Articular Involvement in Disseminated Histoplasmosis in a Kidney Transplant Patient Taking Azathioprine: Figure 1.

Abstract

To the Editor: Histoplasmosis can manifest itself in the joints of immunocompromised patients. It is a potentially fatal opportunistic infection and should be considered when these patients present with unexplained joint swelling, erythema nodosum, or sepsis. An 81-year-old farmer from Minnesota developed acute-onset painful swelling over the ulnar aspect of the right palm. He denied work-related injury or trauma. Hand radiographs did not show evidence of a foreign body. Cephalexin was started for presumed cellulitis, but 4 days later the hand lesion evolved into a localized area of purple discoloration, 3 × 2.5 cm, with central clearing. He developed generalized weakness, myalgias, large-joint arthralgias, worsening hand erythema, productive cough, fever (101.2°F), and hypotension (88/59 mm Hg), and was hospitalized for presumed sepsis. He was treated empirically with vancomycin and ceftriaxone. Physical examination showed a nontender, nonfluctuant, nonindurated ecchymotic lesion on the ulnar aspect of his right hand distal to the hypothenar eminence, with full active and passive range of motion of wrist and fingers and no tenderness along the digital tendon sheaths. There was no synovitis in the metacarpophalangeal, interphalangeal, or radiocarpal joints. His right knee and ankle were warm and swollen with limited range of motion but no erythema. He had a small palatal ulcer. His history was pertinent for hypertension, hyperlipidemia, ischemic cardiomyopathy, gout, and degenerative arthritis of the knees. He underwent a cadaveric kidney transplant in 1982 because of endstage renal disease from chronic interstitial nephritis and was maintained on azathioprine 100 mg and prednisone 5 mg daily with excellent allograft function. Surgical history was pertinent for splenectomy in … Address correspondence to Dr. A. Makol, Mayo Clinic, Division of Rheumatology, Department of Internal Medicine, 200 First St. SW, Rochester, MN 55905, USA. E-mail: makol.ashima{at}mayo.edu