Kamatam Sravani, Akepati Anusha, Shivakumar Divya
Department of Internal Medicine, OSF St Francis Medical Center, Peoria, IL, USA.
Department of Internal Medicine, Kamineni Academy of Medical Sciences and Research Center, Hyderabad, Telangana, India.
Am J Case Rep. 2025 May 6;26:e946631. doi: 10.12659/AJCR.946631.
BACKGROUND Disseminated histoplasmosis is a rare fungal infection caused by dimorphic fungus Histoplasma capsulatum. Immunocompetent patients are usually asymptomatic or have self-limiting disease; however, immunocompromised patients present as disseminated infection. Our case report includes an immunocompromised host with atypical presentation and imaging findings consistent with a miliary pattern that did not fit the classical clinical picture of disseminated histoplasmosis, causing a delay in the diagnosis. CASE REPORT We report a case of a patient who presented with shortness of breath, nonproductive cough, low-grade fevers, and weight loss, who received a diagnosis of disseminated histoplasmosis, with an underlying immunocompromised state. Due to the ineffectiveness of initial management with empiric antibiotics, imaging with computed tomography (CT) of the chest was done, revealing miliary disease, and tuberculosis was first in the differential diagnosis. She had a positive histoplasma urine antigen, and bronchial alveolar lavage fluid tested positive for histoplasma antigen, confirming miliary histoplasmosis. Her CT of the abdomen/pelvis showed multiple lesions in the spleen and adrenal glands bilaterally, concerning for disseminated histoplasmosis, which was treated with amphotericin B, followed by itraconazole. CONCLUSIONS Disseminated histoplasmosis is a rare and challenging diagnosis; there should be a low suspicion for histoplasmosis in patients treated with tumor necrosis factor inhibitors, as mortality is high in such cases. Despite the inability to detect antibodies in immunocompromised patients, definitive diagnostic tests must be considered through culture and histopathology, the criterion standard tests, before excluding infectious causes. This case highlights the challenges faced in diagnosing and treating miliary histoplasmosis in immunocompromised patients.
背景 播散性组织胞浆菌病是一种由双相真菌荚膜组织胞浆菌引起的罕见真菌感染。免疫功能正常的患者通常无症状或患有自限性疾病；然而，免疫功能低下的患者则表现为播散性感染。我们的病例报告包括一名免疫功能低下的宿主，其表现不典型，影像学表现符合粟粒样模式，与播散性组织胞浆菌病的经典临床表现不符，导致诊断延迟。病例报告 我们报告一例患者，其表现为呼吸急促、干咳、低热和体重减轻，被诊断为播散性组织胞浆菌病，伴有潜在的免疫功能低下状态。由于经验性抗生素初始治疗无效，遂进行胸部计算机断层扫描（CT），显示为粟粒样病变，鉴别诊断首先考虑为结核病。她的组织胞浆菌尿抗原呈阳性，支气管肺泡灌洗液的组织胞浆菌抗原检测也呈阳性，确诊为粟粒性组织胞浆菌病。她的腹部/盆腔CT显示双侧脾脏和肾上腺有多个病变，怀疑为播散性组织胞浆菌病，先用两性霉素B治疗，随后用伊曲康唑治疗。结论 播散性组织胞浆菌病是一种罕见且具有挑战性的诊断；对于接受肿瘤坏死因子抑制剂治疗的患者，应高度怀疑组织胞浆菌病，因为此类病例的死亡率很高。尽管免疫功能低下的患者无法检测到抗体，但在排除感染原因之前，必须通过培养和组织病理学等标准诊断试验进行明确诊断。本病例突出了免疫功能低下患者诊断和治疗粟粒性组织胞浆菌病所面临的挑战。
