S2114 Rare Presentation of GI Involvement With Disseminated Histoplasmosis and CMV

Abstract

Introduction: Histoplasmosis is primarily a respiratory disease but can progress to systemic disease in certain populations. Severe disseminated histoplasmosis (DH) can present in immunosuppressed patients as shock and multi-organ system failure. GI histoplasmosis is common in patients with DH, present in about 50-70% of patients however only detected in 3-12%. Co-infection with opportunistic bugs occurs in up to 51% of patients with DH. We present a case of an immunocompromised patient with a history of HIV/AIDS who developed septic and hemorrhagic shock secondary to DH and CMV with GI involvement. Case Description/Methods: Patient was a 40-year-old male with a past medical history of untreated HIV/AIDS and homelessness who was found unresponsive. On presentation, the patient was hemodynamically stable with pertinent labs shown in Table. CT A/P revealed retroperitoneal lymphadenopathy and splenomegaly, and chest x-ray had clear lung fields. Lumbar puncture revealed low glucose and a WBC count of 4. In addition to broad-spectrum antibiotics and acyclovir, amphotericin B was initiated. Clarithromycin and ethambutol were started due to concern for progressive cytopenia secondary to MAC infection. Patient’s status continued to deteriorate, requiring vasopressors. On day 4 of admission, the patient was noted to have hematochezia with a drop in hemoglobin below 7. Endoscopies revealed several lesions that were cultured and biopsied (Image 1). Disease was diffuse and not amenable to endoscopic therapy. The patient was unstable for surgical intervention. Hematochezia persisted, the patient continued to deteriorate despite aggressive supportive therapies. GI pathology had morphology consistent with histoplasmosis in duodenum, cecum, and colon (Image 2), as well as a positive CMV stain in the cecum (Image 3). Urine histoplasmosis antigen was positive. Ultimately, the patient was transitioned to hospice and died shortly after. Discussion: This patient had 2 rare presentations, isolated GI histoplasmosis and co-infection with CMV, which is rarely described, with about 5 case reports written up until 2017. The patient was severely immunocompromised and warranted extensive infectious workup and initiation of broad spectrum antimicrobials. Despite appropriate treatment, the patient’s condition worsened. This case emphasizes the high mortality associated with untreated opportunistic infections as well as the need to recognize rare GI manifestations of those infections in the setting of AIDS. Table 1. - Laboratory results from admission WBC 3.3 ALC 0.00 Hgb 9.4 Platelet 36 CD4 abs. 3 HIV RNA 5,390,000 WBC: White blood cell; ALC: Absolute lymphocyte count; Hgb: hemoglobin Figure 1.: Image 1: Bleeding ulcer with heaped up borders and oozing mucosal lesions Image 2: Small yeast forms. Image 3: Scattered CMV positivity.