Edematous pink plaque in a patient on immunosuppression

A 61-year-old male in Texas presented with 13 months of painful, erythematous swelling of his left arm associated with cough, lymphadenopathy, and migratory polyarthralgias. Cough workup 6 months prior demonstrated calcified lung nodules on chest computed tomography and noncaseating granulomas on lung biopsy. He received 5 months of azathioprine and prednisone for presumed sarcoidosis without improvement. Examination demonstrated an indurated erythematous plaque from the left forearm to dorsal hand on a background of edema (Fig 1). Punch biopsy was obtained due to persistence of the lesion despite broadspectrum antibiotics. Grocott methenamine silver stain demonstrated dermal narrow-based budding yeast (Fig 2).

A 61-year-old male in Texas presented with 13 months of painful, erythematous swelling of his left arm associated with cough, lymphadenopathy, and migratory polyarthralgias.Cough workup 6 months prior demonstrated calcified lung nodules on chest computed tomography and noncaseating granulomas on lung biopsy.He received 5 months of azathioprine and prednisone for presumed sarcoidosis without improvement.Examination demonstrated an indurated erythematous plaque from the left forearm to dorsal hand on a background of edema (Fig 1).Punch biopsy was obtained due to persistence of the lesion despite broadspectrum antibiotics.Grocott methenamine silver stain demonstrated dermal narrow-based budding yeast (Fig 2

C.
Atopic dermatitis e Incorrect.Atopic dermatitis can lead to skin fissuring that allows for bacterial translocation and cellulitis.However, atopic dermatitis is not a risk factor for histoplasmosis.

D.
Family history e Incorrect.Although a family history of sarcoidosis is a risk factor for sarcoidosis, disseminated histoplasmosis is not thought to be due to genetic factors.
E. Immunosuppression e Correct.This patient's history of iatrogenic immunosuppression has most likely led to disseminated histoplasmosis with cutaneous findings.CD4 1 and CD8 1 T cells are required for an effective immune response in histoplasmosis.As such, disseminated histoplasmosis is more common in those with T-cell immunodeficiencies, iatrogenic T-cell suppression, or acquired T-cell deficiencies such as HIV. 5 Question 3: What is the most appropriate treatment for this patient?

Answers:
A. Intravenous corticosteroids e Incorrect.Presumably, this patient's initial fevers, pulmonary nodules, and arthralgias were due to undiagnosed histoplasmosis rather than sarcoidosis and worsening of his symptoms occurred as a result of immunosuppressive therapy.Increasing immunosuppression would not result in improvement.

B. Intravenous amphotericin B and/or an azole e
Correct.Because mortality can be as high as 80% to 100% in disseminated histoplasmosis, all patients should be treated with intravenous amphotericin B and/or an azole. 5The specific choice of drug depends on disease severity and the presence of central nervous system involvement, but in all cases, treatment should be continued for at least 12 m.

C.
Intravenous antibiotics e Incorrect.Bacterial cellulitis is not suspected given the skin biopsy findings, and thus, intravenous antibiotics are not warranted.
D. Incision and drainage e Incorrect.Incision and drainage would be warranted if there was concern for an abscess.However, this would not improve disseminated histoplasmosis, and instead, antifungal therapy is required.
E. Infliximab e Incorrect.Infliximab and other tumor necrosis factor-alpha inhibitors can be used in the treatment of sarcoidosis.However, further immunosuppression in this patient would worsen disseminated histoplasmosis.

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A.
Intravenous corticosteroids B. Intravenous amphotericin B and/or an azole C. Intravenous antibiotics D. Incision and drainage 2. , vesicles, and erythroderma.Much more rarely, disseminated disease has been reported to present with cellulitis-like changes in patients on chronic immunosuppressive therapy.1Histoplasmosispseudocellulitisshouldbeconsidered in patients living in or with recent travel to endemic areas with persistent skin findings despite antibiotics.D. Coccidioidomycosis e Incorrect.Coccidioides infection predominantly starts in the lungs.Dissemination to the skin, similar to histoplasmosis, can be seen in immunocompromised patients.Pathology would demonstrate spherules containing endospores within granulomas.2Living in the southwestern United States e Incorrect.Histoplasmosis is the most prevalent of the major endemic mycoses in the United States, with cases most commonly reported in the Ohio and Mississippi River Valleys but also occurring in Texas among other regions.4Coccidioidomycosis is more common in the southwestern United States.B. Occupational history of working as a sandblaster e Incorrect.Silicosis can be associated with pulmonary disease in sandblasters as a result of inhalation of silica.Systemic sclerosis can be seen with silicosis, but cellulitis-like changes have not been reported.
authors at the time of article submission to the journal stating that all patients gave consent for their photographs and medical information to be published in print and online and with the understanding that this information may be publicly available.Correspondence to: Cristina Thomas, MD, Departments of Internal Medicine and Dermatology The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390.E-mail: cristina.thomas2@utsouthwestern.edu.JAAD Case Reports 2023;39:158-60.2352-5126 ª 2023 by the American Academy of Dermatology, Inc. Published by Elsevier Inc.This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).https://doi.org/10.1016/j.jdcr.2023.07.008