Revista de SIDA e investigación clínica

Vulval Involvement in Acquired Immunodeficiency Syndrome-Associated Disseminated Histoplasmosis

Abstract

Ramdial PK, Sing Y, Ramburan A, Nargan K, Singh B, Bagratee JS and Calonje E

Background: Female genital tract, including vulval, histoplasmosis is reported rarely despite an increased propensity for cutaneous involvement by disseminated histoplasmosis (DH), even in patients with acquired immunodeficiency syndrome (AIDS). Methods: Sixteen year retrospective study investigating vulval involvement by histoplasmosis. Results: Of 239 patients with DH, 6 had vulval involvement and were confirmed to have HIV infection and AIDS. Seventeen biopsies (9 vulval, 8 extravulval) from these 6 patients form the study cohort. Patients 1 to 4 had simultaneous vulval (5) and extravulval (5) cutaneous biopsies. Eight cutaneous biopsies demonstrated diffuse dermal infiltration by histiocytes containing budding yeasts of H. capsulatum variant capsulatum (HCVC). A single thigh lesion demonstrated diffuse dermal karyorrhexis and myriad extracellular HCVC and a lymph node were diffusely effaced by histiocytes containing HCVC. Patient 5 had concomitant, co-lesional disseminated Kaposi sarcoma and HCVC infection. Patient 6 had 2 initial biopsies that demonstrated H. capsulatum variant duboisii (HCVD). Three biopsies of persistent facial and vulval plaques and a vulval ulcer, despite amphotericin treatment, confirmed HCVD, Cytomegalovirus and HCVD and Herpes simplex virus infection in each of the persistent lesions, respectively. Patients 2, 3 and 4 died before treatment was commenced. Patient 5 was lost to follow-up and did not receive any treatment. Patient 1 had resolution of DH following treatment with itraconazole. Persistent cutaneous lesions (Patient 6) healed with aciclovir and ganciclovir but uterine cervical squamous carcinoma was diagnosed 6 months later. Conclusion: Vulval involvement by histoplasmosis shares overlapping clinical features with many infections and tumors. Vulval biopsies are pivotal for diagnosis and allied therapeutic monitoring, particularly in the context of AIDSassociated co-morbid pathology.