- Email: [email protected]
Oral histoplasmosis after radiation therapy for laryngeal squamous cell carcinoma
Case reports 871
J AM ACAD DERMATOL VOLUME 56, NUMBER 5
10. DeLeve LD. Dinitrochlorobenzene is genotoxic by sister chromatid exchange in human skin fibroblasts. Mutat Res 1996;371:105-8. 11. Feldman RJ, Maibach HI. Absorption of some organic compounds through the skin in man. J Invest Dermatol 1970; 54:399-404. 12. Wolf P, Rieger E, Kerl H. Topical photodynamic therapy with endogenous porphyrins after application of 5-aminolevulinic acid. J Am Acad Dermatol 1993;28:17-21.
13. Steinman A, Funk JO, Schuler G, von den Driesch P. Topical imiquimod treatment of a cutaneous melanoma metastasis. J Am Acad Dermatol 2000;43:555-6. 14. Hesling C, D’Incan M, Mansard S, Franck F, Corbin-Duval A, Chevenet C, et al. In vivo and in situ modulation of the expression of genes involved in metastasis and angiogenesis in a patient treated with topical imiquimod for melanoma skin metastases. Br J Dermatol 2004;150:761-7.
Oral histoplasmosis after radiation therapy for laryngeal squamous cell carcinoma Khaled Ezzedine, MD,a Isabelle Accoceberry, MD,b and Denis Malvy, MD, PhDa Bordeaux, France
Histoplasmosis is a usually asymptomatic deep fungal infection of tropical origin with respiratory entry and possible oral, pharyngeal, or metastatic localization. The condition represents an important imported systemic mycosis with oral involvement. We report the case of a patient who developed an oropharyngeal reactivation of a latent Histoplasma infection after receiving local antitumoral radiation therapy of the neck. H capsulatum was shown to be present in the lesion by both histopathology and staining, and was deduced to be the causative organism of the disease. ( J Am Acad Dermatol 2007;56:871-3.)
H
istoplasmosis is a worldwide systemic mycosis caused by Histoplasma capsulatum, a saprophytic and dimorphic ascomycete found globally in soil. Human beings acquire the agent by inhalation of conidia, which are present mainly in warm and humid soils. Some areas are endemic with high prevalence in the Ohio and the Mississippi river valley regions of the United States and scattered areas of Central and South America, Asia, the Far East, Australia, and Africa.1 The clinical findings of histoplasmosis depend on the inoculum exposure and immunity of the patients. The disease may affect only the lung or involve extrapulmonary sites when the fungi spread through the reticuloendothelial system.2
Increased travel as a result of tourism, international cooperation, and trade has increased the risk of H capsulatum infection for travellers from nonendemic areas, such as the European Union.3 In Europe, clinical histoplasmosis is commonly caused by endogenous reactivation of latent infection imported from endemic areas, especially in patients who are immunocompromised.3 We describe the case of oropharyngeal histoplasmosis without detectable systemic involvement in a patient who acquired latent histoplasmosis during a stay in Africa more than 20 years before. He developed the disease 1 year after receiving radiation therapy for a malignant condition of the neck.
CASE REPORT From the Travel Clinics and Tropical Disease Unit, Department of Internal Medicine, Infectious Diseases and Tropical Medicine,a and Laboratory of Parasitology,b University Hospital Center. Funding sources: None. Conflicts of interest: None declared. Reprint requests: Khaled Ezzedine, MD, Unite´ de Me´decine tropicale et Pathologie d’importation, Service de Me´decine interne et des Maladies tropicales (Pr. Maı¨te´ Longy-Boursier), Hoˆpital Saint-Andre´eCHU Bordeaux, 1, rue Jean Burguet, F-33 075 Bordeaux cedex, France. E-mail: [email protected]. Published online January 26, 2007. 0190-9622/$32.00 ª 2007 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2006.10.026
A metropolitan 65-year-old French man consulted for a 6-month history of painful oral lesions, associated with hoarseness, dysphagia, and odinophagia followed by an involuntary weight loss of approximately 4 kg. He denied fever or cough. He had experienced, 2 years earlier, laryngeal squamous cell carcinoma condition treated without relapse by partial laryngectomy and local radiotherapy of the neck. He had travelled 30 years before presentation to Cameroon and Ivory Coast for an 8-year professional expatriation stay. During this period, he was given the diagnosis of a Schistosoma haematobium
872 Case reports
J AM ACAD DERMATOL MAY 2007
DISCUSSION
Fig 1. Craterlike ulcerated and necrotic lesion located on back surface of tongue as result of Histoplasma capsulatum.
infection, medically treated and without sequelae. He denied travel outside of France in the last 20 years. Clinical oral examination revealed craterlike ulcerated and necrotic lesions located on the back surface of the tongue (Fig 1), in the hard and soft palate, tonsil pillar, uvula, left and median buccogingival sulcus, and alveolar ridge. The lesions were covered by pseudomembrane and were extremely painful to palpation. No cervical lymphadenopathy was noted. General clinical examination was unremarkable with normal breath sound. An incisional biopsy of the soft palate was performed and specimen sent for histopathologic and microbiologic examination. Analysis displayed acanthomatous epithelium with areas of ulceration, a granulomatous arrangement, and an infiltration by histiocytes of the subepithelial connective tissue with a chronic inflammatory cell infiltrate. Parasitologic examination revealed 3 small intracellular inclusions, which were stained with periodic acideSchiff and Grocott-Gomori, and were consistent with H capsulatumelike yeasts. H capsulatum identity was confirmed after 15 days of culture and examination of the produced filamentous colony patterns. Laryngoscopy and esophageal endoscopy failed to reveal any area of comparable lesion or suggestive presentation for malignancy relapse. Chest radiograph showed no lung alteration and abdomen computed tomography scan showed no evidence of hepatomegaly, splenomegaly or lymphadenopathy. Serologic tests were positive for antiHistoplasma antibodies (one trait at electrocyneresis) and negative for HIV-1/2 antibodies. Induction therapy with oral itraconazole (200 mg/d) was started to complete a 16-week course. The clinical oropharyngeal lesions noted initially completely resolved and the patient gained weight. The treatment was followed by maintenance therapy with oral itraconazole at the same dosage but administered 1 week per month, during 6 months. At that time and 2 years later, no relapse was found.
H capsulatum has been found in areas contaminated with excreta of bats, gregarious birds (eg, chicken coops), attics, caves, abandoned buildings, trees, and roosting areas. Therefore, the fungi may be disturbed for travellers or expatriates by spelunking or mining, various professional activities involving demolishing old buildings, farm work, or sleeping outdoors.4,5 Primary infection with H capsulatum is usually subclinical, mild, or self-limited among patients who are immunocompetent. After inhalation, the fungi are phagocytized by pulmonary macrophages. The disease may be controlled within a low inoculum exposition, the development of an antigen-specific CD41 T lymphocyteemediated cellular immune response with activation of macrophages, although patients who are infected may continue to harbor yeasts for years. When the cell-mediated immunity of the host is impaired, H capsulatum can produce progressive systemic and potentially lethal disease with the spread of the fungi through the reticuloendothelial system, the fungi acting as an opportunistic agent.1,2 T helper-1 response, which generates T celle derived tumor necrosis factor-a (and interferon-g), may play a critical role in inhibiting or eradicating H capsulatum infection over time after a primary exposure, reducing the risk of reactivation.6 In Europe, cases of even disseminated histoplasmosis are typically the result of an endogenous reactivation of a latent infection in both immigrants and travellers.3,7 Patients who are debilitated or immunocompromised with serious systemic illness, undergoing chemotherapy, HIV infected, or elderly are commonly affected by a severe form of the disease.8 Upper aerodigestive involvement has been reported in patients with chronic pulmonary and chronic disseminated forms of histoplasmosis and may be the initial or only manifestation of the disease, particularly among individuals with HIV infection.9 Although rare in patients who are immunocompromised,10 a few cases of mucocutaneous histoplasmosis in patients without detectable systemic involvement have been reported.11 Indeed, if oral lesions have been considered as resulting from hematogenous spread from an unknown infection locus, oral histoplasmosis should be considered as a localized disease, when no systemic sign or symptom can be detected. In our patient, the lesions were restricted to the oral cavity and the pharynx, without pulmonary or other extrapulmonary or systemic manifestations, and underwent recent exposition to local immunosuppression injury for the treatment of a squamous cell carcinoma by operation and radiation therapy.
J AM ACAD DERMATOL
Case reports 873
VOLUME 56, NUMBER 5
Indeed, such condition has been recognized as a risk factor for oropharyngeal mycosis occurrence in a patient who was previously irradiated,12 but to our knowledge this is the first report of orapharyngeal histoplasmosis after exposition to radiotherapy. Concurrently, the biopsy features of the lesions, owing a granulomatous pattern of inflammation and scarce fungi, might argue for a limited involvement and an efficient response of the host.10 The treatment varies according to severity of the disease and immune status of the patient. The dosage and drug combinations along with suppressive maintenance therapy to prevent relapse are variable and are determined for each case. Itraconazole is the treatment of choice for patients who have mild or moderately severe symptoms, and for maintenance therapy.13,14 Finally, clinicians should always be aware of potential harmful drug-drug interactions particularly as the azoles may share the same metabolic route through the cytochrome P450 system.13
CONCLUSION Although the oral lesion of histoplasmosis is more common in individuals who are immunocompromised, it may also affect patients who are immunocompetent or survivors of irradiated head and neck cancer. In travellers or expatriates returning from endemic areas, histoplasmosis must be considered even if cough is not one of the symptoms affecting these patients for an early diagnosis and a prompt and specific treatment. REFERENCES 1. Cano MV, Hajjeh RA. The epidemiology of histoplasmosis: a review. Semin Respir Infect 2001;16:109-18.
2. Woods JP, Heinecke EL, Luecke JW, Maldonado E, Ng JZ, Retallack DM, et al. Pathogenesis of Histoplasma capsulatum. Semin Respir Infect 2001;16:91-101. 3. Manfredi R, Mazzoni A, Nanetti A, Chiodo F. Histoplasmosis capsulati and duboisii in Europe: the impact of the HIV pandemic, travel and immigration. Eur J Epidemiol 1994;10:675-81. 4. Gascon J, Torres JM, Jime´nez M, Mejias T, Trivino L, Gobbi F, et al. Histoplasmosis infection in Spanish travellers to Latin America. Eur J Clin Microbiol Infect Dis 2005;12:839-41. 5. Panackal AA, Hajjeh RA, Cetron MS, Warnock DW. Fungal infections among returning travellers. Clin Infect Dis 2002;35: 1088-95. 6. Jain VV, Evans T, Peterson MW. Reactivation histoplasmosis after treatment with anti-tumor necrosis factor a in a patient from a non-endemic area. Respir Med 2006;100: 1291-5. 7. Desmet P, Vogelaers D, Afschrift M. Progressive disseminated histoplasmosis 10 years after return out of Africa in an immunocompetent host. Acta Clin Belg 2004;59:274-8. 8. Subramanian S, Abraham OC, Rupati P, Zachariah A, Mathews MS, Mathai D. Disseminated histoplasmosis. J Assoc Physicians India 2005;53:185-9. 9. Hernandez SL, Lopez de Blanc AS, Sambuelli RH, Roland H, Cornelli C, Lattanzi V, et al. Oral histoplasmosis associated with HIV infection: a comparative study. J Oral Pathol Med 2004;33:445-50. 10. Alcure ML, Di Hipolito O Jr, Paes de Almeida O, Bouilhah H, Lopes MC. Oral histoplasmosis in an HIV-negative patient. Oral Med Oral Pathol Oral Endod 2006;101:E33-6. 11. Mignogna MD, Fedele S, Lo Russo L, Ruoppo E, Lo Muzio LA. A case of oral localized histoplasmosis in an immunocompetent patient. Eur J Clin Microbiol Infect Dis 2001;20:753-5. 12. Epstein JB, Freilich MM, Le ND. Risk factors for oropharyngeal candidiasis in patients who receive radiation therapy for malignant conditions of the head and neck. Oral Surg Oral Med Oral Pathol 1993;73:169-74. 13. Negroni R, Robles AM, Arechavala A, Taborda A. Itraconazole in human histoplasmosis. Mycoses 1989;32:123-30. 14. Doughan A. Disseminated histoplasmosis: case report and brief review. Travel Med Infect Dis doi:10.1016/j.tmaid. 2006.01.013. Published online April 19, 2006.
Deep cutaneous infection by Fusarium solani in a healthy child: Successful treatment with local heat therapy Yasuhiro Nakamura, MD,a Xuezhu Xu, MD,b Yoshio Saito, MD,a Takeshi Tateishi, MD,b Takenori Takahashi, MD,b Yasuhiro Kawachi, MD,b and Fujio Otsuka, MDb Ibaraki, Japan
From the Departments of Dermatology at Hitachi Ltd, Taga General Hospital,a and Institute of Clinical Medicine, University of Tsukuba.b Funding sources: None. Conflicts of interest: None declared. Reprint requests: Yasuhiro Nakamura, MD, Department of Dermatology, Hitachi Ltd, Taga General Hospital. 2-1-2 Kokubu-cho,
Hitachi, Ibaraki 316-0035, Japan. E-mail: ynakamurta3@yahoo. co.jp. Published online December 12, 2006. 0190-9622/$32.00 ª 2007 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2006.10.960
J AM ACAD DERMATOL VOLUME 56, NUMBER 5
10. DeLeve LD. Dinitrochlorobenzene is genotoxic by sister chromatid exchange in human skin fibroblasts. Mutat Res 1996;371:105-8. 11. Feldman RJ, Maibach HI. Absorption of some organic compounds through the skin in man. J Invest Dermatol 1970; 54:399-404. 12. Wolf P, Rieger E, Kerl H. Topical photodynamic therapy with endogenous porphyrins after application of 5-aminolevulinic acid. J Am Acad Dermatol 1993;28:17-21.
13. Steinman A, Funk JO, Schuler G, von den Driesch P. Topical imiquimod treatment of a cutaneous melanoma metastasis. J Am Acad Dermatol 2000;43:555-6. 14. Hesling C, D’Incan M, Mansard S, Franck F, Corbin-Duval A, Chevenet C, et al. In vivo and in situ modulation of the expression of genes involved in metastasis and angiogenesis in a patient treated with topical imiquimod for melanoma skin metastases. Br J Dermatol 2004;150:761-7.
Oral histoplasmosis after radiation therapy for laryngeal squamous cell carcinoma Khaled Ezzedine, MD,a Isabelle Accoceberry, MD,b and Denis Malvy, MD, PhDa Bordeaux, France
Histoplasmosis is a usually asymptomatic deep fungal infection of tropical origin with respiratory entry and possible oral, pharyngeal, or metastatic localization. The condition represents an important imported systemic mycosis with oral involvement. We report the case of a patient who developed an oropharyngeal reactivation of a latent Histoplasma infection after receiving local antitumoral radiation therapy of the neck. H capsulatum was shown to be present in the lesion by both histopathology and staining, and was deduced to be the causative organism of the disease. ( J Am Acad Dermatol 2007;56:871-3.)
H
istoplasmosis is a worldwide systemic mycosis caused by Histoplasma capsulatum, a saprophytic and dimorphic ascomycete found globally in soil. Human beings acquire the agent by inhalation of conidia, which are present mainly in warm and humid soils. Some areas are endemic with high prevalence in the Ohio and the Mississippi river valley regions of the United States and scattered areas of Central and South America, Asia, the Far East, Australia, and Africa.1 The clinical findings of histoplasmosis depend on the inoculum exposure and immunity of the patients. The disease may affect only the lung or involve extrapulmonary sites when the fungi spread through the reticuloendothelial system.2
Increased travel as a result of tourism, international cooperation, and trade has increased the risk of H capsulatum infection for travellers from nonendemic areas, such as the European Union.3 In Europe, clinical histoplasmosis is commonly caused by endogenous reactivation of latent infection imported from endemic areas, especially in patients who are immunocompromised.3 We describe the case of oropharyngeal histoplasmosis without detectable systemic involvement in a patient who acquired latent histoplasmosis during a stay in Africa more than 20 years before. He developed the disease 1 year after receiving radiation therapy for a malignant condition of the neck.
CASE REPORT From the Travel Clinics and Tropical Disease Unit, Department of Internal Medicine, Infectious Diseases and Tropical Medicine,a and Laboratory of Parasitology,b University Hospital Center. Funding sources: None. Conflicts of interest: None declared. Reprint requests: Khaled Ezzedine, MD, Unite´ de Me´decine tropicale et Pathologie d’importation, Service de Me´decine interne et des Maladies tropicales (Pr. Maı¨te´ Longy-Boursier), Hoˆpital Saint-Andre´eCHU Bordeaux, 1, rue Jean Burguet, F-33 075 Bordeaux cedex, France. E-mail: [email protected]. Published online January 26, 2007. 0190-9622/$32.00 ª 2007 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2006.10.026
A metropolitan 65-year-old French man consulted for a 6-month history of painful oral lesions, associated with hoarseness, dysphagia, and odinophagia followed by an involuntary weight loss of approximately 4 kg. He denied fever or cough. He had experienced, 2 years earlier, laryngeal squamous cell carcinoma condition treated without relapse by partial laryngectomy and local radiotherapy of the neck. He had travelled 30 years before presentation to Cameroon and Ivory Coast for an 8-year professional expatriation stay. During this period, he was given the diagnosis of a Schistosoma haematobium
872 Case reports
J AM ACAD DERMATOL MAY 2007
DISCUSSION
Fig 1. Craterlike ulcerated and necrotic lesion located on back surface of tongue as result of Histoplasma capsulatum.
infection, medically treated and without sequelae. He denied travel outside of France in the last 20 years. Clinical oral examination revealed craterlike ulcerated and necrotic lesions located on the back surface of the tongue (Fig 1), in the hard and soft palate, tonsil pillar, uvula, left and median buccogingival sulcus, and alveolar ridge. The lesions were covered by pseudomembrane and were extremely painful to palpation. No cervical lymphadenopathy was noted. General clinical examination was unremarkable with normal breath sound. An incisional biopsy of the soft palate was performed and specimen sent for histopathologic and microbiologic examination. Analysis displayed acanthomatous epithelium with areas of ulceration, a granulomatous arrangement, and an infiltration by histiocytes of the subepithelial connective tissue with a chronic inflammatory cell infiltrate. Parasitologic examination revealed 3 small intracellular inclusions, which were stained with periodic acideSchiff and Grocott-Gomori, and were consistent with H capsulatumelike yeasts. H capsulatum identity was confirmed after 15 days of culture and examination of the produced filamentous colony patterns. Laryngoscopy and esophageal endoscopy failed to reveal any area of comparable lesion or suggestive presentation for malignancy relapse. Chest radiograph showed no lung alteration and abdomen computed tomography scan showed no evidence of hepatomegaly, splenomegaly or lymphadenopathy. Serologic tests were positive for antiHistoplasma antibodies (one trait at electrocyneresis) and negative for HIV-1/2 antibodies. Induction therapy with oral itraconazole (200 mg/d) was started to complete a 16-week course. The clinical oropharyngeal lesions noted initially completely resolved and the patient gained weight. The treatment was followed by maintenance therapy with oral itraconazole at the same dosage but administered 1 week per month, during 6 months. At that time and 2 years later, no relapse was found.
H capsulatum has been found in areas contaminated with excreta of bats, gregarious birds (eg, chicken coops), attics, caves, abandoned buildings, trees, and roosting areas. Therefore, the fungi may be disturbed for travellers or expatriates by spelunking or mining, various professional activities involving demolishing old buildings, farm work, or sleeping outdoors.4,5 Primary infection with H capsulatum is usually subclinical, mild, or self-limited among patients who are immunocompetent. After inhalation, the fungi are phagocytized by pulmonary macrophages. The disease may be controlled within a low inoculum exposition, the development of an antigen-specific CD41 T lymphocyteemediated cellular immune response with activation of macrophages, although patients who are infected may continue to harbor yeasts for years. When the cell-mediated immunity of the host is impaired, H capsulatum can produce progressive systemic and potentially lethal disease with the spread of the fungi through the reticuloendothelial system, the fungi acting as an opportunistic agent.1,2 T helper-1 response, which generates T celle derived tumor necrosis factor-a (and interferon-g), may play a critical role in inhibiting or eradicating H capsulatum infection over time after a primary exposure, reducing the risk of reactivation.6 In Europe, cases of even disseminated histoplasmosis are typically the result of an endogenous reactivation of a latent infection in both immigrants and travellers.3,7 Patients who are debilitated or immunocompromised with serious systemic illness, undergoing chemotherapy, HIV infected, or elderly are commonly affected by a severe form of the disease.8 Upper aerodigestive involvement has been reported in patients with chronic pulmonary and chronic disseminated forms of histoplasmosis and may be the initial or only manifestation of the disease, particularly among individuals with HIV infection.9 Although rare in patients who are immunocompromised,10 a few cases of mucocutaneous histoplasmosis in patients without detectable systemic involvement have been reported.11 Indeed, if oral lesions have been considered as resulting from hematogenous spread from an unknown infection locus, oral histoplasmosis should be considered as a localized disease, when no systemic sign or symptom can be detected. In our patient, the lesions were restricted to the oral cavity and the pharynx, without pulmonary or other extrapulmonary or systemic manifestations, and underwent recent exposition to local immunosuppression injury for the treatment of a squamous cell carcinoma by operation and radiation therapy.
J AM ACAD DERMATOL
Case reports 873
VOLUME 56, NUMBER 5
Indeed, such condition has been recognized as a risk factor for oropharyngeal mycosis occurrence in a patient who was previously irradiated,12 but to our knowledge this is the first report of orapharyngeal histoplasmosis after exposition to radiotherapy. Concurrently, the biopsy features of the lesions, owing a granulomatous pattern of inflammation and scarce fungi, might argue for a limited involvement and an efficient response of the host.10 The treatment varies according to severity of the disease and immune status of the patient. The dosage and drug combinations along with suppressive maintenance therapy to prevent relapse are variable and are determined for each case. Itraconazole is the treatment of choice for patients who have mild or moderately severe symptoms, and for maintenance therapy.13,14 Finally, clinicians should always be aware of potential harmful drug-drug interactions particularly as the azoles may share the same metabolic route through the cytochrome P450 system.13
CONCLUSION Although the oral lesion of histoplasmosis is more common in individuals who are immunocompromised, it may also affect patients who are immunocompetent or survivors of irradiated head and neck cancer. In travellers or expatriates returning from endemic areas, histoplasmosis must be considered even if cough is not one of the symptoms affecting these patients for an early diagnosis and a prompt and specific treatment. REFERENCES 1. Cano MV, Hajjeh RA. The epidemiology of histoplasmosis: a review. Semin Respir Infect 2001;16:109-18.
2. Woods JP, Heinecke EL, Luecke JW, Maldonado E, Ng JZ, Retallack DM, et al. Pathogenesis of Histoplasma capsulatum. Semin Respir Infect 2001;16:91-101. 3. Manfredi R, Mazzoni A, Nanetti A, Chiodo F. Histoplasmosis capsulati and duboisii in Europe: the impact of the HIV pandemic, travel and immigration. Eur J Epidemiol 1994;10:675-81. 4. Gascon J, Torres JM, Jime´nez M, Mejias T, Trivino L, Gobbi F, et al. Histoplasmosis infection in Spanish travellers to Latin America. Eur J Clin Microbiol Infect Dis 2005;12:839-41. 5. Panackal AA, Hajjeh RA, Cetron MS, Warnock DW. Fungal infections among returning travellers. Clin Infect Dis 2002;35: 1088-95. 6. Jain VV, Evans T, Peterson MW. Reactivation histoplasmosis after treatment with anti-tumor necrosis factor a in a patient from a non-endemic area. Respir Med 2006;100: 1291-5. 7. Desmet P, Vogelaers D, Afschrift M. Progressive disseminated histoplasmosis 10 years after return out of Africa in an immunocompetent host. Acta Clin Belg 2004;59:274-8. 8. Subramanian S, Abraham OC, Rupati P, Zachariah A, Mathews MS, Mathai D. Disseminated histoplasmosis. J Assoc Physicians India 2005;53:185-9. 9. Hernandez SL, Lopez de Blanc AS, Sambuelli RH, Roland H, Cornelli C, Lattanzi V, et al. Oral histoplasmosis associated with HIV infection: a comparative study. J Oral Pathol Med 2004;33:445-50. 10. Alcure ML, Di Hipolito O Jr, Paes de Almeida O, Bouilhah H, Lopes MC. Oral histoplasmosis in an HIV-negative patient. Oral Med Oral Pathol Oral Endod 2006;101:E33-6. 11. Mignogna MD, Fedele S, Lo Russo L, Ruoppo E, Lo Muzio LA. A case of oral localized histoplasmosis in an immunocompetent patient. Eur J Clin Microbiol Infect Dis 2001;20:753-5. 12. Epstein JB, Freilich MM, Le ND. Risk factors for oropharyngeal candidiasis in patients who receive radiation therapy for malignant conditions of the head and neck. Oral Surg Oral Med Oral Pathol 1993;73:169-74. 13. Negroni R, Robles AM, Arechavala A, Taborda A. Itraconazole in human histoplasmosis. Mycoses 1989;32:123-30. 14. Doughan A. Disseminated histoplasmosis: case report and brief review. Travel Med Infect Dis doi:10.1016/j.tmaid. 2006.01.013. Published online April 19, 2006.
Deep cutaneous infection by Fusarium solani in a healthy child: Successful treatment with local heat therapy Yasuhiro Nakamura, MD,a Xuezhu Xu, MD,b Yoshio Saito, MD,a Takeshi Tateishi, MD,b Takenori Takahashi, MD,b Yasuhiro Kawachi, MD,b and Fujio Otsuka, MDb Ibaraki, Japan
From the Departments of Dermatology at Hitachi Ltd, Taga General Hospital,a and Institute of Clinical Medicine, University of Tsukuba.b Funding sources: None. Conflicts of interest: None declared. Reprint requests: Yasuhiro Nakamura, MD, Department of Dermatology, Hitachi Ltd, Taga General Hospital. 2-1-2 Kokubu-cho,
Hitachi, Ibaraki 316-0035, Japan. E-mail: ynakamurta3@yahoo. co.jp. Published online December 12, 2006. 0190-9622/$32.00 ª 2007 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2006.10.960