An Unusual Case of Esophageal Histoplasmosis

Abstract

Purpose: A 44 year-old African American female with HIV, CD4 count of 8, non-compliant on HAART, presented with dysphagia and odynophagia of two months duration. She also had weight loss of 50 lbs over same period. About six months ago, she was treated for PCP, oral candidiasis and meningitis. At presentation, her vitals were stable. She appeared cachectic without any evidence of oral thrush. The laboratory values revealed WBC count of 5400, hemoglobin of 8.3 and albumin of 2.8. Her chest x-ray did not show any abnormalities. She was empirically started on diflucan and acyclovir for possible candida esophagitis and herpes esophagitis, respectively. EGD showed diffuse deep ulcers with irregular borders with friable mucosa and nodularity involving the entire length of esophagus. Esophageal biopsies were positive for histoplasma capsulatum on Gomori's methenamine-silver and periodic acid-Schiff stains. Her blood, urine and sputum cultures were negative. A urine and serum histoplasma antigen test was negative. She was subsequently started on itraconazole with improvement of dysphagia.FigureDiscussion: Histoplasma capsulatum, a dimorphic fungus, is frequently encountered to cause opportunistic infections in immunocompromized hosts. In AIDS patients with disseminated histoplasmosis, symptomatic gastrointestinal tract involvement has been reported in 3–12% of cases. The most commonly reported sites of infection are colon followed by small bowel. Esophageal involvement with histoplasmosis is very rare, almost always occurring either due to mediastinal adenitis or mediastinal fibrosis. Our patient presented with dysphagia leading to the diagnosis of esophageal histoplasmosis without signs of pulmonary or systemic histoplasmosis. The diagnosis of histoplasmosis requires a high index of suspicion, more so in patients living in endemic areas.[figure1][figure2]Figure