Leonine facies and hoarseness in disseminated histoplasmosis: A diagnostic pitfall

Abstract

A 56-year old immuno-competent male from a non-endemic region in India presented with progressive weight loss, hoarseness of voice and widespread cutaneous lesions, including leonine facies, genital nodules and diffuse scaling. Magnetic resonance imaging of the neck revealed oedematous thickening of the false vocal cords, epiglottis and aryepiglottic folds, suggesting laryngeal involvement. All routine investigations were normal. Urine Histoplasma antigen levels were markedly elevated. Skin biopsy revealed granulomatous inflammation with intracellular yeast-like organisms, and polymerase chain reaction confirmed Histoplasma capsulatum DNA. A diagnosis of disseminated histoplasmosis with probable laryngeal involvement was made. The patient responded well to liposomal amphotericin B followed by itraconazole for 12 months. Although histoplasmosis commonly affects immunocompromised individuals, its rising incidence in immuno-competent patients from non-endemic regions necessitates greater clinical vigilance and emphasises the role of dermatological assessment and targeted fungal testing in systemic mycoses.