Gastrointestinal histoplasmosis with small intestinal perforation: 20-year experience.

Postmortem studies show gastrointestinal tract involvement in as many as 70% of patients affected by disseminated histoplasmosis. Although gastrointestinal involvement is common in disseminated disease, the presentation of small intestinal perforation is exceedingly rare with few reported cases in the literature. Herein we present our institutional case series. The aim of the study is to describe small intestinal perforation in gastrointestinal histoplasmosis with attention to management and outcomes. This is a retrospective single-institution review of patients ≥ 18 years of age treated for small intestinal perforation due to gastrointestinal histoplasmosis. A prospectively maintained institutional database was searched from 2002 to 2022. Data obtained included demographics, comorbidities, treatment course, and outcomes. Five patients with a mean age of 54 years (range 25-72) were identified. Pertinent underlying comorbid conditions included Crohn's disease, psoriatic arthritis, rheumatoid arthritis, and solid organ transplantation. All patients were on chronic immunosuppressive medication(s) with the most common being tumor necrosis factors alpha inhibitors and corticosteroids. Four had a clinical diagnosis of perforation based on physical examination and imaging. All patients underwent segmental resection(s) of the small intestine and received medical treatment with intravenous amphotericin B and eventual transition to an oral antifungal. No patients experienced complications related to surgery. The limitations of the study include nonrandomized retrospective review, single-institution experience, and small patient sample size. Although rare, histoplasmosis should be considered in the differential of patients on chronic immunosuppressive therapy who present with gastrointestinal symptoms concerning perforation, especially from endemic areas. Small intestinal perforation due to gastrointestinal histoplasmosis can be successfully treated with resection and antifungal therapy.

Isolated Colonic Histoplasmosis in Patients Undergoing Immunomodulator Therapy: A Systematic Review.

Gastrointestinal histoplasmosis remains an inconspicuous clinicopathologic entity. It is predominantly considered a protean manifestation of disseminated disease. We hereby delineate a unique case of biopsy-proven isolated colonic histoplasmosis in a patient undergoing methotrexate therapy. Furthermore, we present the first systematic review of the MEDLINE, Google Scholar, Embase, and Scopus databases regarding isolated colonic histoplasmosis in adult patients receiving immunomodulator therapy (IMT). A total of 13 case reports (level of clinical evidence: IV) were identified. The mean age was 55.6 ± 11.1 years, with 9 (69.2%) cases reported in women. Patients with subclinical disease (5, 38.5%) were often incidentally diagnosed by screening colonoscopy. Symptomatic individuals predominantly presented with diarrhea (4, 30.8%), weight loss (3, 23.1%), and/or abdominal pain (3, 23.1%). IMT was mainly administered for liver transplant (4, 30.8%), renal transplant (4, 30.8%), and ulcerative colitis (2, 15.4%). Common colonoscopy features included colonic ulcerations (7, 53.8%), polyps or pseudopolyps (3, 23.1%), and/or mass-like lesions (3, 23.1%). Diagnosis was made by histology of colonic biopsy in 11 (84.6%) and resected specimens in 2 (15.4%) patients. Treatment consisted of a combination of amphotericin B with oral itraconazole in 6 (46.2%), oral itraconazole alone in 5 (38.5%), and amphotericin B alone in 2 (15.4%) patients. Complete clinical recovery was achieved in all patients. This article illustrates that isolated colonic involvement can be the only clinical presentation of histoplasmosis. It may masquerade as other bowel disorders, presenting diagnostic and therapeutic conundrums. Gastroenterologists should rule out colonic histoplasmosis in IMT recipients who develop unexplained colitis symptoms.

Reactivation of Disseminated Histoplasmosis With Central Nervous System Involvement Following a Primary Gastrointestinal Histoplasmosis Infection: A Case Report.

A 78-year-old white male with chronic pancytopenia presented with acute transient aphasia and dysarthria. He had a National Institutes of Health Stroke Scale (NIHSS) of zero. Physical examination revealed slight aphasia with mild dysarthria. Brain magnetic resonance imaging (MRI) revealed nine ring-enhancing lesions in the left precentral gyrus with significant vasogenic edema. Lung computed tomography (CT) showed no evidence of pulmonary nodules. The serology of blood and urine for infectious organisms was negative. Four weeks later, the patient was re-admitted with worsening dysarthria and right upper extremity weakness. Repeat head MRI showed a slight increase in the size of the multiple supratentorial ring-enhancing lesions. The magnetic resonance spectroscopy (MRS) findings of the evaluated lesion suggested a fungal etiology. Empiric amphotericin B treatment was initiated, which mitigated central nervous system (CNS) ring-enhancing lesions and resolved the patient's neurological deficits. Early empiric medical treatment of CNS histoplasmosis should be considered in the setting of multiple CNS ring-enhancing lesions and a positive history of histoplasmosis infection, despite negative serological studies.

Granulomatous Hepatitis Secondary to Histoplasmosis in an Immunocompetent Patient.

Histoplasma capsulatum is the most common endemic mycosis in the United States and usually occurs in certain geographic areas, such as the Mississippi or Ohio River valleys. Histoplasmosis usually causes a mild disease in the immunocompetent but can progress to disseminated disease in patients with impaired immunity. Granulomatous hepatitis as a manifestation of disseminated histoplasmosis in immunocompetent patients is extremely rare. We report the case of a 62-year-old immunocompetent gentleman with a history of histoplasmosis who presented with abdominal pain, elevated liver enzymes, who was diagnosed with granulomatous hepatitis secondary to histoplasmosis.

Gastrointestinal Histoplasmosis Mimicking Crohn's Disease.

Disseminated histoplasmosis is a life-threatening disease usually seen in immunocompromised patients living in endemic areas. We present an apparently immunocompetent patient with gastrointestinal histoplasmosis who was initially diagnosed with biopsy-proven Crohn's disease. Following discontinuation of anti-inflammatory drugs and institution of antifungal therapy, his gastrointestinal illness completely improved. Specific fungal staining should be routinely included in histopathologic assessment of tissue specimens diagnosed as Crohn's disease.

An HIV-Positive Patient With Disseminated Histoplasmosis Complicated by Histoplasma Ileitis-Induced Small Bowel Obstruction.

A 43-year-old male has a medical history of Human immunodeficiency virus (HIV) with no anti-retroviral therapy for six years prior to admission. He presented from an outside hospital with 40 lbs weight loss over one year, worsening abdominal pain, and odynophagia, with CT-confirmed small bowel obstruction (SBO) in the setting of untreated cytomegalovirus (CMV) ileitis. Treatment for both the untreated HIV and CMV ileitis was started during this hospitalization, and his hospital course was complicated by disseminated histoplasmosis in his lungs and GI tract, leading to stricture and a recurrent SBO. This case report will focus on an unusual complication of untreated HIV and a late diagnosis of histoplasmosis: Histoplasma ileitis-induced stricture and recurrent SBO. To date, there are a limited number of reports that describe gastrointestinal histoplasmosis in HIV patients, and SBO remains a rare and serious complication of disseminated histoplasmosis.

A case report of gastrointestinal histoplasmosis in a patient treated with infliximab.

Histoplasmosis is an endemic mycosis in some areas of North and South America. This disease is usually asymptomatic, but it can result in severe and disseminated infection involving gastrointestinal tract, especially in immunocompromised individuals. We report a case of a 33-years-old Ecuadorian male treated with infliximab who developed disseminated histoplasmosis with gastrointestinal affection. Due to the non-specific presentation of gastrointestinal histoplasmosis, the diagnosis is often delayed and it causes poor outcomes. It is important to consider this diagnosis in immunocompromised patients with compatible symptoms, like patients on TNF inhibitors.

Intractable hypercalcemia in a patient with multiple myeloma: An infectious etiology.

Hypercalcemia is a common laboratory finding in patients with malignancy, as well as with granulomatous disease. We report the case of a 75-year-old man with multiple myeloma (MM) who presented with generalized weakness, fever, and intractable hypercalcemia. The hypercalcemia proved difficult to treat despite well-controlled MM, as well as adequate use of bisphosphonates and calcitonin. Biopsy of sub-centimeter mesenteric adenopathy was significant for Histoplasma capsulatum and negative for malignancy, suggesting disseminated gastrointestinal histoplasmosis as the sole etiology for uncontrolled hypercalcemia. He was successfully treated with voriconazole. Disseminated histoplasmosis can be fatal if left untreated and warrants vigilance of non-malignant etiologies of hypercalcemia. While hypercalcemia is a common clinical manifestation of MM, our patient is an exemplar of maintaining a broader differential diagnosis in immunocompromised hosts.

Gastrointestinal Histoplasmosis as an Obstructing Ileocecal Mass.

Histoplasmosis is a self-limiting and asymptomatic disease in immunocompetent individuals. Patients in an immunocompromised state are susceptible to disseminated disease. We present a case of a 60-year-old male with a history of psoriatic and rheumatoid arthritis treated with a tumor necrosis factor inhibitor (adalimumab), who presented with abdominal pain and was found to have gastrointestinal histoplasmosis as an obstructing ileocecal mass. Although gastrointestinal involvement is common in disseminating disease, symptomatic involvement is rare. This case presentation has implications in rheumatological patients on biologic medications.

Gastrointestinal histoplasmosis ileal stricture successfully treated with through-the-scope balloon dilation in a patient with hyperimmunoglobulin M syndrome.

Gastrointestinal histoplasmosis is common in patients with disseminated disease affecting both immunocompetent and immunocompromised patients. However, it is often unrecognized due to a lack of specific signs and symptoms. It has only rarely been reported to cause small bowel obstruction, during which surgical treatment was nearly always necessary. Little is known about the usefulness of endoscopic therapy in gastrointestinal histoplasmosis associated strictures. We report the case of a 32-year-old man with a history of hyperimmunoglobulin M syndrome who presented with small bowel obstruction secondary to disseminated gastrointestinal histoplasmosis. Treatment was successful with a through-the-scope balloon dilator in combination with medical therapy. This report adds to the limited data available on the benefit of endoscopic therapy in infectious strictures, particularly gastrointestinal histoplasmosis.

Úlceras gastroduodenais como manifestação clínica de histoplasmose disseminada em paciente com vírus da imunodeficiência humana positivo: relato de caso / Progressive disseminated histoplasmosis presenting as gastroduodenal ulcers in a human immunodeficiency virus patient: case report

JUSTIFICATIVA E OBJETIVOS: A histoplasmose é uma doença fúngica causada pelo Histoplasma capsulatum. É rara em imunocompetentes;no entanto, em pacientes imunossuprimidos, a infecção ocorre de forma disseminada e grave, podendo acometer vários órgãos, incluindo o trato gastrintestinal. O objetivo deste estudo foi relatar o caso de uma apresentação incomum de infecção pelo H. capsulatum, alertando os clínicos quanto à inclusão da histoplasmose no diagnóstico diferencial de úlceras gastrintestinais, principalmente no paciente imunocomprometido. RELATO DO CASO: Paciente do sexo masculino, 45 anos,portador de síndrome da imunodeficiência adquirida (SIDA),com perda de peso, febre, sudorese noturna, adenomegalias cervicais e sangramento gastrintestinal. A radiografia de tórax mostrou infiltrado intersticial bilateral difuso, e a tomografia computadorizada (TC) de abdômen mostrou hepatomegalia e adenomegalias intra-abdominais. Na endoscopia digestiva alta foram encontradas úlceras no estômago e duodeno. O exame anatomopatológico das lesões foi compatível com histoplasmose do trato gastrintestinal. CONCLUSÃO: É de extrema importância o diagnóstico diferencial de úlceras gastrintestinais, principalmente em pacientes imunossuprimidos, uma vez que diversas doenças que assim se manifestam se não tratadas adequadamente, têm evolução fatal.

BACKGROUND AND OBJECTIVES: Histoplasmosis is afungal disease caused by Histoplasma capsulatum. It rarely occurs in immunocompetent individuals; however, in immunocompromised patients, the infection is usually severe and disseminated. Many organs can be affected, including the gastrointestinal tract.The objective of this study is to report an uncommon presentation of histoplasmosis, showing that the differential diagnosis of gastrointestinal ulcers is of great importance, particularly in the immunocompromised patient. CASE REPORT: Male patient, 45-year-old, immunodeficiency virus human-positive, was admitted to the hospital presenting with weight loss, night sweats, fever, cervical adenomegalies and gastrointestinal bleeding. Chest radiography showed diffuse interstitial pulmonary infiltrates bilaterally; computerized tomography of the abdomen showed hepatomegaly and intraabdominal adenomegalies. Upper gastrointestinal endoscopy revealed gastric and duodenal ulcers. The pathologic examination of the ulcerswas consistent with gastrointestinal histoplasmosis. CONCLUSION: Reassures the need for the differential diagnosis of gastrointestinal ulcers, particularly in immunosuppressed patients, since many diseases that present this way, have fatal outcomeif not treated properly.

Histoplasmosis colónica como manifestación diagnóstica de Sida / Colonic histoplasmosis as a diagnostic manifestation of AIDS

Se reporta caso de paciente mujer de 48 años, sin antecedentes importantes (niega transfusión de sangre), con cuatro meses con diarrea y pérdida ponderal de 8 kg. Presenta episodio de hematoquezia y anemia aguda que requirió transfusión. Se realizó colonoscopía intrahemorrágica detectando tres lesiones ulceradas: una a 10 cm del ano, otra en colon transverso distal, otra úlcera de similares características en el transverso proximal. Las biopsias mostraron tejido de granulación de úlcera, abundantes macrófagos con estructuras intracitoplasmáticas consistentes con histoplasmosis. Los exámenes no demostraron tuberculosis, ni parasitosis intestinal. Las pruebas de VIH (ELISA y Western Blot) fueron positivas. El recuento de linfocitos CD4 (78 células) y la histoplasmosis extrapulmonar fueron los criterios que definieron el estadio SIDA. La histoplasmosis extrapulmonar define el estadio IV en pacientes inmunosuprimidos por el VIH. La hemorragia digestiva baja por úlceras colónicas secundarias a Histoplasma es una forma de presentación infrecuente como manifestación diagnóstica de SIDA.

We report the case of 48 year old female patient without a history of significance importance (refuses blood transfusion). She complaint of diarrhea of four months of duration and weight loss of 8 kg. She added episodes of hematochezia and severe anemia requiring transfusion. An Intrahemorrhagic colonoscopy was performed detecting three ulcerated lesions. First at 10 cm from the anus, one in transverse colon distal, another similar ulcer in the proximal transverse The biopsies showed ulcer granulation tissue, abundant macrophages within tracytoplasmic structures consistent with histoplasmosis. Tests showed no tuberculosis or intestinal parasitosis. HIV testing (ELISA and Western Blot) were positive. The CD4 (78 cells) and extrapulmonary histoplasmosis were the criteria defined stage AIDS. The extrapulmonary histoplasmosis defines stage IV in immunosuppressed patients with HIV. Lower gastrointestinal bleeding colonic ulcer secondary to Histoplasma is a rare form presentation as a diagnostic manifestation of AIDS.