CASE REPORT: We describe a case of a 33 years old gentleman who was clinically diagnosed as acute appendicitis at initial presentation in view of a one-week history of fever, right lower quadrant abdominal pain- and guarding at right iliac fossa. He had thrombocytopenia and lymphopenia on presentation. Mesenteric lymphadenitis and small bowel lesion were found intraoperatively, which was respectively biopsied and resected. Histopathological result confirms disseminated histoplasmosis. Retroviral screen was positive. He was treated with amphotericin B for one week, subsequently switched to oral itraconazole, followed by initiation of highly active antiretroviral therapy (HAART).
DISCUSSION: This case illustrates the various nature of histoplasmosis presentation. A high index of suspicion is needed to clinch the diagnosis and subsequently institute prompt treatment as disseminated disease can be fatal if left untreated in an immunosuppressed host.
PATIENT CONCERNS: An 83-year-old Japanese man was hospitalized with general fatigue and high fever. He had been treated with prednisolone at 13 mg/d for 7 years because of an eczematous skin disease. He had a history of travel to Los Angeles, Egypt, and Malaysia 10 to 15 years prior to admission. Five years earlier, computed tomography (CT) identified a solitary calcified nodule in the left lingual lung segment. The nodule size remained unchanged throughout a 5-year observation period. Upon admission, his respiratory condition remained stable while breathing room air. CT revealed small, randomly distributed nodular shadows in the bilateral lungs, in addition to the solitary nodule.
DIAGNOSIS: Disseminated histoplasmosis, based on fungal staining and cultures of autopsy specimens.
INTERVENTIONS: The patient's fever continued despite several days of treatment with meropenem, minocycline, and micafungin. Although he refused bone marrow aspiration, isoniazid, rifampicin, ethambutol, and prednisolone were administered for a tentative diagnosis of miliary tuberculosis.
OUTCOMES: His fever persisted, and a laboratory examination indicated severe thrombocytopenia with disseminated intravascular coagulation. He died on day 43 postadmission. During autopsy, the fungal burden was noted to be higher in the calcified nodule than in the disseminated nodules of the lung, suggesting a pathogenesis involving endogenous reactivation of the nodule and subsequent hematogenous and lymphatic spread.
LESSONS: Physicians should consider histoplasmosis in patients with calcified nodules because the infection may reactivate during long-term corticosteroid therapy.
CLINICAL PICTURE: A 55-year-old man presented with intermittent low back pain which was progressively worsening, fever, anorexia, low back pain and a 10-kg weight loss. He had underlying diabetes mellitus and ischaemic heart disease. He gave a history of travel to caves for worship. Clinically, the most significant findings included nodular lesions in the anterior fauces and left palatoglossal region. Computed tomographic scan revealed bilateral adrenal masses. Biopsies were taken from the palatal nodules, which revealed histiocytes with numerous histoplasma organisms.
TREATMENT: He was commenced on itraconazole 200 mg daily for a period of 9 months. There was a dramatic initial response with settling of his fever and this was followed by subjective improvement in his well-being.
OUTCOME: He is presently on follow-up and has completed 9 months of itraconazole therapy with resolution of all his symptoms and has gained about 10 kg of weight.