Unusual Presentation of Disseminated Histoplasmosis

Abstract

Histoplasma capsulatum is the most common endemic mycosis in the United States and in rare cases, it could progress to disseminated histoplasmosis in immunocompromised patients. Hepatic manifestations as the primary presenting symptom are uncommon. Fever is the most common symptom in disseminated histoplasmosis, and gastrointestinal symptoms have been reported to be rare, which makes it a diagnostic challenge. We present a 61-year-old female with past medical history of rheumatoid arthritis who had been treated with Plaquenil in the past, presented with abdominal pain, jaundice, fever, chills and poor appetite. Vitals were remarkable for blood pressure of 129/63 mmhg, pulse of 111 beats per minute, temperature of 102.2 °F (oral), respiratory rate of 19 breaths per minute. Physical examination was remarkable for sclera icterus, right upper quadrant abdominal tenderness and jaundice. Her LFTs peaked at AST of 449 U/L, ALT of 745 U/L, ALP of 1045 U/L, total bilirubin of 11.6 mg/dL with direct bilirubin of 2.4 mg/dL, and GGT of 620 U/L. Negative work up included HAV, HBV, HCV, ANA, AMA, ASMA, ANCA, LKM, CMV IgM, EBV IgM, and HIV. APAP, Salicylate, CA 19-9 and CEA levels were within normal range. Abdominal ultrasound was unremarkable. CT and MRI abdomen were remarkable for mild splenomegaly. Patient was started on Vancomycin and Zosyn due to her septic picture, but symptoms did not improve. After few days blood cultures started growing Histoplasmosis Capsulatum, the histoplasma antigen was positive as well. Patient was started on Amophotericin B and Voriconazole and discharged home on Itraconzaole. Follow up appointment 2 months later showed improved LFTs and significant improvement in symptoms, with resolution of her jaundice. Disseminated histoplasmosis in our patient presented with hepatocellular jaundice and was diagnosed with acute hepatitis. Early diagnosis of disseminated histoplasmosis should be made by histoplasma antigen detection in urine and serum. In severe cases, Amphotericin B should be used initially and then it could be switched to Itraconazole due to the more desirable side effect profile. Once symptoms resolve and antigen levels return to normal, treatment can be discontinued. Prospective studies are needed to accurately assess the risk of fungal infections presenting like hepatitis in immunocompromised patients. Hence, clinicians should have a high index of suspicion for disseminated histoplasmosis in immunocompromised patients.