MANAGEMENT DILEMMA: A RARE CASE OF PULMONARY HISTOPLASMOSIS WITH SARCOID LIKE REACTION

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Co-existence of histoplasmosis with sarcoidosis is an increasingly recognized disease.1 Here we present a 59 years old gentleman who was diagnosed with histoplasmosis on lymph node biopsy. He had an incomplete response to Itraconazole with persistent symptoms and was subsequently required systemic steroids for what looked like a severe sarcoid like reaction. CASE PRESENTATION: 59 years old never smoker Caucasian male with allergic rhinitis and obstructive sleep apnea was evaluated for worsening fatigue, exertional dyspnea, subjective fevers, polyarthralgia, and resolving lower extremity rash of four week duration. He had two dogs at home, with no bird exposure. On admission, his complete blood workup including ESR and CRP were completely unremarkable. Extensive hilar and mediastinal lymphadenopathy on CT scan of his chest led to bronchoscopy and trans-bronchial tissue biopsies. Lung biopsies were negative for any pathology, but lymph node aspiration showed necrotic lymph nodes with necrotizing granulomas. Within granulomas were small fungal elements consistent with histoplasmosis. HIV and syphilis screen were negative, as were anti-nuclear antibodies (ANA) and anti-nuclear cytoplasmic antibodies (ANCA). He was started on itraconazole for histoplasmosis. Cardiac MRI was completely unremarkable. Due to his incomplete recovery on itraconazole and persistent symptoms, alternative diagnosis was sought after and histoplasmosis with sarcoid like reaction/ sarcoidosis was thought of as one of the likely possibilities. After a long discussion involving a multidisciplinary team, the patient was started on steroids and continued itraconazole. He had remarkable subjective improvement with steroids and was able to resume his daily routines. He was continued on itraconazole and steroids and for about one month and plan to continue itraconazole and taper the steroids thereafter. DISCUSSION: Sarcoidosis and histoplasmosis have a striking resemblance in terms of clinical presentation, lab abnormalities, and radiographic findings.2 What made the case more unique and challenging to manage was an inadequate response to standard treatment and the patient’s persistent symptoms. His persistent and eventually worsening symptoms led to additional investigations to rule out disease complications and alternative diagnoses. There have been case reports where the transformation of histoplasmosis to sarcoidosis has been described.3 It was particularly challenging to whether to attribute non-caseating granulomas to natural history of Histoplasma infection or a co-existing separate process like sarcoidosis. CONCLUSIONS: Co-existence of sarcoidosis with Histoplasma infection is now being increasingly recognized. Patients with pulmonary histoplasmosis and incomplete response to standard treatment, coexisting alternative diagnosis and possible coexistence of sarcoidosis should be sought after. Reference #1: 1.Wheat LJ, French ML, Wass JL. Sarcoidlike manifestations of histoplasmosis. Arch Intern Med. 1989;149(11):2421-2426. Reference #2: 2.Mathur P, Zurlo JJ, Crook TJ. The intricate relationship of histoplasmosis and sarcoidosis: a case report. J Med Case Rep. 2014;8:235. Published 2014 Jun 27. doi:10.1186/1752-1947-8-235 Reference #3: 3.Wynbrandt JH, Crouser ED. Transformation of pulmonary histoplasmosis to sarcoidosis: a case report. Respir Med. 2007;101(4):863-864. doi:10.1016/j.rmed.2006.08.01 DISCLOSURES: No relevant relationships by Vincent Chan, source=Web Response No relevant relationships by Adrian Estepa, source=Web Response No relevant relationships by Ahmad Raza, source=Web Response