Associates' Presentations
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The Fungus Among Us: Disseminated Histoplasmosis (DH) in an Immunocompetent Host
K. Bruce, N. Safdar, C. Seibert, University of Wisconsin Medical School, Madison, WI
Learning objectives: 1) Identify common features of DH, and 2) Recognize that DH can occur in immunocompetent hosts. Case: a 31 yo previously healthy man was transferred to a general medicine service with 10 days of severe generalized headache, high-grade fever and bilateral pulmonary infiltrates. Previous work-up included normal LP, normal head CT and negative HIV tests. He has been treated for 5 days with doxycycline and ceftriaxone without improvement. On exam, temp was 39.5C. Scleral icterus was present. Lung CV and neurologic exams were unremarkable. Hepatosplenomegaly was present. Labs revealed WBC 4.4, hct 36, t.billi 3.4, AST 126, ALT 152. CXR showed diffuse small nodular pulmonary infiltrates. H. Capsulatum urinary antigen was strongly positive. Bone marrow biopsy showed histoplasma and non-caseating granulomas.
The patient was diagnosed with DH and started on Amphotericin B. He defervesced on Day 2 of therapy. All symptoms and lab abnormalities resolved. He was discharged on home IV AmphoB for a total of 3 weeks, followed by oral itraconazole.
Discussion: Histoplasmosis is caused by the divorphic fungi H. Capsalatum and is endemic in the Mississippi River Valley. The fungal spores are inhaled and hematogenous spread can occur. Though unusual, DH can occur in immunocompetent hosts. DH usually presents as fever, headache and pulmonary symptoms. Leukopenia, anemia and hepatitis are common. H. Capsalatum urinary antigen is positive in 90% of cases. Mortality without treatment is 80%. Ampho B is the treatment of choice.
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