PMC3703707_01
Intraoral aspect showing an ulcerative lesion with a granulomatous aspect destructing the gingival papilla between the central incisors
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F1
The lesions were asymptomatic and oral examination revealed ulcerative areas with granulomatous bed affecting the gingival papillae between lower central incisors, partially covered by a pseudomembranous material [Figure 1].
Radiography showing bilateral peri.hilar pulmonary involvement
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F2
The chest radiography [Figure 2a] and computed tomography scan [Figure 2b] of the thorax have revealed a diffuse infiltrate of nodular and linear/irregular coalescent opacities, distributed throughout both lungs [Figure 2].
Pulmonary computed tomography scan of patient showing nodular opacities of varying sizes, with scattered areas of consolidation
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F3
Routine sections show fragments of squamous mucosa with a marked granulomatous infiltrate composed by Langhans-type multinucleated giant cells interspersed with extensive macrophagic infiltrate with variable amounts of lymphocytes and neutrophils [Figure 3a]. Staining slides with Grocott-Gomori methenamine silver, scarce oval structures with apparent single budding, measuring 3-5 mm in diameter were found suggesting histoplasmosis [Figure 3b]. In slide culture preparations, hyaline and septated hyphae producing numerous thick-walled and tuberculated macroconidia were also consistent with histoplasmosis [Figure 3c]. The incubation of this material on Sabouraud Dextrose Agar at room temperature by 3 weeks was sufficient to reveal the typical growth pattern of H. capsulatum, which consists of white to brownish filamentous colonies on the slants [Figure 3d].
Photomicrography (Hematoxylin and Eosin) showing a granulomatous reaction with formation of Langhans-type giant cells and prominent macrophages (x20)
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F4
The patient was treated with Itraconazol 200 mg, given 6 times/day, reducing to two tablets per day after the 3rd day until the condition improves [Figure 4].