Ulcer over Chin in an Immunocompromised Individual

A 45-year-old human immunodeficiency virus (HIV)-positive male from northeastern India presented with fever and cough as well as a 3-month-old ulcer over the chin. On examination, there was a 5 × 5-cm superficial ulcer with a thick adherent crust over the chin ( Figure 1 ). The individual had three papules with central umbilication over the neck and face. He had anemia (hemoglobin = 7.5 g) and a cluster of differentiation 4 (CD4) count of 89 cells/μL. His chest radiograph and computed tomography (CT) scan of the thorax showed right midand lower-zone consolidation. Histopathology of the umbilicated papule and the ulcer showed numerous yeast forms and a few sausage-shaped structures with central septation within the histiocytes ( Figure 2 ). Fungal tissue cultures from skin lesions and bronchoalveolar lavage aspirates showed a greenish yellow, flat, velvety wrinkled colony with surrounding diffusible red pigment ( Figure 3 ). This was diagnostic of Penicillium marneffei infection. Sputum smears and culture were negative for tuberculosis. Direct immunofluorescence detection for Pneumocystis carinii from sputum sample was negative. Mucocutaneous lesions are seen in two-thirds of patients with Penicillium marneffei infection. These include generalized papular eruptions, central umbilicated papules resembling molluscum contagiosum, acne-like lesions, folliculitis, subcutaneous nodules, necrotic nodules, papules and nodules with ulceration, oropharyngeal papules, palatal perforation, and genital papules. 1