AN UNEXPECTED ETIOLOGY OF RESPIRATORY FAILURE DURING COVID-19 PANDEMIC

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: As a result of the pandemic, anchoring and premature closure on the novel virus as the etiology for a patient's shortness of breath is prevalent. We present an interesting case of concurrent follicular lymphoma and acute disseminated histoplasmosis in a HIV-negative patient that was admitted as COVID-19 pneumonia. CASE PRESENTATION: 83 year old negative HIV status Philippino male with tobacco abuse, recent diagnosis of pulmonary adenocarcinoma and pancreatic mass status post distal pancreatectomy with splenectomy presented with worsening dyspnea and admitted for acute hypoxic respiratory failure with oxygen saturations 79% on room air. He tested positive for COVID-19 six days prior. He was treated as COVID-19 pneumonia with Dexamethasone and Remdesivir. During his hospitalization, the outpatient pathology results from splenic tissue showed grade 3A follicular lymphoma and necrotizing granulomas consistent with Histoplasmosis. He was started on Amphotericin B and transitioned to oral Itraconazole due to acute kidney injury. Management of his pulmonary adenocarcinoma and follicular lymphoma were concomitantly followed up as outpatient oncology with plans to initiate radiation and rituximab. DISCUSSION: Follicular lymphoma and disseminated histoplasmosis are both rare, accounting for about 5% of hematological neoplasms and approximately 0.05% of acute infections, respectively. Patients diagnosed with these two disease states concomitantly are extremely rare. Immunosuppression increases the risk for acute infection and presentations often resemble other common conditions. Pulmonary imaging may be unrevealing in 10-50% of disseminated histoplasmosis cases. Gastrointestinal histoplasmosis is most commonly reported in the small intestine and colon, though can be seen in reticuloendothelial organs such as the spleen. The mortality of untreated disseminated histoplasmosis is 80%, but decreases substantially to 25% when treated. In addition, follicular lymphoma has largely favorable outcomes when treated. Early detection is critical in patients with either of these conditions to reduce morbidity and mortality. CONCLUSIONS: While many patients developed respiratory failure secondary to COVID-19, other etiologies of respiratory failure are still plausible. It is imperative for physicians to develop broad differential diagnoses on admission and reassess those differentials when patients do not respond to standard of care to reduce delay in making the correct diagnosis and reduce exposure to unnecessary treatments. REFERENCE #1: Aggarwal A, Garg S. Isolated Pancreatic Histoplasmosis: An Unusual Suspect of Pancreatic Head Mass in an Immunocompetent Host. Perm J. 2015;19(4):e145-e147. doi:10.7812/tpp/14-238 REFERENCE #2: Carbone A, Roulland S, Gloghini A, Younes A, von Keudell G, Lopez-Guillermo A, Fitzgibbon J. Follicular lymphoma. Nat Rev Dis Primers. 2019 Dec 12;5(1):83. doi: 10.1038/s41572-019-0132-x. PMID: 31831752. REFERENCE #3: Kahi CJ, Wheat LJ, Allen SD, Sarosi GA. Gastrointestinal histoplasmosis. Am J Gastroenterol. 2005 Jan;100(1):220-31. doi: 10.1111/j.1572-0241.2005.40823.x. PMID: 15654803. DISCLOSURES: No relevant relationships by Robert Blessing, source=Web Response No relevant relationships by Alyson Bundy, source=Web Response No relevant relationships by jennifer mundell, source=Web Response