Case Presentation: A 49-year-old man with a history of ulcerative colitis presented to the emergency department (ED) with progressive symptoms of fever, myalgias, night sweats, and diffuse abdominal pain. He recently completed a course of ciprofloxacin, metronidazole, and prednisone after developing fever following his infliximab infusion. In ED, his physical exam was unrevealing. Laboratory results were significant for an alkaline phosphatase of 733 U/L, aspartate aminotransferase of 51 U/L, alanine aminotransferase of 66 U/L, and a C-reactive protein of 18.8 mm/hr. Remaining labs were unremarkable. Abdominal computed tomography (CT) showed hepatosplenomegaly with multiple ill-defined splenic masses, prominent periportal and periaortic lymphadenopathy. Chest CT revealed multiple left lower lung and sub-pleural nodules. Gastroenterology then performed a sigmoidoscopy which demonstrated chronic active colitis. At this time, laboratory results were significant for a leukocyte count of 4.49 K/mcL, hemoglobin of 13.4 g/dL, and platelet count of 183 K/mcL. With concern for lymphoma, oncology was consulted and ordered an outpatient PET scan to further evaluate his radiographic findings. Given persistent fevers, infectious disease evaluated with strong suspicion for histoplasmosis considering his immunocompromised state. Empiric itraconazole was initiated resulting in notable clinical improvement. He was discharged with close outpatient follow up. Further testing confirmed disseminated histoplasmosis based on positive antibodies along with urine and blood antigens.
Discussion: This case illustrates the diagnostic challenge of histoplasmosis in individuals with ulcerative colitis, leading to misdiagnosis, improper treatment, and prolonged delays in appropriate care. Disseminated histoplasmosis can commonly present as an ulcerative colitis flare with diffuse abdominal pain, fever, and mucosal ulcerations on endoscopy [1]. With similar presentations of these illnesses, steroids are frequently prescribed instead of the appropriate treatment for histoplasmosis [2]. The risk of invasive fungal infections with corticosteroids is doubled in patients with inflammatory bowel disease on tumor necrosis factor alpha inhibitor therapy making recognition critical [3, 4]. Patients that fit this clinical picture can be tested for histoplasmosis via antigen testing, blood cultures, cytology, and histopathology.
Conclusions: Once the diagnosis is confirmed, treatment can include amphotericin B or itraconazole depending on severity of the disease [5]. For patients with concurrent immunosuppressive therapy, such as tumor necrosis factor alpha inhibitor therapy, it is recommended to stop the medication for at least several months. The decision to re-start tumor necrosis factor alpha inhibitor therapy should be a joint decision between the patient and physician. The immunosuppressive medication can be restarted with close follow up or the patient can remain on life-long maintenance therapy for histoplasmosis [6].