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Disseminated histoplasmosis presenting with chronic ulcerative tongue lesions in a patient with diabetes
  1. Mohamed Hadzri Hasmoni1,
  2. Azarisman Shah Mohd Shah1,
  3. Suhaimi Ayoub2,
  4. Lau Shin Hin3,
  5. Mohd Amran Abd Rashid4
  1. 1Department of Internal Medicine, International Islamic University Malaysia, Kuantan, Malaysia
  2. 2Kuantan Medical Center, Kuantan, Malaysia
  3. 3Department of Oral Pathology and Medicine, Institute for Medical Research, Kuala Lumpur, Malaysia
  4. 4Department of Radiology, International Islamic University Malaysia, Kuantan, Malaysia
  1. Correspondence to Azarisman Shah Mohd Shah, risman1973{at}hotmail

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We describe a case of chronic tongue ulceration with systemic symptoms in a patient with poorly controlled diabetes. A biopsy of a lesion from the posterior third of the tongue showed features typical of histoplasmosis (figure 1). A CT of the thorax and abdomen revealed a diffuse reticulonodular pattern bilaterally (figure 2A). The intra-abdominal organs were normal. A diagnosis of disseminated histoplasmosis was made. The patient was started on intravenous amphotericin B for 3 weeks followed by oral itraconazole 100 mg twice a day for 1 month. A repeat CT thorax 6 weeks after antifungal treatment revealed resolution of the lesions (figure 2B).

Figure 1

Tissue biopsy taken from the tongue lesion shows multinucleated giant cells containing encapsulated fungal organism.

Figure 2

(A) CT of the thorax showing a diffuse reticulonodular pattern bilaterally which was more evident in the upper and middle zones. (B) CT of the thorax showing resolution of the reticulonodular shadowing 6 weeks after treatment.

Disseminated histoplasmosis refers to a process of severe fungus colonisation in the lungs and other organs and body sites 1 The first ever case of disseminated histoplasmosis in a patient with diabetes living in a non-endemic area was reported in 1977.2 Since the AIDS epidemic, disseminated histoplasmosis is more commonly seen. Chronic infection often presents with pancytopenia, hepatosplenomegaly, hepatitis and oropharyngeal or gastrointestinal lesions.3 A definitive diagnosis requires a positive blood culture or histological demonstration in involved tissue.3

Learning points

  • Despite no obvious immunocompromise except for diabetes, a high suspicious of index is required to diagnose disseminated histoplasmosis.

  • Recognition of the typical fungal infection is essential for a correct diagnosis.

  • The finding of a diffuse reticulonodular pattern on CT of the thorax should be correlated with clinical presentation for accurate diagnosis and treatment.



  • Competing interests None.

  • Patient consent Obtained.