Histoplasmosis, caused by the dimorphic fungus Histoplasma capsulatum, is a rare disease in immunocompetent individuals, often presenting diagnostic challenges due to its variable manifestations and prolonged incubation period. We report an unusual case of locally advanced soft tissue histoplasmosis in an 80-year-old immunocompetent man with a lobulated cystic lesion between the left scapula and thoracic wall, initially misdiagnosed as scapulothoracic bursitis. Over four years, the lesion progressively enlarged and developed complex features, prompting surgical excision. Histopathological examination with Grocott-Gomori Methenamine Silver and Periodic Acid Schiff staining confirmed intracellular and extracellular Histoplasma yeasts, with fungal PCR corroborating the diagnosis. Systemic examination revealed no disseminated involvement, and blood investigations, including fungal cultures, were negative. Postoperative antifungal therapy with oral Voriconazole, followed by Itraconazole for six weeks, led to clinical resolution. This case highlights the importance of considering histoplasmosis in atypical soft tissue lesions, even in immunocompetent hosts. It underscores the diagnostic value of histopathology and fungal PCR in challenging cases, where imaging and systemic investigations may be inconclusive. Early surgical intervention combined with appropriate antifungal therapy can achieve favorable outcomes in localized histoplasmosis, avoiding progression to disseminated disease.
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