Disseminated Histoplasmosis and CMV Colitides Coinfection in AIDS

Abstract

Purpose: The number of immunocompromised patients continues to grow, with improved screening and treatment of HIV, as well as the increasing use of immunosuppressive medications. Such patients are at increased risks for developing GI opportunistic infections. Even though cytomegalovirus (CMV) remains one of the most common opportunistic infection, patients may have coinfections with other rare, opportunistic fungal infections that may be associated with high mortality. We present a rare case of disseminated Histoplasmosis and CMV coinfection in an AIDS patient. A 41-year-old Hispanic male with history of AIDS and recently started on HAART therapy now presents with progressive, persistent diarrhea. He reports between 8-10 non-bloody, watery bowel movements daily, associated with a 20-pounds weight loss, intermittent night sweats, and subjective fevers. On physical exam, the patient had low-grade fever with mild hypotension. He was non-toxic appearing, with evidence of epigastric tenderness with mild voluntary guarding, but no rebound tenderness. On laboratory review, his white count was 3,400, CD4 count of 31, and an alkaline phosphatase of 190, but otherwise normal liver function tests. His blood cultures, stool cultures, ova, parasites, and Clostridium difficile were negative. The patient's abdominal computed tomography showed mild thickening of the small bowel and colon, with moderate mesenteric adenopathy. His upper endoscopy showed severe candidal esophagitis in the entire esophagus, non-erosive gastritis, and duodenitis, with multiple biopsies showing evidence of many yeast organisms present on GMS and PAS stains without evidence of mycobacterium present on AFB stain. His colonoscopy showed severe left-sided colitis with ulcerating, edematous, and erythematous mucosa, with multiple biopsies and viral and fungal cultures positive for histoplasmosis, CMV via PCR, as well as demonstrating aggregates of histiocytes in the lamina propria, granulomas, and chronic active colitis. His serology was consistently positive for histoplasmosis, but negative for giardia, cryptosporidium, cyclospora, and microsporidia. The patient was subsequently treated for combined histoplasmosis, CMV, and esophageal candidiasis with marked symptom and biochemical improvement, and he continues to be on antifungal therapy for one-year for disseminated histoplasmosis. Our case highlights the importance of screening for coinfections in immunocompromised patients involving CMV, but also less frequent opportunistic infections, like histoplasmosis, that can be associated with high mortality.