Toe ulcers

H capsulatum var capsulatum is rare in France and in Algeria: most infected people have a history of visiting regions of high endemicity (West and Central Africa, the USA, and Central America). Some autochthonous cases have been described in Italy.1 Chronic histoplasmosis is due to reactivation of a latent infection and usually affects patients with prediposing factors such as tuberculosis and immunodeficiency. This patient, whose predisposing factors were age and alcohol-related disease, had a recrudescence due to steroid treatment. Disseminated histoplasmosis can sometimes simulate sarcoidosis or another granulomatous disease, clinically and pathologically delaying diagnosis.2 This case illustrates the importance of screening all patients with unexplained granulomatous disease for rare infective causes, especially patients who may have lived in endemic areas in their distant past. Initially, the yeasts undetected on the gum biopsy done in March, 2000, were clearly identified by an expert. This encourages us to propose the use of special stains, especially methenamine silver stain, when facing sarcoid-like lesions.3 Skin involvement in disseminated H capsulatum infection is unusual, unlike in H duboisii infection whereas mucous lesions are frequent: oropharyngeal, or more rarely anal (especially in immunodeficient patients). Distal skin lesions have seldom been reported in the literature: these lesions are acute ischaemia caused by embolisation because of involvement of the cardiovascular system. Previous case reports have reported infected cardiac valves and aortic aneurysms.4,5