SESSION TYPE: Infectious Disease Student/Resident Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Disseminated histoplasmosis can rarely be found in patients without known underlying immunodeficiency.
CASE PRESENTATION: 58 year-old woman presented for evaluation of progressive dyspnea with non-productive cough and generalized weakness for eight months. She also reported intermittent fever, pleuritic chest pain, dysphagia, and easy bruisability. Her past medical history was unremarkable. She was not taking immunosuppressive medications. She did not have sick contacts nor did she have outdoor activities such as camping or travelled recently. At presentation, she was febrile, tachycardic, tachypneic, and hypotensive. She had diffuse crackles on lung auscultation. Initial laboratory tests showed hemoglobin of 9.1 g/dL, platelet count of 82 x 10^9/L, and WBC count of 3.9 x10^9 /L with 4% lymphocytes and CD4 count of 78. High resolution chest CT revealed bilateral nodular and ground-glass peribronchiolar infiltrates, cavitary lesion in left upper lobe, hilar and mediastinal adenopathy. She was admitted and empiric antibacterial therapy was initiated. Viral serology for HIV, EBV, and Influenza, RSV and Parvovirus PCR, urine Legionella antigens, Mycobacterium TB QuantiFERON were negative. Fungal serology was positive for histoplasma. The patient’s hypoxic respiratory failure worsened and required intubation. Bronchoscopy with bronchoalveolar lavage was negative for malignancy, but positive for both Histoplasma and Pneumocystis by PCR. Blood cultures grew Histoplasma capsulatum. Urine histoplasma antigen was detected at high levels. Bone marrow biopsy was performed and extensive involvement by histoplasma was determined to be the cause of her pancytopenia. Antimicrobial therapy was changed to amphotericin B and sulfamethoxazole/trimethoprim along with methylprednisolone for treatment of disseminated histoplasmosis and Pneumocystis pneumonia. She improved significantly shortly after initiation of appropriate treatment. She tolerated extubation and ultimately was discharged from the hospital in good condition.
DISCUSSION: The presented patient did not have history of immunosuppression. She underwent extensive negative evaluation by immunologists for underlying immunosuppressive disorders such as cellular or humoral immunodeficiencies. Nevertheless, she developed severe disseminated histoplasmosis with bone-marrow involvement. This caused pancytopenia with a low CD4 count which ultimately predisposed her to pneumocystis infection. This case is an example of disseminated histoplasmosis with subsequent co-infections in apparently immunocompetent host.
CONCLUSIONS: Histoplasmosis should be in the differential diagnosis when a patient presents with pulmonary infiltrates, adenopathy, cytopenia, even when he/she is not from the Mississippi and Ohio River valleys.
1) Disseminated histoplasmosis: clinical and pathologic correlations. Goodwin RA Jr, Shapiro JL, Thurman GH, Thurman SS, Des Prez RM. Medicine (Baltimore). 1980;59(1):1
DISCLOSURE: The following authors have nothing to disclose: Benyam Addissie, Joseph Skalski
No Product/Research Disclosure InformationMayo Clinic, Rochester, MN