Histoplasmos in HIV infection patient. Case study

Abstract

The article presents a case of the development of histoplasmosis in an HIV-infected patient, describes the possibilities of diagnosis and treatment. The causative agent of the disease is Histoplasma capsulatum (dimorphic fungi). Reduced immunity significantly increases the risk of histoplasm infection. Generalized histoplasmosis occurs in HIV-infected patients. Diagnosis of histoplasmosis is very difficult, especially in areas that are not endemic. To confirm the diagnosis, the pathogen is isolated from sputum, scrapings of the oral mucosa, blood, punctate abscesses of the lymph nodes, liver, spleen, bone marrow, smear microscopy, and culture of the fungus.Patient A., born in 1975, went to the doctor with complaints of fever, cough, weakness. On CT Scan of the chest from 12.07.2017, infiltrative focal changes were not detected, mediastinal lymph nodes 3—7 mm. Ultrasound examination of the abdominal cavity: enlarged lymph nodes are determined to 13—15 mm. The CD4 level is 2.5 % 10 cells/μl blood. 13.07.2017, diagnosed: first diagnosed pulmonary and mesenteric lymphatic tuberculosis, Destr.(–), MBT0. Treatment prescribed according to the regimen: isoniazid, rifampicin, ethambutol, pyrazinamide. During treatment, the temperature returned to normal, the condition improved, and on October 23, 2017, the CD4 level was 10 % 197 cells/μl. From 10.10.2017, she receives ART drugs: dolutegravir, emtricitabine, tenofovir. In January, a significant decrease in the mesenteric lymph nodes was observed on ultrasound. 03/27/2018, the patient suddenly had a telado temperature of 39.0 °C, cough, chills. On a radiograph of the chest on April 13, 2018, focal infiltration changes in S1,2 of the right lung, paratracheal lymph nodes measuring 39 × 28 mm, bifurcation — 15 × 8 mm were revealed. The process in the lungs was regarded as tuberculosis of the intrathoracic lymph nodes and lungs. In the sputum Mycobacterium tuberculosis (smear, GeneXpert and culture) were not determined. Treatment: isoniazid, rifampicin, ethambutol, pyrazinamide, levofloxacin and kanamycin. During therapy, the patient's condition worsened. X-ray 7.06.2018: the left lung is transparent. On the right in the upper, middle and lower lobes of the lung S6,9 polymorphic dissemination is noted, in the lower and middle lobes — areas of consolidation. On the right paratracheal lymph nodes up to 45 mm, bronchopulmonary — up to 15 mm. In order to clarify the diagnosis, a thoracoscopy was performed with a biopsy of lung tissue and lymph nodes. Histologically — histoplasmosis of the lungs and lymph nodes. Received itraconazole. After a month of treatment: the temperature is normal, on the radiograph —- a positive dynamics of the process (resorption of focal infiltration changes). For patient was recommended to continue taking itraconazole 200 mg twice a day for 12 months.Сonclusions. In the absence of the effect of anti-tuberculosis therapy in an HIV-infected patient and the absence of bacteria excretion, it is necessary to take into account possible mycotic damage to the lymphatic system and lungs.