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42 year old hispanic female with past medical history of:
- HIV infection since 1995 currently on HAART with tenofovir, ritonavir, atazanivir
- Cerebral toxoplasmosis diagnosed in 2000 currently on dapsone, pyrimethamine and folinic acid
Presented to the hospital with lesion on the right nostril extended over a period of 3 months to include the right side of the nose, the right malar area and the upper lip with no improvement with oral antibiotics.
Physical examination revealed bilateral cervical lymphadenopathy in the addition to her nose lesion. CT scan of the sinuses revealed pansinusitis with no bony involvement. Chest X-ray is negative. WBC 8.8, CD4 count 21, normal electrolytes and normal liver function test and kidney functions.
Differential diagnosis included: Leishmaniasis, lymphoma, mycobacterial disease, cryptococcoma, aspergillosis,, midline lethal granuloma and sarcoidosis.
Skin biopsy is done and revealed chronic inflammatory reaction with exuberant intracellular organisms which appeared as yeast-like on Gomori-methenamine silver stain.
Culture of the biopsy revealed macroconidia with large ovoid bodies with slender protrusions on the surface (tuberculate) and multiple small, smooth oval bodies (microconidia ) consistent with histoplama capsulatum.
Patient was initially treated with Amphotericine B Lipid complex then was changed to oral itraconazole. Her follow up picture after three months of treatment is shown below.
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