Abstract
In this case report we describe a case of pulmonary histoplasmosis in a healthy adult female living in Kentucky. The patient presented with two months history of poly-arthralgia and myalgia, intermittent dry cough, chest tightness, exertional dyspnea, malaise, fatigue and one week history of skin rash. She did not respond to broad-spectrum antibiotic therapy and she also had extensive endocrine and rheumatologic work up that was negative. A diagnosis of histoplasmosis was established based on radiological findings as well as endobronchial ultrasound-guided transbronchial needle aspiration cytology (EBUS-TBNA) of mediastinal lymph nodes demonstrating necrotizing granuloma with fungal stains positive for Histoplasma. Patient showed significant clinical improvement on antifungal treatment. Since symptoms of histoplasmosis are often similar to the symptoms of community acquired pneumonia, other lung infections or malignancy, our case highlights the importance of maintaining a high index of suspicion and appropriate radiological, microbiology, and histologic evaluation especially in patients who live in or have traveled to areas endemic for histoplasmosis and are not responding to antibiotic therapy. Early diagnosis coupled with prompt initiation of antifungal treatment may lead to favorable outcomes.
Highlights
Histoplasmosis has worldwide distribution, occurring most commonly in North, Central, and South America, as well as parts of Africa and Asia [1, 2]
We have described a case of pulmonary histoplasmosis in a healthy adult female living in Kentucky who presented with cough, dyspnea, pulmonary nodule and rheumatologic manifestations
It has two distinct pathogenic forms H. capsulatum var. capsulatum which is endemic in eastern United States and Latin America [3], and H. capsulatum var. duboisii which is prevalent in Africa and South East Asia [4]
Summary
Histoplasmosis has worldwide distribution, occurring most commonly in North, Central, and South America, as well as parts of Africa and Asia [1, 2]. Photograph of the rash on both of her lower extremities is shown in (Figure 1) Vital signs during her initial visit to primary care doctor were temperature 97.5o F, heart rate 82 beats per minute, respiratory rate 16 breaths per minute, blood pressure 132/78 mm Hg, ULJRI Vol 2, (2) 2018 and oxygen saturation 98% on room air. PET/CT skull base to mid-thigh was obtained that showed minimal level of metabolic activity at the site of the right lung pulmonary nodule, and hypermetabolic sub-carinal and right para-tracheal lymph nodes (Figure 4). There was superficial and deep perivascular lymphocytic infiltrate, with likely diagnosis of granuloma annulare She was placed on five week course of a low dose oral prednisone taper with some improvement noted in her skin rash and joint symptoms. She tolerated the treatment well and successfully completed her 12-week course of itraconazole for histoplasmosis with significant improvement in her symptoms
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