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Chest Infections |

Disseminated Histoplasmosis Presenting as Multiple Ring Enhancing Intracranial Cystic Lesions in an Immune Competent Adult

Christopher Radchenko, MD; Gurpreet Johal, MD; Shais Jallu*, MD; Jason Mohr, MD; Kush Tripathi, MD; Abid Bhat, MD
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University of Missouri Kansas City, Kansas City, MO


Chest. 2012;142(4_MeetingAbstracts):175A. doi:10.1378/chest.1389355
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Abstract

SESSION TYPE: Infectious Disease Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Disseminated histoplasmosis is uncommon in an immune competent adult. We report a case of disseminated histoplasmosis presenting as multiple ring enhancing intracranial cystic lesions in an immune competent adult.

CASE PRESENTATION: A 20-year-old Caucasian male presented with 10 days of high grade fever, headache and altered mental status. Review of systems revealed nausea , vomiting ,chest discomfort and bouts of inappropriate laughter. He had fever (101.5 F),tachycardia (105),tachypanea (27) and oxygen saturation of 96 % on room air. Physical exam was normal other than nuchal rigidity, diffusely brisk deep tendon reflexes and ankle clonus. Initial laboratory work was normal except an elevated WBC count (16900).HIV test was negative. CT head showed multiple lesions with surrounding edema thought to be septic emboli. CSF was consistent with WBC 278, RBC 59, Protein 130, Glucose 43. Necrotic mediastinal and hilar nodes were seen on CT chest. MRI brain revealed innumerable ring enhancing lesions with surrounding edema.Mediastinal lymph node biopsy revealed necrotising granulomas.Serum Histoplasma complement fixation titer was positive( 1:8)with a corresponding positive Histoplasma antibody by immunodiffusion.All other infectious workup was negative. A full immunological workup was normal.Patient was treated with liposomal amphotericin B for 4 weeks.Patient showed signs of clinical and radiological improvement and was discharged home on Iatraconazole . A repeat MRI of the brain at 8 weeks later showed significant improvement of the brain lesions.

DISCUSSION: Disseminated histoplasmosis can occur in immune compromised states and rarely at extremes of age. [1] Only few cases of intracranial histoplasmosis have been reported in immune competent individuals [2] The findings in these cases were consistent with meningitis, focal lesions, stroke and never innumerable cystic lesions.Diagnosis is a challenge,with cases reporting chronic infections diagnosed several years later.[3] This case deserves attention ,for the sake of an exceedingly unusual presentation in a host where such infection is extremely uncommon; perhaps alluding to an underlying process yet to be characterized.

CONCLUSIONS: Diagnosing disseminated Histoplasmosis with unusual presentation can be challenging in an immune competent adult.

1) Goodwin R, Shapiro J, Thurman G, et al. Disseminated histoplasmosis: clinical and pathologic correlations. Medicine (Baltimore) 1980; 50:1-33.

2) Berger J, Greenberg R. Isolated central nervous system histoplasmosis in an immunocompetent patient: 53-month hiatus to diagnosis and treatment. J Neurovirol 2010; 16(6): 472-4.

3) Wheat L, Musial C, Jenny-Avital E. Diagnosis and Management of Central Nervous System Histoplasmosis. Clin Infect Dis 2005; 40(6): 844-52.

DISCLOSURE: The following authors have nothing to disclose: Christopher Radchenko, Gurpreet Johal, Shais Jallu, Jason Mohr, Kush Tripathi, Abid Bhat

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University of Missouri Kansas City, Kansas City, MO

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