January 2012

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History: A 31 year-old African-American male with a history of HIV/AIDS presented to the Barnes-Jewish Hospital emergency department complaining of several days of nausea/vomiting, headache, subjective fevers, chills, and dry cough. Examination of the skin on admission was notable for scattered 3-6 mm dome-shaped papules, some of which were delled, on the neck, trunk, and upper extremities (Figures 1,2).

Past medical history: HIV/AIDS (most recent CD4 count 78), currently on HAART; history of pneumocystis pneumonia and syphilis

Medications: Azithromycin, Bactrim DS, Didanosine, Norvir, Rayataz, Truvada, Tylenol, Senna, Loperamide

Allergies: No known drug allergies.

Physical exam: 3-6 mm dome-shaped papules (some with  umbilication) scattered on the neck, trunk, and upper extremities

Labs: CBC, BMP within normal limits; ESR 49; CD4 count 79; Blood cultures (bacterial) negative x 2; CSF analysis negative for bacteria, viruses, fungi ; direct antigen testing negative for Cryptococcus neoformans, positive for histoplasma antigen at 27.11 ng/mL (considered “highly” positive); blood fungal cultures positive for histoplasma capsulatum.

 

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