Pharyngeal Histoplasmosis Presenting as a Tumor Mass in an Immunocompetent Host

Sir, Histoplasmosis is an infrequently reported disease in India, and we have come across sporadic case reports from various parts of the country. We would like to share details of a case of oropharyngeal histoplasmosis that we recently came across in our practice, because of its unique presentation and its histopathologic appearance. The patient was a 62-year-old immunocompetent man who presented with a mass in the pharynx. His chief complaints were progressively worsening difficulty in swallowing and alteration of voice of 4 months duration. The patient was a known diabetic. Findings from his baseline investigations, including X-ray chest, were within normal limits. Indirect laryngoscopy revealed presence of a mass in the left posterior pharyngeal wall, extending up to the base of tongue and involving the epiglottis. The lower limit of the mass was not visualized. A clinical diagnosis of a possible malignant lesion in the pharynx was considered. A punch biopsy was performed. Histopathological examination revealed a highly cellular lesion composed of sheets of polygonal cells with eosinophilic granular cytoplasm, separated by small blood vessels [Figure 1]. No mitotic activity or necrosis was seen. Initial impression was that of a benign tumor. However, on careful inspection, intracellular inclusions with peripheral halo were seen within the cells at the periphery of the lesion [Figure 2]. Sprinkling by lymphocytes and plasma cells was noted. No feature of active inflammation, including ulceration or granulation tissue, was seen. No granulomas were seen. A Gomori methamine silver stain highlighted small oval yeast forms with narrow-base budding [Figure 2]. Immunostain for CD68 highlighted histiocytes. A diagnosis of oropharyngeal mycosis with fungal forms morphologically consistent with histoplasma was rendered, and a microbiological evaluation was suggested. On further investigations, it was found that the patient was a construction engineer with a history of traveling within and outside the country. He did not have any features of chronic lung disease or enlarged lymph nodes that are often described with oral histoplasmosis.

Sir, Histoplasmosis is an infrequently reported disease in India, and we have come across sporadic case reports from various parts of the country. We would like to share details of a case of oropharyngeal histoplasmosis that we recently came across in our practice, because of its unique presentation and its histopathologic appearance. The patient was a 62-year-old immunocompetent man who presented with a mass in the pharynx. His chief complaints were progressively worsening difficulty in swallowing and alteration of voice of 4 months duration. The patient was a known diabetic. Findings from his baseline investigations, including X-ray chest, were within normal limits. Indirect laryngoscopy revealed presence of a mass in the left posterior pharyngeal wall, extending up to the base of tongue and involving the epiglottis. The lower limit of the mass was not visualized. A clinical diagnosis of a possible malignant lesion in the pharynx was considered. A punch biopsy was performed. Histopathological examination revealed a highly cellular lesion composed of sheets of polygonal cells with eosinophilic granular cytoplasm, separated by small blood vessels [ Figure 1]. No mitotic activity or necrosis was seen. Initial impression was that of a benign tumor. However, on careful inspection, intracellular inclusions with peripheral halo were seen within the cells at the periphery of the lesion [ Figure 2]. Sprinkling by lymphocytes and plasma cells was noted. No feature of active inflammation, including ulceration or granulation tissue, was seen. No granulomas were seen. A Gomori methamine silver stain highlighted small oval yeast forms with narrow-base budding [ Figure 2]. Immunostain for CD68 highlighted histiocytes. A diagnosis of oropharyngeal mycosis with fungal forms morphologically consistent with histoplasma was rendered, and a microbiological evaluation was suggested. On further investigations, it was found that the patient was a construction engineer with a history of traveling within and outside the country. He did not have any features of chronic lung disease or enlarged lymph nodes that are often described with oral histoplasmosis.
Histoplasmosis in immunocompetent host usually presents as a mild or clinically insignificant respiratory disease. Mucus membrane lesions are more common in indolent cases and are found in up to two thirds of the chronic cases. [1] Most of these lesions are ulcerated and are commonly accompanied by hepatosplenomegaly and adrenal insufficiency. [1,2] Presentation as an isolated mass lesion in the pharynx is rare and can be clinically misdiagnosed as a tumor.
The available information on the disease in India is largely based upon sporadic case reports and so the endemic zones of histoplasmosis have not been delineated; consequently, the disease should not be suspected only on the basis of the patient's origin.
We present this case because histoplasmosis can pose a diagnostic dilemma to both the clinicians and pathologists. Oral histoplasmosis is difficult to diagnose clinically as it can resemble other more common clinical entities such as carcinoma (as in our case), syphilis, sarcoidosis, lymphoma and tuberculosis. A pathologist should suspect or look for histoplasmosis when an isolated population of macrophages is seen in absence of other inflammatory cells or granulomas. Sir, Infection of the joint, following joint replacement surgery, is one of the most dreaded complications. The reason for this is the morbidity and expenditure involved in treating such infections. Common organisms causing infection are coagulase-negative staphylococci, staph aureus, mixed flora, streptococci, etc. We treated one patient of knee joint replacement, who later developed tuberculous infection. This infection manifested as sinus tract opening at ankle joint. Only one such case has been reported in literature.

Fouzia Siraj, Varsha Manucha
This patient, a 72-year-old woman, presented with complaints of a non-healing wound over inner aspect of right ankle joint for the last 3 years. There was intermittent bloody-to-clear discharge from the wound. The wound used to heal for a short period and then recur spontaneously. There was no history of fever, trauma or purulent discharge. Past history of the patient was very eventful. She had undergone knee replacement surgery in 1987, which had to be repeated because of loosening of prosthesis. It was 1 month after the second surgery that the patient developed swelling in ankle region. The swelling was diagnosed as isolated abscess, which was incised and drained. The patient was put on broad-spectrum antibiotics, but the incision site turned into chronic sinus. Pus cultures were sterile. Blood cultures were not done as it was a localized swelling with no systemic manifestations like fever. Later, biopsy of sinus wall was done, which revealed tuberculosis. Though acid fast bacilli staining was negative, the patient was put on antitubercular treatment for 9 months. The sinus healed temporarily, just to recur after a few months. Local examination showed a sinus opening just above the medial malleolus over the right ankle joint.
The surrounding skin was healthy. We observed another 2 × 2 cm-sized firm nontender swelling in the region of medial head of gastrocnemius muscle. Sinogram was done, which revealed sinus tract extending from sinus opening at ankle joint, upwards towards the knee joint [ Figure 1]. Excision of sinus tract was planned and patient taken up for surgery. Methylene blue was injected into the sinus tract and dissection made circumferentially around the tract.
There was approximately 20 cm long tract starting from medial aspect of knee joint and extending upwards through the gastrocnemius muscle and ending in a closed cavity at ankle joint through which knee prosthesis could be felt [ Figure 2]. The whole sinus tract was excised [ Figure 3] and the blind cavity at upper end closed. Histopathology of the sinus tract biopsy suggested tuberculosis. The patient was again put on a 9-month course of antitubercular treatment, after which the patient became asymptomatic.
Tubercular infection of the knee joint has been mentioned in literature, [1][2][3] but infection of a replaced knee joint with Mycobacterium tuberculosis is not common.
[4] Cases of granulomatous inflammation following joint replacement secondary to foreign body reaction have also been reported in literature. [5] In this case, the possible explanation could be local reactivation of quiescent tuberculosis of the knee joint. The patient had undergone replacement of knee prosthesis