Chronic Foot Ulcers in a Patient with Hepatitis C

Abstract

The warty lesions (figure 1) and ulcers (figure 2) were consistent with a chronic, indolent infectious process. Biopsy of the heel ulcer revealed marked verrucuform hyperplasia and occasional microabscesses in the epidermis. The biopsy showed spherules with mixed inflammatory infiltrates and granulomas characteristic of Coccidioides immitis in the dermis (figure 3). Fungal culture of a deep swab of the calcaneal ulcer grew C. immitis. Routine culture grew mixed gram-negative species, including Pseudomonas aeruginosa. Serologic tests showed a highly elevated Coccidioides complement-fixation antibody titer of 1:256. Results of a total coccidioidal IgG EIA were positive. Findings of a chest radiograph were normal. Plain films of the foot showed no bone destruction, but a bone scan of the affected foot revealed uptake consistent with osteomyelitis. The case we report illustrates disseminated coccidioidomycosis in a patient with classic risk factors. He was of Filipino descent, lived for an extended time in the southwest corner of the United States, and worked outdoors. All of these factors, in addition to his sex, increased the risk for the development of active disease caused by this endemic fungus [1]. Coccidiomycosis has also been reported in patients with end-stage liver disease who live in an area where Coccidioides species are endemic [2]. The stage of this patient's liver disease, which resulted from hepatitis C infection, was not known at the time this report was prepared. Despite the localized presentation of his coccidioidal infection, this patient most likely had an initial pulmonary infection with subsequent dissemination. Disseminated coccidioidal infection is thought to result from hematogenous spread from the lungs after inhalation of arthroconidial spores, which can survive in soil [1, 3]. At least two-thirds of primary pulmonary infections are benign and self-limited [3, 4]. A recent, large