A Case of the Hiccups in the Setting of Colonic Ulcers

Abstract

Question: A 51-year-old seasonal farm worker with the human immunodeficiency virus (HIV; CD4 count, 122 cells/mm3) presented with persistent unexplained diarrhea, fevers, and hiccups. Although he had no pulmonary symptoms, the admission chest radiograph revealed bilateral miliary nodular opacities that were concerning for granulomatous processes including tuberculosis and fungal disease (Figure A). Sputum analysis and subsequently bronchoscopy with extensive brushing revealed no evidence of acid-fast bacilli. He was anemic with a hemoglobin of 8.4 g/dL and his albumin level was decreased at 2.8 g/dL. Blood, stool, and urine cultures to evaluate his recurrent fevers were also noncontributory; thus, more extensive imaging was obtained. Abdominal CT demonstrated bowel thickening of the right hemicolon and proximal transverse colon as well as adjacent inflammatory changes (Figure B). Subsequent colonoscopy revealed multiple, small ulcers (Figure C). Biopsy of the ulcer edges was performed and histology is presented in Figure D–G. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. On pathologic examination (Figure D–G) spherules were seen on Grocott's methenamine silver stain consistent with the fungus Coccidioides immitis. Serum coccidioides titer via complement fixation was significantly elevated at 1:64. He was started on fluconazole and his symptoms promptly abated. Disseminated coccidioidomycosis rarely presents with gastrointestinal symptoms.1Adam R.D. Elliott S.P. Taljanovic M.S. The spectrum and presentation of disseminated coccidioidomycosis.Am J Med. 2009; 122: 770-777Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar Diarrhea illness is even more unusual; those with gastrointestinal manifestations almost always present with peritonitis.2Smith G. Hoover S. Sobonya R. et al.Abdominal and pelvic coccidioidomycosis.Am J Med Sci. 2011; 341: 308-311Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar It is postulated that an immune response mediated by intrinsic CD-8 T cells, natural killer T cells, and pre-mast cells in the lamina propria protects the hollow luminal organs of the gastrointestinal tract from fungal pathogens. Given the nonspecific presentation, a high index of suspicion is critical to obtain the appropriate histologic stains and serologic tests. Given its rarity the sensitivity of stool studies for coccidioidomycosis is unknown, but is likely poor based on its performance in other fungal gastrointestinal infections in HIV-positive patients.3Cello J.P. Day L.W. Idiopathic AIDS enteropathy and treatment of gastrointestinal opportunistic pathogens.Gastroenterology. 2009; 136: 1952-1965Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar The patient’s history of HIV and vocation as a seasonal farm labor in California’s San Joaquin Valley prompted the appropriate evaluation.