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A 44-year- old man presented with dry cough, diffuse joint pain, fevers, and night sweats for one month and poor appetite and weight loss for three months. Physical examination showed hepatosplenomegaly. A chest computed tomogram (Panel A and B) showed diffuse miliary nodules. Sputum for acid fast bacilli was negative. Testing for HIV-1 was positive with a high viral load and a low CD4 count of 4/µL. Bronchoscopy with bronchoalveolar lavage was performed. Gomori methenamine-silver stain of the bronchoalveolar lavage specimen showed intracellular yeasts within macrophages with narrow-based budding (Panel C).
Figure 1Figure 1 A an B. Computed chest tomogram showing diffuse miliary nodules, and C. Intracellular yeastswithin macropahges with narrow-based budding on Gomori methanamine-silver stain of bronchoalveolar lavage.
Together with the clinical presentation, findings on imaging studies and bronchoalveolar lavage, a diagnosis of disseminated histoplasmosis with acquired immunodeficiency syndrome (AIDS) was established. The patient also tested positive for urine histoplasma antigen.
3. Discussion
Histoplasma capsulatum is a thermally dimorphic fungus transmitted via inhalation of spores from the soil in endemic areas which causes acute infection [
]. Some patients can develop disease many years after travel to an endemic area, consistent with reactivation of latent foci. T-cell immunity plays the predominant role in the recovery from histoplasmosis. Cytokines including IL-12 and interferon (IFN) gamma arm macrophages to kill the fungus and halt the progression of disease. Individuals with underlying conditions like AIDS with impaired defences are at risk for developing more severe and disseminated infection. Patients with AIDS frequently develop progressive disseminated histoplasmosis characterized by fever, night sweats, weight loss and hepatosplenomegaly [
]. Most common radiographic abnormalities are diffuse interstitial or reticulonodular infiltrates.
Induction therapy with liposomal Amphotericin B for one to two weeks followed by maintenance therapy with itraconazole for a minimum of one year is recommended to prevent relapse. Anti-retroviral therapy should be initiated as soon as possible to improve cellular immunity. The patient was treated with liposomal amphotericin B for two weeks and is currently doing well on oral itraconazole and highly active anti-retroviral therapy.
Contributors
AM provided care for the patient. All authors wrote and revised the manuscript.
Funding information
This report received no specific funding.
Informed consent
written consent to publication was obtained.
Declaration of Competing Interest
There are no competing interests.
References
Wheat L.J.
Freifeld A.G.
Kleiman M.B.
et al.
Clinical Practice Guidelines for the Management of Patients with Histoplasmosis: 2007 Update by the Infectious Diseases Society of America.
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