Purpose: Gastrointestinal involvement with histoplasmosis in patients with AIDS is a rare but documented phenomenon. Most patients present with diarrhea, fever, and abdominal pain. We report a patient who presented with lower GIB and perforation. Case report: A 51-year-old Hispanic male with hepatitis C and AIDS on HAART was admitted after having 4 episodes of large volume bright red bleeding per rectum for two days, associated with mild right upper quadrant abdominal pain. He was orthostatic, hypotensive and continued to have persistent bleeding. Fluid resuscitation and blood transfusions were started promptly and the patient was placed on an intravenous proton pump inhibitor as well as octreotide infusion. On colonoscopy, blood was seen but no bleeding site identified. No blood was observed upon terminal ileum intubation. Upper endoscopy showed candida like plaques in the esophagus. The stomach and duodenum showed no varices or stigmata of bleeding. After two days, the patient developed sudden onset vaguely localizing abdominal pain with abdominal distension, which progressively worsened. A CT abdomen showed free air and fluid in the peritoneal cavity. Emergency laparotomy revealed a perforated ulcerated lesion 25 cm distal to the ligament of Treitz with thickening of the proximal jejunum. Small bowel resection with primary stapled anastomoses and peritoneal lavage was done. GMS stain was positive for fungal ulcer. Patient recovered from the surgery well and was discharged uneventfully. Discussion: Although CMV enteritis, Kaposi's sarcoma and lymphomas are more commonly expected small bowel lesions in AIDS patients', other lesions like histoplasmosis can present similarly and clinicians need to maintain a high index of suspicion for these atypical etiologies for GIB and perforation in immunocompromised patients.Figure: Segments of jejunum, showing a central located perforation, nearby serosa with gray exudates and fine granular surface. The mucosa shows a well-circumscribed ulcer 0.5 cm away from the perforation site.