Case Presentation:
A 35‐year‐old woman presented with 1 month of fever and diarrhea. She had been diagnosed with HIV 1 year earlier with a current CD4 count of 22/mm3. She was on no anti‐retroviral therapy. The watery, nonbloody diarrhea occurred 10 or more times/day, associated with a colicky lower abdominal discomfort. Additionally, she reported chills, and soaking night sweats that had begun 1 week after the start of the diarrhea. She had been hospitalized 2 weeks earlier with a similar presentation and diagnosed with gastroenteritis and placed on a course of an unknown antibiotic. Despite this, she reported never returning to her baseline after discharge. Her temperature was 102.2°F with a heart rate of 104 bpm. She presented with dry mucous membranes, oropharyngeal petechiae and ulcers, and axillary lymphadenopalhy. She had significant diffuse abdominal tenderness without guarding or rebound. On evaluation of her labs, she was mildly anemic with an elevated LDH and transaminitis. The abdominal CT‐scan was normal. Stool cultures, a C. difficile toxin, and an acute hepatitis panel were normal. She was initially treated with moxifloxacin and Flagyl for a presumed infectious colitis. After 3 days without improvement, a blood smear was obtained revealing intracellular organisms. A urine histoplasma antigen was positive. Treatment was initiated with AmBisome. Within days, her fever and diarrhea resolved. She was discharged home to complete her course of itraconazole.
Discussion:
With appropriate outpatient management, patients with HIV are living longer. As a result, the hospitalist can expect a corresponding increase in the prevalence of HlV‐releted infections Gastrointestinal manifestations are among the most common features of AIDS and are usually a result of opportunistic infections. Although the list is expansive, the hospitalist should be aware of the most common causes of febrile diarrhea, which, in addition to standard bacterial pathogens and C. difficile, include histoplasmosis, cytomegalovirus, Cryptosporidium, Candida, mycobacterium avium, and Kaposi's sarcoma.
Conclusions:
Disseminated histoplasmosis presents with fever, weight loss, fatigue, skin lesions, oropharyngeal ulcers, nausea, diarrhea, or abdominal pain. Laboratory studies may reveal an elevated alkaline phosphatase level, pancytopenia, and increased ferritin. None of these diagnostic tests are specific for the diagnosis, making the diagnosis contingent on a high degree of clinical suspicion. The H. capsulatum polysaccharide antiger test is sensitive and specific and is most sensitive for urine samples. As was the case in our patient, a Wright stain of the buffy coat may reveal intracellular organisms. Biopsies of lymph nodes, liver, cutaneous lesions, and lungs may be diagnostic. Treatment of severe histoplasmosis requires intravenous amphotericin B. After clinical stabilization, therapy is switched to oral itraconazole for 6‐16 months, with daily maintenance therapy in AIDS patients.
Author Disclosure:
C. Tyson, none; C. Jones, none; H. Hefler, none.