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Gursharan Kaur Grover, Sobhana Vallabhaneni, Krishna Baradhi, Supriya Koya
(Department of Medicine, Government Medical College, Amritsar, India)
Med Sci Case Rep 2016; 3:28-31
Histoplasmosis is the most common endemic mycosis in the United States. Most infections are self-limited, but the organism has the ability to cause severe acute pulmonary and disseminated infection, as well as chronic pulmonary and disseminated infection. Disseminated histoplasmosis should be considered early in the evaluation of patients residing in Histoplasma capsulatum endemic areas. Disseminated infection predominantly occurs in immunocompromised populations either due to systemic conditions or when on immune suppressants like infliximab or etanercept. Atypical presentation such as panniculitis or focal myositis may be seen in some patients. Rarely, chronic progressive disseminated histoplasmosis may occur in elderly people with no known underlying co-morbid conditions.
CASE REPORT: A 50-year-old woman presented with a 2-week history of debilitating fatigue, fever and pancytopenia. Routine blood cultures were negative. Peripheral smear to evaluate pancytopenia was characteristic for intracellular inclusions in the white cells suggestive of yeast. Bone marrow biopsy revealed intracellular organisms suspicious for histoplasmosis, and subsequently the diagnosis of disseminated histoplasmosis was confirmed with the identification of Histoplasma antigen and the growth of Histoplasma capsulatum from bone marrow aspirate and blood culture. Amphotericin B was initiated, which resulted in improvement in the clinical condition and laboratory parameters and the patient was then discharged on oral voriconazole after normalization of blood counts.
CONCLUSIONS: Appropriate diagnosis of disseminated histoplasmosis requires a high index of suspicion by the physician, ability to recognize the less common modes of presentation, and a low threshold to order the required diagnostic tests. Initiating the treatment immediately is mandatory, as disseminated infections may be fatal. Antifungal agents are very effective in managing the dissemination but relapse is common in severely immunocompromised individuals who might require lifelong suppression with antifungal agents if the immunity cannot be regained.