Chest Infections: Fellow Case Report Poster - Chest Infections I |

Disseminated Histoplasmosis in an Immunocompetent Host FREE TO VIEW

April McDonald, MD; Kiran Joglekar, MD; Amik Sodhi, MD; Dipen Kadaria, MD
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University of Tennessee Health Science Center, Memphis, TN

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):121A. doi:10.1016/j.chest.2016.08.130
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SESSION TITLE: Fellow Case Report Poster - Chest Infections I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Histoplasmosis is the most common endemic mycosis in the United States with higher prevalence in states along the Ohio and Mississippi River valleys. Approximately 500,000 new infections occur each year though clinically significant disease rarely manifests.1 Even more unusual is symptomatic disease in a host with intact cell-mediated immunity. We present a case of disseminated histoplasmosis in an immunocompetent host.

CASE PRESENTATION: A 44-year-old man presented with several weeks of malaise, weakness, lymphadenopathy, and fevers. He endorsed a 60-lb weight loss over the past year that he attributed to poor oral intake due to a large tongue ulceration that he thought he incurred after biting his tongue during a seizure. Past medical history included seizure disorder and remote history of skin squamous cell carcinoma on the lower abdomen status post wide excision. Interestingly, he had an inguinal lymph node excision at that time that was remarkable for non-caseating granulomatous inflammation. The patient was found to be septic thus started on broad-spectrum antibiotics. CT neck, chest, and abdomen were performed demonstrating development of extensive small cysts with associated consolidation. Diffuse lymphadenopathy was also noted suggesting the presence of a reactive process. Immunosuppression workup was negative. Within 12 hours of presentation, he experienced acute respiratory failure requiring endotracheal intubation. Fiberoptic bronchoscopy with brocheoalveolar lavage (BAL) was performed. Over the next 24-hrs the patient continued to deteriorate requiring escalating vasopressor support. He eventually went into pulseless electrical activity arrest and 36-hrs after presenting to the hospital, died. Pathology from BAL returned demonstrating histoplasmosis.

DISCUSSION: Histoplasmosis is a reportedly rare symptomatic disease in the immunocompetent host; disseminated disease is even more elusive. Often in this patient population it is not included in the differential as more common entities like bacterial pneumonia are presumed. However, without early bronchoscopy, this patient’s actual diagnosis would have been missed.

CONCLUSIONS: Disseminated histoplasmosis is a rare disease in the immunocompetent host. A high index of suspicion in endemic areas along with early bronchoscopy when pulmonary involvement is present is necessary for diagnosis to avoid potentially fatal outcomes through treatment delays.

Reference #1: Kauffman CA. Histoplasmosis: a clinical and laboratory update. Clin Microbiol Rev. 2007;20(1):115

DISCLOSURE: The following authors have nothing to disclose: April McDonald, Kiran Joglekar, Amik Sodhi, Dipen Kadaria

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