A human immunodeficiency virus (HIV)-positive male from Cameroon who had recently started antiretroviral therapy presented with a new rash, night sweats and loss of weight. On examination, erythematous to flesh-coloured papules were noted on the trunk (a). Intraoral examination revealed granular-appearing lesions of the hard and soft palate, with areas of pigmentation in keeping with HIV-associated mucosal hyperpigmentation (b). A full blood count showed a pancytopenia, with a moderate neutropenia. He had a severe lymphopenia, and his CD4+ T-cell count was 46 cells/microlitre (µL). Serum (1-3)-β-d-glucan and ferritin levels were markedly elevated at > 500 picograms per millilitre (pg/mL) and 5533 micrograms per litre (µg/L), respectively. Periodic Acid–Schiff with Diastase (PAS-D) and Grocott-Gomori histochemical stains of a skin punch biopsy showed numerous small, round intracytoplasmic organisms within histiocytes, consistent with histoplasmosis (c and d) (see Figure 1). A pan-fungal polymerase chain reaction (PCR) assay confirmed infection with either Histoplasma capsulatum or Emergomyces africanus. This PCR assay cross-reacts with Blastomyces species; however, the yeast phase of this pathogen has a different histological appearance.