18 Jun 2021

1/4/21: Disseminated Histoplasmosis

Happy New Year!

For the first morning report of 2021, PGY2 Matthew Phillips presented a case of a 39 y/o M with history of HIV, Syphilis and Hepatitis B presents with 2 months of rectal discharge and 1 week of multiple skin abscesses.  He states the symptoms started 2 months ago when he began having rectal discomfort and a pressure like sensation along with malodourous, mucoid, white discharge from the rectum.  He also reports developing abscesses in his bilateral axilla and on the R leg.  Denies any recent trauma.  No home medications and social history significant for being born in Guatemala, intermittently homeless, previous methamphetamine/alcohol use (last used 2 months ago) and has unprotected, anal receptive sex.

Vitals: T 39.4, HR 126, RR 20, BP 105/67, O2 sat 100% on RA

Physical Exam significant for marked lymphadenopathy on bilateral axilla, L>R, LNs are large, rubbery, mobile and tender to palpation, normal cardiac and pulmonary exam, abdominal exam significant for hepatosplenomegaly, nontender, +rectal discharge, posterior perirectal ulcer with skin breakdown, L inguinal lymphadenopathy, not tender to palpation and skin with abscesses on bilateral axilla and R shin with some overlying erythema.

CBC: WBC 1.8> Hb 8.8/Hct 26.8 <Plt 161 (MCV 75.4, RDW 18%)

CMP:

Na 121/K 4.4/Cl 92/HCO3 20/BUN 13/Cr 0.82<Glucose 96

ALP 203>T.protein 6.9/Albumin 1.7/AST 30/ALT 14/Tbili 0.3/Dbili <0.2

Ca 7, Mg 2.0, Phos 3.9

Coags: PT 16.4, INR 1.34

Infectious workup initiated, with the following findings:

  • BCx negative, UA negative
  • HIV positive with viral load at 3 million copies
  • CD4: 58
  • AFB smear negative x3, MTB PCR negative x2 and QuantiFERON gold negative
  • Fungal culture positive for Histoplasma capsulatum
  • RPR reactive at 1:8 (prior elevated at 1:32)
  • GC/CT urine negative
  • C. trachomatis anal swab positive
  • Toxo Ab negative
  • PCP DFA negative
  • Stool studies negative including O&P, C. diff
  • Viral:
    • CMV Ab IgG elevated >10, IgM <30
    • CMV PCR detected
    • EBV Ab IgG >750, IgM <36
    • HSV negative
  • Fungal:
    • Crypto Ag negative
    • Cocci Ab: 1:4
    • Blasto Ab negative
    • Histo Urine negative x2
    • Histo Serum Positive

Heme workup initiated, with the following findings:

  • Iron studies significant for a combination of iron deficiency anemia and anemia of chronic disease
  • LDH elevated at 253 U/L
  • SPEP/UPEP shows polyclonal gammopathy
  • LN Core biopsy done which showed scant lymphoid tissue

CXR shows mediastinal nodal disease particularly in the R paratracheal region and L hilum.  Patchy pulmonary opacities are noted diffusely.

CT Chest/Abdomen/Pelvis shows enlarged lymph nodes within the chest, rectosigmoid wall thickening, diffuse multi-station abdominopelvic and retroperitoneal lymphadenopathy and splenomegaly.

Treatment: Patient started on amphotericin B and ganciclovir and doxycycline to treat both disseminated histoplasmosis, presumed CMV colitis and LGV.  He was discharged on itraconazole, valgancilovir and biktarvy.

Teaching points:

  1. Histoplasmosis is found near rivers, particularly in the Mississippi River Valley and Southern Mexico.
  2. Clinical symptoms include fever, hepatosplenomegaly, lymphadenopathy, GI symptoms, skin lesions, pancytopenia and elevated ALP.
  3. Diagnosis is made by culture via blood/bone marrow/BAL/skin lesions, Ag detection via urine/blood/CSF or Ab vis complement fixation or immunodiffusion.
  4. Treatment: Amphotericin B qday x4-6 weeks or amphotericin B qday x2-4 weeks followed by itraconazole BID to complete 3 months of therapy.  Lifelong suppressive therapy with itraconazole may be required in immunosuppressed patients.  Ag levels should be monitored during therapy and for 12 months after therapy has ended to monitor for relapse.

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