Histoplasma Meets Crohnʼs: A Rare Case of New Onset Ascites

Abstract

Learning Objectives: 1) Recognize Crohn's Disease patients on immunosuppressive therapy are at increased risk of serious adverse events. 2) Recognize isolated Histoplasma peritonitis as a rare opportunistic infection in a Crohn's Disease patient on immunosuppressive therapy. 3)Discuss therapeutic options for Crohn's Disease in the setting of opportunistic infections. Case Description: A 53 yo male with history of Crohn's Disease presented to the ER with abdominal pain and fatigue of one month duration. He had associated fever, chills, and 15lb weight loss. He denied any nausea, vomiting, or diarrhea. His Crohn's Disease management was intermittent prednisone tapers and adalimumab. On presentation, vital signs were normal. Labwork was significant for WBC 8.8, ESR 39, CRP 13, and albumin 2.7. A CT Abdomen revealed wall thickening of the terminal ileum and cecum and moderate volume abdominal ascites. A paracentesis revealed yellow, hazy fluid with 6287 nucleated cells (7% neutrophils, 38% monocytes, 55% lymphocytes), total protein 4.5, and albumin 2.2. His serum-ascites albumin gradient was 0.5. Ascitic fluid bacterial culture, AFB smear and cytology were negative. Further labwork revealed a weakly positive urine and serum histoplama antigen. A diagnostic laparoscopy for peritoneal biopsy showed metastatic caking of the omentum and abdominal wall. Peritoneal biopsies revealed Histoplasma peritonitis. Peritoneal fluid was positive for histoplasma capsulatum. No evidence of disseminated Histoplasmosis was found in his lungs, central nervous system, or adrenal glands. Our patient completed two weeks of IV liposomal amphotericin B and was transitioned to oral itraconazole. Adalimumab was stopped and he was started on azathioprine and vedolizumab. With treatment, patient noticed remarkable improvement in abdominal symptoms and fatigue. Discussion: Crohn's Disease patients on immunosuppressive therapy are at risk for opportunistic infections. We present a Crohn's patient with intermittent prednisone use and adalimumab therapy with new onset non portal hypertensive ascites. To our knowledge, this is the first reported case of histoplasma peritonitis associated with immunosuppression in a patient with Crohn's Disease. Our patient was treated with vedolizumab, which has a lower serious infection profile and may be an alternative therapeutic option for Crohn's disease with opportunistic infections.