FATAL CAVITARY PULMONARY HISTOPLASMA CAPSULATUM IN AN ELDERLY IMMUNOCOMPETENT PATIENT

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Histoplasma Capsulatum (HC) infection can present with various manifestations, such as acute pulmonary infection, chronic cavitary lung disease, fibrosing or granulomatous mediastinitis and disseminated mycotic infection. Histoplasmosis is typically more serious in immunosuppressed patients. Disease is usually self-limited or subclinical in immunocompetent patients. Clinical presentation and prognosis of HC infection is variable. We hereby present a rare case which was fatal to an elderly immunocompetent host from an endemic area. CASE PRESENTATION: A 77-year-old Caucasian, long standing Ohio resident male, with past medical history significant for heavy tobacco and alcohol use, and hepatic cirrhosis, presented to the pulmonary clinic for follow up after numerous outside hospital admissions for pneumonia. Patient served in Vietnam, however he was not aware of previous tuberculosis infection or exposure. He had been treated with prolonged antibiotics course for suspected Acinetobacter infection. However, he subsequently presented with worsening dyspnea, fatigue, loss of appetite, and 80lb unintentional weight loss within a one-year period. CT chest revealed a large progressive left upper lobe necrotic cavitary lesion, diffuse bronchiectasis, tree-in-bud inflammatory pneumonitis, a new 1.7cm right middle lobe solitary pulmonary nodule and bilateral cavitary lesions. Initial concern was for invasive Aspergillus superimposed on past Acintetobacter baummanii infection. Bronchoalveolar lavage (BAL) from six months prior during one of his previous admissions was neutrophilic but negative for tuberculosis, fungi and malignancy. Repeat bronchoscopy with BAL of the left upper lobe was performed. HC was confirmed by DNA probe identification on the BAL growth. Immunodiffusion serological testing was positive for both H and M bands of HC. Histoplasma antibody complement fixation was positive (1:256) that suggested acute infection. HC urine antigen was also detected. These reflect advanced disease course. Unfortunately, patient died prior to initiation of treatment. DISCUSSION: Clinical presentation of HC is thought to be dependent on duration of exposure and host response. In this case, the prolonged clinical presentation suggests significant dormant progressive histoplasma disease in an immunocompetent host. Despite negative initial testing, patient subsequently tested positive HC. Unfortunately, this patient died prior to initiation of antifungal treatment. CONCLUSIONS: In conclusion, this case highlights the significance of assessing for cavitary HC infection even in immunocompetent older patients. Reference #1: Evrard S, Caprasse P, Gavage P, Vasbien M, Radermacher J, Hayette MP, et al. Disseminated histoplasmosis: case report and review of the literature. Acta Clin Belg. 2018;73(5):356-63. Reference #2: Staffolani S, Buonfrate D, Angheben A, Gobbi F, Giorli G, Guerriero M, et al. Acute histoplasmosis in immunocompetent travelers: a systematic review of literature. BMC Infect Dis. 2018;18(1):673 DISCLOSURES: No relevant relationships by Batool Abuhalimeh, source=Web Response No relevant relationships by Randall Harris, source=Web Response No relevant relationships by Tanya Marshall, source=Web Response No relevant relationships by Rami Sabri, source=Web Response