Medical Case Reports

Description

Histoplasmosis is a systemic fungal disease caused by the fungus H. capsulatum, which is mostly found in bird and bat guano and feces. This condition has multiple manifestations and is more severe in its disseminated form and immunosuppressed patients. If it is not detected early, the patient runs the risk of dying. In endemic regions like South America, the most common AIDS-defining condition is invasive histoplasmosis. When invasive histoplasmosis is mistakenly diagnosed as miliary tuberculosis in non-endemic regions where the diagnosis is less common, there is a high mortality rate. Here, we discuss a case in which invasive histoplasmosis was mistaken for tuberculosis. The diagnosis of histoplasmosis was considered later due to the patient's clinical deterioration and positive Aspergillus galactomannan antigens. This case highlights the significance of taking into account other opportunistic infections when confronted with a culture-negative case of miliary tuberculosis that has not improved clinically despite receiving anti-tuberculosis treatment. In addition, it draws attention to the diagnostic tools for invasive histoplasmosis that are readily available in areas where the disease is not widespread. Immunocompetent patients typically present with an asymptomatic or self-limiting infection, while immunocompromised hosts may present with severe and disseminated histoplasmosis. Hematochezia, fever, and diarrhea had been present for six months in this male patient, 26 years old, who was receiving long-term TNF-alpha inhibitor therapy. He had had ulcerative colitis in the past. When he was admitted, he was febrile and had low blood pressure, and pancytopenia was the initial diagnosis. Pancolitis, pulmonary infiltrates, and enlarged mesenteric lymph nodes were seen on imaging. The patient had disseminated histoplasmosis, according to the findings of the colonic biopsy.

Symptoms in the Brain

A bone marrow biopsy confirmed histoplasmosis and also revealed hemophagocytic lymphohistiocytosis. In the end, the patient received intravenous immunoglobulin, etoposide, corticosteroids, and amphetamine B. Histoplasmosis is benign, self-limiting, and typically affects the lungs. However, it may manifest as a disseminated disease in immunocompromised individuals. Only a few isolated cases of CNS histoplasmosis have been reported in the literature, but about 5–10 percent of cases of disseminated disease involve the CNS. On imaging studies, it typically appears as a single ring-enhancing lesion. It presents with a diverse set of symptoms, ranging from acute, severe infection to progressive, chronic meningitis, making it challenging to obtain the appropriate diagnosis, testing, and treatment. A 57-year-elderly person from the Midwest of the US is the subject of our case. He was misdiagnosed with gliosarcoma in 2019, for which he received appropriate treatment before presenting for follow-up with new neurological symptoms; Ring-enhancing brain lesions were observed to be getting worse on an MRI.

Re-examination of surgical pathological cases led to the identification of histoplasmosis of the CNS. The patient's chances of recovery can be reduced if CNS histoplasmosis is not diagnosed promptly. Histoplasma capsulatum causes the fungal infection known as histoplasmosis. It is believed that the disease is not endemic in Japan. The larger parts of patients who have been determined to have histoplasmosis in the past commonly have made a trip to endemic regions and have been presented to caverns and bat guano. Because this crucial information may be overlooked, travel history and risky activities should be thoroughly evaluated whenever there is a suspicion of histoplasmosis. Local American cases have additionally been proposed, yet in little numbers. In addition, it is anticipated that the recent outbreak of the coronavirus in 2019 has reduced the number of travelers and endemic mycoses. However, clinicians should carefully consider the differential diagnosis of histoplasmosis when treating travelers traveling to endemic areas. An immunocompliant Japanese lady who headed out to an endemic country in the past created histoplasmosis is the subject of this case report. Our case report suggests that physicians should still include histoplasmosis in their differential diagnosis, even in the absence of risk factors like travel-associated activities or immunodeficiencies. An Argentina renal transplant recipient was found to have disseminated histoplasmosis and COVID-19 infection in this instance. In addition to the patient's respiratory symptoms, a chest Computed Tomography (CT) scan revealed multiple bilateral centrilobular opacities in a tree-in-bud pattern in both lobes. After being diagnosed with bacterial community-acquired pneumonia, the patient received initial treatment for tuberculosis. The Histoplasma capsulatum LAmB clade was isolated from oral, skin, and sputum lesions after histoplasmosis was discovered a month later. Intravenous liposomal amphotericin B was given to the patient upon admission to the hospital to begin treatment. The patient's respiratory symptoms worsened during the antifungal treatment, a new chest CT revealed a unilateral lesion that looked like ground glass, and SARS-CoV-2 was found in a new nasopharyngeal sample.

Histoplasmosis Spread Throughout

Plasma treatment was likewise given, and the immunosuppressive routine was changed (everolimus was halted, mycophenolate mofetil was chopped down, and meprednisone was made all the more remarkable). The patient's progress finally improved after five days of oral itraconazole treatment for histoplasmosis, and he was discharged. Disseminated histoplasmosis frequently affects immunocompromised patients, such as those with AIDS, hematologic cancers, transplant recipients, and people who take corticosteroids for an extended period of time. We describe the story of a 53-year-old man who had a kidney transplant in 2013 and had a history of end-stage renal disease brought on by uncontrolled high blood pressure. He presented to the hospital with a history of dyspnea for five days, and blood tests revealed pancytopenia. The diagnosis of disseminated histoplasmosis via peripheral blood smear was made quickly. We urge doctors to perform a peripheral blood smear if they suspect disseminated histoplasmosis. Histoplasmosis is a fungal infection caused by the fungus Histoplasma capsulatum. It can spread through the droppings of birds or bats and is regularly tracked down in few endemic regions in the US. Disseminated histoplasmosis, a serious symptom of the fungus infection, is more common in people who already have immunosuppression. Disseminated histoplasmosis is unusual in our 60-year-old immunocompetent male with a history of significant alcohol abuse that resulted in end-stage liver failure. The patient started getting treatment, and at first, there were some signs that things were getting better; However, despite receiving treatment, his severe histoplasmosis infection continued to deteriorate. The significance of maintaining a high suspicion level even in immune-compromised patients with no apparent risk factors is demonstrated by this case. It likewise exhibits that an incorporated treatment approach requires a brief conclusion in light of a high doubt file. Histoplasmosis-associated hemophagocytic lymphohistiocytosis is a fatal disease with a rate-limiting course in immune-compromised hosts. Atypical clinical presentations further complicate the process of determining whether a patient has an invasive fungal infection. This case examines hemophagocytic lymphohistiocytosis caused by progressive disseminated histoplasmosis presenting as cellulitis in a patient with systemic lupus erythematosus. A high suspicion index, histopathology, and molecular diagnostic techniques are required in immune-compromised patients to accurately and promptly diagnose opportunistic infections. Cytomegalovirus viremia and diffuse lymphadenopathy dominated the initial examinations. Disseminated histoplasmosis and necrotizing lymphadenitis were discovered after a biopsy of an axillary lymph node. He continued to show clinical signs of deterioration despite receiving a lot of antibiotics, which led to the suspicion that he had hemophagocytic lymphohistiocytosis. This case demonstrates that this high-risk patient population can successfully treat and survive acquired hemophagocytic lymphohistiocytosis, despite the high mortality rates and poor clinical outcomes of hemophagocytic lymphohistiocytosis in HIV/AIDS patients. The patient was treated with dexamethasone and etoposide in accordance with the HLH-94 protocol, as she met 5 of the 8 diagnostic criteria from HLH-2004. Our case also shows how important it is to keep a wide range of HIV/AIDS patients with sepsis in the differential.