Histoplasmosis After Liver Transplantation—a Skate on Thin Ice if Left Undiagnosed

Abstract

Histoplasma capsulatum, a dimorphic fungus often, is asymptomatic in the immunocompetent but can cause life threatening infection in immunocompromised patients. It is uncommon in the solid organ transplant recipients with an incidence of < 1%, majority occurring within 2 years of transplantation. It can be either endogenous reactivation of latent infection, de novo acquisition, or donor-derived infection. Disseminated infection is common, with non-specific symptoms, fever being the commonest. None of the available tests is 100% accurate. Modification of immunosuppression and anti-fungal can achieve 90% success rate. We report a liver transplant recipient, 3 months post-transplantation on everolimus, prednisolone, mycophenolate, and tacrolimus who had isolated hepatic histoplasmosis and responded to treatment. Liver biopsy revealed epithelioid granulomas with narrow-based budding yeast, suggesting histoplasma. Contrast CT abdomen revealed normal attenuation of graft liver few small non-enhancing hypodense lesions seen scattered in both lobes. And this patient was managed with just reduction of immunosuppressive doses as the patient was having renal dysfunction; starting itraconazole will lead to further deterioration in the clinical course and also interact with calcineurin inhibitors and mycophenolate mofetil.