [7] Histopathology is the prime investigative modality, as identification of Histoplasma organism in the sections provides conclusive evidence of the disease. [4] Serologic tests have limited value in HIV patients because of diminished antibody production. Histoplasmin skin test is of limited value, as the reagents are no longer available. Additionally, a positive histoplasmin skin test boosts antibody levels, compromising the interpretation of serologic tests. [7] Direct immunofluorescence is diagnostic in case of HIV patients. [7]

The disease is self-limiting in immunocompetent patients. [3],[4] Amphotercin B, at a dose of 2 gms IV for 10 weeks, is used in the management of pulmonary histoplasmosis, in HIV patients. Studies have shown that in immunocompetent patients without AIDS, amphotercin B is effective by 68-92%, itraconozole by 100%, and ketaconozole by 56-70%, whereas, in patients with AIDS, amphotercin B is effective by 74-88% and itraconozole by 85%. [3] In addition, itraconozole is known to have rapid action and is effective in preventing a relapse. [8]


   Conclusion Top


The consistently raising incidence of histoplasmosis in India and other parts of Asia is quiet alarming. As the disease is the second most common opportunistic infection associated with HIV, and is one of the AIDS defining diseases, [5],[8] it should be considered in the differential diagnosis of an unusual, exaggerated, oral ulceration, when encountered with HIV seropositivity. When such cases are encountered, an attempt must be made to evaluate the underlying HIV infection. A thorough clinical knowledge about oral histoplasmosis is important in diagnosing and preventing further dissemination, thereby, preventing the fulmination of this fatal disease in order to improve and prolong the lives of patients with AIDS.


   Acknowledgments Top


The authors wish to acknowledge Dr. Lakshman K, MD (General Pathology), and Dr. Shantha Krishnamurthy, MD (General Pathology), for their contribution.

 
   References Top

1.Hernández SL, López De Blanc SA, Sambuelli RH, Roland H, Cornelli C, Lattanzi V, et al. 'Oral histoplasmosis associated with HIV infection. J Oral Pathol Med 2004;33:445-50.  Back to cited text no. 1      
2.Ng KH, Siar CH. Review of oral histoplasmosis in Malaysians. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:303-7.  Back to cited text no. 2      
3.Wheat J, Sarosi G, McKinsey D, Hamill R, Bradsher R, Johnson P, et al. 'Practice guidelines for the management of patients with histoplasmosis'. Clin Infect Dis 2000;30:688-95.  Back to cited text no. 3      
4.Patil K, Mahima VG, Patil S. Oral histoplasmosis in a HIV patient - A case report. J Indian Acad Oral Med Radiol 2003;15:43-8.  Back to cited text no. 4      
5.Oda D, MacDougall L, Fritsche T, Worthington P. Oral histoplasmosis as a presenting disease in acquired immunodeficiency syndrome. Oral Surg Oral Med Oral Pathol 1990;70:631-6.  Back to cited text no. 5      
6.Cohen PR. Oral histoplasmosis in HIV - infected patients. Oral Surg Oral Med Oral Pathol 1994;78:277-8.  Back to cited text no. 6      
7.Wheat JL. Current diagnosis of histoplasmosis. Trends in microbiology, 2003; 11:488-94.  Back to cited text no. 7      
8.Economopoulou P, Laskaris G, Kittas C. Oral histoplasmosis as an indicator of HIV infection. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:203-6.  Back to cited text no. 8      
9.Ferreira OG, Cardoso SV, Borges AS, Ferreira MS, Loyola AM. oral histoplasmosis in Brazil. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:654-9.  Back to cited text no. 9      
10.Chinn H, Chernoff DN, Migliorati CA, Silverman S Jr, Green TL. Oral histoplasmosis in HIV-infected patients a report of two cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:710-4.  Back to cited text no. 10      


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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