HISTOPLASMOSIS IN PATIENT WITH SARCOIDOSIS

Abstract

SESSION TITLE: Fellows Chest Infections Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: A patient with sarcoidosis presented with persistent shortness of breath after being diagnosed with a virus and suspected sarcoidosis flare He was treated with supportive measures and steroids, but did not improve In a patient receiving immunosuppression to control an autoimmune disease, it is important to have a high suspicion for opportunistic infections CASE PRESENTATION: 51-year-old male with history of sarcoidosis was admitted three times in three weeks with fevers, chills, sweats, non-productive cough, and headaches A computerized tomography (CT) of the chest showed extensive mediastinal/hilar adenopathy and worsening of pre-existing parenchymal lung disease (figure 1) During the first two hospital admissions, the patient tested positive for coronavirus OC43 strain (not COVID-19) and was treated supportively He was also treated with steroids for a possible flare of his sarcoidosis Because of lack of improvement, fungal infection was considered Cultures from bronchoscopy with bronchoalveolar lavage and transbronchial biopsy of the right upper lobe revealed Histoplasma capsulatum (figure 2) Because of persistent headaches, the patient underwent a lumbar puncture which also demonstrated Histoplasma capsulatum in the cerebrospinal fluid He was diagnosed with disseminated histoplasmosis and started on amphotericin B Symptoms resolved and respiratory status returned to baseline He completed about 1 1/2 weeks of amphotericin before being transitioned to itraconazole He completed three months of itraconazole before being switched to posaconazole due to drug intolerances Urine histoplasma antigen was undetectable at 6-month follow-up Immunosuppressive regimen was judiciously decreased to balance controlling his sarcoidosis while limiting risk for reigniting the histoplasmosis and developing future opportunistic infections DISCUSSION: Histoplasmosis is the most prevalent endemic mycosis in the United States, typically found in the soil from bird droppings in the Midwest However, it can be found on the east coast, and patients receiving immunosuppression to control their autoimmune disease are at risk for fungal infections such as histoplasmosis This patient was receiving infliximab, a tumor necrosis factor antagonist that has been associated with histoplasmosis Although discontinuing or at least reducing immunosuppressant agents is standard of care while treating histoplasmosis, it is unclear when to restart them However, a retrospective analysis of 98 cases of histoplasmosis reported that it appears safe to resume immunosuppression, and even tumor necrosis factor antagonist therapy, if antifungal therapy was administered for at least 12 months with an appropriate clinical response CONCLUSIONS: Opportunistic infections must be ruled out in the setting of any immunosuppression, which can further exacerbate the acute illness and vastly increase mortality Reference #1: Kasper DL, Fauci AS, Hauser SL, et al Histoplasmosis Harrison’s Infectious Diseases 3rd Ed 2017;111:996-999 Reference #2: Vergidis P, Avery RK, Wheat LJ, et al Histoplasmosis Complicating Tumor Necrosis Factor-α Blocker Therapy: A Retrospective Analysis of 98 Cases Clinical Infectious Diseases 2015;61(3):409-17 Reference #3: Kobayashi T, Cho C Mediastinal granuloma due to histoplasmosis in a patient on infliximab Cleveland Clinic Journal of Medicine 2019;86(9);579-81 DISCLOSURES: No relevant relationships by Paul Cook, source=Web Response No relevant relationships by Poorvi King, source=Web Response No relevant relationships by Ogugua Obi, source=Web Response No relevant relationships by William Wooten, source=Web Response