AN UNUSUAL PRESENTATION OF HISTOPLASMOSIS IN AN IMMUNOCOMPETENT PATIENT

Abstract

SESSION TITLE: Chest Infections 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Histoplasma capsulatum can present as a wide variety of clinical syndromes including disseminated histoplasmosis, pulmonary histoplasmosis in acute, subacute or chronic forms, and mediastinal adenitis, granuloma or fibrosis (1). We report a case of mediastinal granuloma due to histoplasmosis in an immunocompetent patient. CASE PRESENTATION: A 26-year-old female with no significant past medical history presented with five days of sharp pleuritic substernal chest pain associated with intermittent fevers and chills. Upon presentation she had a fever of 103°F and leukocytosis of 18.3 K/μL. A computed tomography scan demonstrated 5.6cm x 2.6cm x 6.2cm partially calcified subcarinal lymphadenopathy and a 6mm calcified right lower lobe granuloma. Her urine Histoplasma antigen was negative. Endobronchial ultrasound with fine needle aspiration of the station 7 lymph node was performed which demonstrated bronchial cells with abundant necrosis and a positive Grocott silver stain with organisms resembling histoplasmosis. Upon further questioning, the patient reported that she had moved from El Salvador five years prior to presentation and that she had significant contact with chickens around her home. The patient was diagnosed with mediastinal granuloma secondary to histoplasmosis and treatment was started with itraconazole as she continued to have chest pain and recurrent fevers. DISCUSSION: Diagnosis and treatment of histoplasmosis is frequently delayed due to its variety of possible clinical presentations and often remote history of fungal exposure. Generally, treatment of Histoplasma granuloma consists of only nonsteroidal anti-inflammatory drugs for symptom management (2). Our patient presented with persistent substernal chest pain localized over an extremely large subcarinal lymph node. This combined with continued systemic signs of infection prompted us to treat her with a twelve-week course of itraconazole for symptom control and to prevent progression of disease. CONCLUSIONS: A high level of clinical suspicion is required to diagnose histoplasmosis infections as it can mimic other diseases and delay treatment. While not all cases of Histoplasma granuloma warrant antifungal treatment, clinical judgment must be used to treat symptoms and prevent further disease complications. Reference #1: Hage CA, Azar MM, Bahr N, et al. Histoplasmosis: Up-to-Date Evidence-Based Approach to Diagnosis and Management. Seminars in Respiratory and Critical Care Medicine. 2015; 36(5):729-45. Reference #2: Wheat LJ, Freifeld AG, Kleiman MB, et al. Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2007; 45(7):807-25. DISCLOSURES: No relevant relationships by Sohi Ashraf, source=Web Response No relevant relationships by Chelsea Kennedy-Snodgrass, source=Web Response No relevant relationships by Sarun Thomas, source=Web Response