An Epidemic of Erythema Multiforme and Erythema Nodosum Caused by Histoplasmosis

Abstract

An epidemic of 42 cases of erythema multiforme and erythema nodosum occurred in Greenwood, South Carolina over a 17-month period from Jan. 1962 to May 1963. Significant findings were the characteristic skin lesions, arthralgia, fever, and pulmonary infiltrates. All cases were white, predominantly females of middle age, whose residences tended to be in northwest Greenwood. The evidence for histoplasmosis included a positive scalene node biopsy, positive skin tests in 95%, positive complement fixation titers in 89%, and isolation of H. capsulatum from 3 starling roosts in Greenwood. Although South Carolina is considered to have a low histoplasmin skin test rate (2%), 39% of Greenwood high school students were positive. Localization of skin test rates by place of residence indicated a marked concentration of positive akin tests near a newly constructed golf course. It is postulated that this golf course was the source of a widespread airborne dissemination of histoplasmosis spores causing several thousands of skin test conversions and the epidemic of erythema multiforme and erythema nodosum. This is only the 2nd report of erythema multiforme due to primary histoplasmosis. Since erythema multiforme is known to be associated with a wide variety of other conditions and is presumably only rarely a manifestation of histoplasmosis, it is likely that few epidemics of histoplasmosis have been large enough to allow recognition of the occasional association of erythema multiforme with primary histoplasmosis.