Histoplasmosis of the tibia.

CASE REPORT A 60-year-old man was referred from his primary care physician in December 1999 with a 2-week history of pain and swelling in his left lower leg. He reported the pain had started suddenly with no recent trauma. He recalled striking his left leg on a metal carriage at work 2 months earlier, but noted there was no laceration of the skin and he developed only minor pain and swelling that resolved after a few days. Physical examination revealed a 4 6-cm erythematous lesion with 2 cm of elevation on the anteromedial aspect of the left lower leg just proximal to the ankle. There were no open lacerations or drainage from the area, and the patient was afebrile. Anteroposterior (AP) and lateral radiographs demonstrated an expansile osteolytic lesion at the junction of the middle and distal thirds of the tibial shaft (Figure 1). A computed tomography (CT) scan showed a 2 4-cm area of bone destruction within the thickened cortex. The CT scan also showed a 2 3-cm soft-tissue mass anterior to and communicating with the bony lesion (Figure 2). The patient had a history of non-Hodgkin’s lymphoma (small follicular lymphocytic type) diagnosed in 1993. He was treated with chemotherapy, which consisted of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) with fludarabine and mitoxantrone, as well as eight courses of rituximab. His therapy was completed in November 1998. He denied any history of increased susceptibility to infection or any respiratory diseases since he finished his chemotherapy and has been otherwise healthy. Surgery was performed on the tibial lesion in December 1999. The cortex was found to have a 6-mm anterior opening with purulent discharge. The cortex was saucerized, and the surrounding tissues were irrigated and debrided. Cultures were taken from the lesion, and vancomycin beads were inserted (Figure 3). The wound edges were loosely reapproximated. Cultures initially were found to be positive for coagulase-negative Staphylococcus and Streptococcus viridans, but fungi also were noted and cultured. An infectious disease specialist was consulted. Postoperatively, the patient was stable and afebrile, and the wound healed with no difficulties. A peripherally inserted central catheter line was inserted and intravenous ceftriaxone was started. He initially ambulated weight bearing with crutches with minimal pain and was quickly able to progress to ambulating with a walker. One month later, the fungal culture report showed H capsulatum, and he was started on 200 mg of oral itraconazole twice daily. Eight weeks after the initial surgery, he underwent a second irrigation and debridement, and the vancomycin beads were removed. The lesion