ATYPICAL PRESENTATION OF HISTOPLASMA INFECTION IN A PREVIOUSLY HEALTHY YOUNG PREGNANT FEMALE

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Symptomatic mediastinal mass presenting in young adults is concerning for neoplasm, especially lymphoma and germ cell tumor. However, diagnostic possibilities are broad and include non-neoplastic etiologies. CASE PRESENTATION: The patient is a 29-year-old woman pregnant at 18+4 weeks with a history of hypertension who presented to the Pulmonary Clinic for evaluation of abnormal chest CT findings. The patient recently returned from Florida and presented to the ED elsewhere for dyspnea. A CXR showed atelectasis bilaterally, LE US was negative for DVT. She was given morphine for chest discomfort and discharged home. A follow up CTA of the chest the next day revealed no PE but notable for a partially calcified, necrotic 6.6 cm subcarinal mass along with bilateral pleural effusions. She was referred to the Pulmonary Clinic for further evaluation. In the Pulmonary Clinic, she described dyspnea with pleuritic chest pain and night sweats. Her travel history was notable for travel to California and Colorado within the last year. She was admitted from clinic to the hospital for expedited workup and symptom management. Initial evaluation was notable for positive Histoplasma serology (1:64 CF titer to yeast phase) and EBUS-guided bronchoscopic needle biopsy of the subcarinal mass yielded Streptococcus anginosus on bacterial culture (felt to be a superimposed infection). Thoracic surgery was consulted and felt surgical intervention was not needed. Infectious Diseases was consulted and recommended treatment with IV vancomycin for two weeks and itraconazole for 6-12 weeks. She was discharged after a 7 day hospitalization. At a one month follow up visit with OB, she was feeling symptomatically improved and her pregnancy was continuing uneventfully. DISCUSSION: Histoplasma is an endemic fungus found in the environment, mainly in the Ohio and Mississippi river valleys and is the most common endemic mycosis diagnosed in the US. Infection with Histoplasma can lead to various syndromes including acute/chronic histoplasmosis, fibrosing mediastinitis, or mediastinal granuloma. Less than 5 % of patients exposed to the Histoplasma species develop symptoms. Milder case can be monitored without antifungal therapy as the disease is self-limiting. Moderate-severe case are treated with itraconazole +/- amphotericin B. Laboratory studies with rodents indicate that itraconazole is embryotoxic and teratogenic; however, clinical studies have not demonstrated this risk. Itraconazole is labeled as a Category C medication by the FDA. CONCLUSIONS: Histoplasma is a common endemic fungus found in the Ohio and Mississippi river valleys that can lead to various pulmonary syndromes including development of mediastinal granuloma. Although symptomatic mediastinal mass presenting in young adults is concerning for neoplasm, mediastinal granuloma can present in a similar manner. Reference #1: Chu J, Feudtner C, Heydon K, Walsh T, Zaoutis T. Hospitalizations for endemic mycoses: a population-based national study. Clin Infect Dis. 2006;42(6):822–825. Reference #2: Wheat L. Diagnosis and management of histoplasmosis. Eur J Clin Microbiol Infect Dis. 1989;8(5):480. Reference #3: Pilmis B, Jullien V, Sobel J, Lecuit M, Lortholary O, Charlier C. Antifungal drugs during pregnancy: an updated review. J Antimicrob Chemother. 2015; 70(1):14–22. DISCLOSURES: No relevant relationships by Jay Ryu, source=Web Response No relevant relationships by Alex Schwegman, source=Web Response