[1, 2] The isolate was identified as Histoplasma capsulatum. The patient was diagnosed Cabozantinib as having progressive disseminated histoplasmosis (PDH), and was treated with oral itraconazole

according to current guidelines.[3] Within 3 weeks all signs and symptoms resolved. On follow up visit, 5 months after treatment was initiated, the patient felt well and had resumed all regular activities. Histoplasma capsulatum is a dimorphic fungus with a wide geographic distribution. It is most prevalent in the Mississippi and Ohio River valleys in the United States and in Central and South America. Histoplasmosis also occurs, albeit less commonly, in Africa, the Indian subcontinent, Southeast Asia,

China, and Australia. In Africa, H capsulatum var. duboisii coexists with the H capsulatum var. capsulatum. Histoplasmosis is acquired through inhalation of the fungus, usually from contaminated soil. The presence of H capsulatum in the soil is strongly linked to the presence of bird and bat guano.[4] There are three clinical FK506 concentration syndromes of histoplasmosis: acute pulmonary histoplasmosis, cavitary pulmonary histoplasmosis, and PDH. The patient described in this case had a disseminated disease, but also pulmonary nodules. We have noted in the past that the distinction between disseminated disease and pulmonary disease is not always clear in returning travelers. Some studies suggest that histoplasmosis occurs predominantly in males.[4] The incidence, however, may be skewed because of association between histoplasmosis and travel, cave exploration, construction, and smoking, all of which were male-dominated activities in the past. Histoplasmosis in the patient was probably acquired in South 3-oxoacyl-(acyl-carrier-protein) reductase America. The most

prominent risk factors for PDH are old age and immunosuppression. Unlike other forms of histoplasmosis, PDH is a multisystem disease characterized by constitutional symptoms and involvement of various organ systems.[5] Skin manifestations associated with histoplasmosis are maculopapular eruptions, petechiae, ecchymosis, erythema multiforme, and erythema nodosum.[6, 7] Such skin manifestations are more common with the South American H capsulatum variants. A study from Brazil suggests this is due to two specific H capsulatum strains typical to Latin America.[8, 9] African histoplasmosis, caused by H capsulatum var. duboisii, is different from “classic” histoplasmosis, and is characterized most commonly by skin and skeletal involvement.[4] The patient had developed splinter hemorrhages during the course of his disease. Splinter hemorrhages are associated with vasculitis, which can be related to infectious and non-infectious diseases, and with certain drugs, trauma, high altitude, and old age.