FigurePurpose: Disseminated histoplasmosis is a common opportunistic infection in AIDS patients who are severely immunocompromised. Gastrointestinal histoplasmosis (GIH) generally occurs in association with disseminated histoplasmosis or rarely as localized lesions. GIH is defined by radiological or endoscopic findings in conjunction with positive gastrointestinal tissue cultures or histopathologic observation of broad budding yeasts of H. capsulatum in tissue specimens. GIH typically occurs with median CD4 counts of 35 and patients naïve to anti-retroviral therapy. Common clinical features include fever, abdominal pain and diarrhea. Colon is the most frequently affected site (67%) followed by the cecum (17%). Endoscopic findings of GIH are usually multiple ulcers or pseudopolyps; however it can rarely present as a mass or constricting lesion suspicious for malignancy. We describe a case of a 45-year-old white male with history of hemophilia A and AIDS. Patient was admitted to us with a three week history of sharp right lower quadrant abdominal pain and weight loss. Patient had no history of opportunistic infection and was naïve to anti-retroviral therapy. On physical examination, the right lower quadrant was tender to palpation with voluntary guarding. Laboratory examination revealed a CD4 count of 17/μL. A computed tomography (CT) scan of his abdomen showed a non-obstructing cecal mass with an ‘apple-core’ appearance highly suspicious for malignancy (marked by white arrow in Fig. 1). Subsequent colonoscopy showed multiple small ulcers in the cecum, ascending colon and the transverse colon with a three centimeter mass in the cecum (Fig. 2). Histopathology of the ulcers and the mass showed numerous intracellular budding yeasts consistent with H. capsulatum. Patient was started on itraconazole and reported resolution of abdominal pain during an outpatient follow-up after a three week period.[figure1][figure2]Figure
Read full abstract