African histoplasmosis: the first report of an indigenous case in India.

OBJECTIVES: African histoplasmosis, caused by Histoplasma capsulatum var. duboisii, is an invasive fungal infection endemic in Central and West Africa. Cases seen outside Africa are generally imported. We report a disseminated purely cutaneous form of this infection in an otherwise healthy person from Kerala, in southern India. METHODS: A 59-year-old farmer presented with asymptomatic, generalized, reddish skin lesions of five months in duration. Dermatologic examination revealed multiple erythematous papules and plaques of varying sizes, predominantly over the trunk and upper limbs. The patient was otherwise in good health. Systemic examination including the pulmonary and musculoskeletal systems revealed no abnormalities. RESULTS: Skin biopsy was performed from a lesion on the thigh. Histopathologic examination revealed epithelioid and suppurative granulomas in the upper dermis, with lymphocytes, neutrophils, and plenty of giant cells. Fite-Faraco staining for Mycobacterium leprae was negative. Fungus cultured from the specimen was identified as H. capsulatum var. duboisii, the rarer variant of H. capsulatum. The patient was treated with ketoconazole 200 mg/day for four months and attained complete clearance. No relapse has been detected over two years of follow-up. CONCLUSIONS: To the best of our knowledge, this case represents the first instance of African histoplasmosis to be reported from India. The occurrence of such a rare infection in an immunocompetent individual, who had not travelled elsewhere, raises the possibility of the indigenous existence of H. capsulatum var. duboisii in Kerala. Further studies of the ecology and epidemiology of this rare infection are essential.

Low dose intravenous immunoglobulins and steroids in toxic epidermal necrolysis: a prospective comparative open-labelled study of 36 cases.

BACKGROUND: Toxic epidermal necrolysis (TEN) is a severe adverse drug reaction associated with high mortality. Though different modalities of treatment are advocated, there is no consensus regarding specific therapy. Corticosteroids have shown conflicting results and for high dose intravenous immunoglobulins (IVIG), cost is a limiting factor. AIM: To find out the effectiveness of combination therapy with low-dose IVIG and steroids versus steroids alone in our TEN patients. METHODS: After obtaining Ethical Committee approval, 36 consecutive TEN patients (2008-2012) were alternately allocated to 2 groups - Group A was given combination of low-dose IVIG (0.2-0.5 g/kg) and rapidly tapering course of steroids (intravenous dexamethasone 0.1- 0.3 mg/kg/day tapered in 1-2 weeks) while Group B was given same dose of steroids alone. Outcome parameters assessed were time taken for arrest of disease progression, time taken for re-epithelization, duration of hospital stay and mortality rates. RESULTS: Both groups had 18 patients. Baseline characteristics like age, sex ratio, SCORTEN, body surface area involvement and treatment interval were comparable. Time for arrest of disease progression and for re-epithelization was significantly lowered in Group A (P = 0.0001, P = 0.0009 respectively). Though duration of hospital stay and deaths were less in Group A, difference was not statistically significant. SCORTEN based standardized mortality ratio (SMR) analysis revealed that combination therapy reduced the probability of dying by 82% (SMR = 0.18 ± 0.36) and steroids by 37% (SMR = 0.63 ± 0.71). Difference in SMR was statistically significant (P = 0.00001). No significant side effects due to either modality were found in any of the patients. CONCLUSION: Combination therapy with low-dose IVIG and steroids is more effective in terms of reduced mortality and faster disease resolution when compared to steroids alone in TEN.