Interesting case - May 2021

A fifty-year-old clerk from West Bengal presented with gradually progressive ulceration and excoriation of skin over the penile shaft and anterior surface of the scrotum for 1 month He also has reddish, non-pruritic, raised skin rash over the abdomen, thighs, axillae, arms, feet, and left eyelid. There is no history of fever, cough, dyspnoea, chest pain, oral ulcers, abdominal complaints, headache, seizures, or focal symptoms.

He underwent renal transplant (1996); Native kidney disease- details unknown; currently on Tab Prednisolone (10mg) and Tab Azoran (100mg) once a day; Diabetic for 4 years - uncontrolled.

Examination:

Left eyelid: nodular erythematous rash

Skin: Erythematous, raised, palpable indurated papulo-nodular rash over abdomen, axillae, thighs, arms, and legs

Systemic examination: Right iliac fossa kidney palpable, nontender

External Genitalia: Excoriation of skin over penile shaft and ant surface of the scrotum. Forming an ulcer- with well-defined margins, sloping edge, base- slough

What is the most likely diagnosis? View Answer

Answer

The differentials we considered were:

  • Disseminated Histoplasmosis
  • Disseminated Cryptococcosis
  • Cutaneous tuberculosis with papulonecrotic tuberculids
  • Post-transplant lymphoproliferative disorder (PTLD)

Further course:

His skin biopsy showed granulomatous inflammation with yeast forms. Cultures grew Histoplasma capsulatum.

He was treated with Inj Liposomal Amphotericin B 3mg/kg IV OD for 2 weeks followed by oral Itraconazole for 12 months and recovered well.