Case Presentation: Case Presentation:A 64-year-old woman presented with a year of night sweats and a four-month history of thirty-pound weight loss and mental fogginess. She was febrile and hypotensive, appearing thin and weak, with cervical lymphadenopathy.
Prior outpatient workup included EGD showing Barrett’s esophagus, elevated alkaline phosphatase and ferritin, positive HFE gene carrier status, and MRI with mild splenomegaly and moderate bilateral adrenal enlargement.
Hospital imaging revealed pulmonary emboli and a spiculated 8mm lung nodule. Admission labs were notable for WBC 3,500, hematocrit 38%, platelets 106,000, low total protein and albumin, ALT 63 U/L, AST 40 U/L, ALK 149 U/L, and normal bilirubin.
Workup was negative for bacteremia, endocarditis, HIV, hepatitis, EBV, CMV, tuberculosis, and adrenal insufficiency. ANA was 1:80. ANCA screen was negative and bone marrow biopsy did not show malignancy. The lung lesion could not be safely accessed. EGD/EUS with biopsy of porta hepatis lymph node showed no malignancy.
Finally, histoplasma urine antigen returned positive and fungal blood isolators grew Histoplasma capsulatum. She was diagnosed with chronic progressive disseminated histoplasmosis. She had initially denied bat exposure, but after diagnosis recalled seeing bats in her gardening shed in the past.
Discussion: Discussion:
Hospitalists frequently encounter patients with constitutional symptoms and fever. Malignant, infectious, and inflammatory processes are usually considered in these cases, but disseminated fungal infections are often only placed high on the differential in immunosuppressed patients. It is important to know that chronic disseminated histoplasmosis is most often seen in older, non-immunosuppressed patients – as opposed to the acute disseminated form, typically seen in the immunosuppressed.
Histoplasma capsulatum is commonly found in bat and bird feces, and is the most prevalent endemic mycosis in the United States. Severe pulmonary or disseminated infections can occur. Symptoms and signs of chronic disseminated infection include fever, fatigue, weight loss, pancytopenia, hepatosplenomegaly, hepatic enzyme elevation, gastrointestinal tract lesions, adrenal involvement, and skin lesions.
As seen in this case, diagnosis can be delayed while awaiting tests sent out to reference laboratories. Untreated disseminated histoplasmosis is progressive and fatal. Treatment of severe cases is usually amphotericin B followed by itraconazole step-down therapy. At least one year of therapy is preferred.
Conclusions: Conclusions:
The presentation of chronic disseminated histoplasmosis can mimic other disease entities. While immunosuppression is a major risk factor for histoplasmosis, hospitalists should keep the chronic form of the disease in mind, particularly in older patients with constitutional symptoms and seemingly disparate findings.