S3050 Obstructive Histoplasmosis Resulting in Recurrent Nausea and Vomiting

Abstract

Introduction: Histoplasmosis is a relatively uncommon invasive fungal infection that occurs via inhalation of microconidia in susceptible hosts. It most commonly affects individuals with HIV/AIDS and other immunocompromised states. Although uncommon, gastrointestinal histoplasmosis can present with bowel obstruction. Here we present a case of histoplasmosis of the proximal jejunum resulting in bowel obstruction in an HIV patient. Case Description/Methods: 37-year-old transgender woman presented to the emergency room for evaluation shortness of breath and weakness over the past few days. Review of systems was positive for intractable nausea and vomiting over the past few months. Her medical history was significant for AIDS and recurrent small bowel obstructions with last known CD4 count of < 50. She also had known histoplasmosis and was receiving treatment on fluconazole. Exam revealed normal vitals with diffuse abdominal pain and severe bilateral cervical adenopathy. A CT scan of the abdomen/pelvis showed dilation of the 1st, 2nd and 4th portions of the duodenum and stomach with a transition point near the ligament of Treitz. An NG tube was placed for decompression and GI was consulted for evaluation. An upper endoscopy with push enteroscopy of the duodenum revealed diffuse erythematous mucosa and a large friable mass in the 4th portion of the duodenum expanding into the jejunum. Pathology report revealed fungal elements consistent with histoplasmosis. She completed 14 days of amphotericin induction therapy followed by Itraconazole. A robotic gastrojejunal bypass was performed to alleviate the obstruction. Discussion: Clinically diagnosed histoplasmosis affecting the GI tract occurs in about 3-12% of disseminated cases. Disseminated cases commonly involve immunosuppressed patients, in whom the lymphoid tissue of the GI tracts is susceptible. Majority of cases that involve the GI tract will involve the terminal ileum or colon and usually manifests as abdominal pain associated with diarrhea. The obstructive symptoms as well location in the distal duodenum/jejunum are uncommon findings. Although there have been reported cases of obstructive histoplasma masses in the GI tract, most involve the colon and very rarely will affect the small bowel. Our case highlights that gastrointestinal histoplasmosis can present as an obstruction and may present at unusual locations. It is important to make the diagnosis early to prevent further complications, such as bowel perforation.Figure 1.: Obstructive Mass in the Fourth Portion of the Duodenum.