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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 19  |  Issue : 2  |  Page : 113-114

Disseminated histoplasmosis in a patient with rheumatoid arthritis and interstitial lung disease


Department of Respiratory Medicine, Indraprastha Apollo Hospitals, New Delhi, India

Date of Submission07-Mar-2022
Date of Decision26-Mar-2022
Date of Acceptance28-Mar-2022
Date of Web Publication06-May-2022

Correspondence Address:
Deepak Rosha
Department of Respiratory Medicine, Indraprastha Apollo Hospitals, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_37_22

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  Abstract 


Histoplasmosis is a rare systemic fungal ailment. The clinical presentation of this disease is nonspecific and most physicians lack awareness about this disease. There is a paucity of diagnostic tests, due to which fungal infections remain undiagnosed. The dissemination of this infection beyond the lungs can remain asymptomatic. Infection mostly heals on its own but in few cases, it manifests as a pulmonary disease, very similar to tuberculosis. Systemic spread occurs in patients with debilitating diseases and those who are immunocompromised. We report a rare case of disseminated histoplasmosis in a 54-year-old female suffering from rheumatoid arthritis with interstitial lung disease with lung and bone marrow involvement. Appropriate administration of antifungal agents led to remarkable improvement.

Keywords: Histoplasmosis, interstitial lung disease, rheumatoid arthritis


How to cite this article:
Rosha D, Gupta I, Gandham VK, Goyal P. Disseminated histoplasmosis in a patient with rheumatoid arthritis and interstitial lung disease. Apollo Med 2022;19:113-4

How to cite this URL:
Rosha D, Gupta I, Gandham VK, Goyal P. Disseminated histoplasmosis in a patient with rheumatoid arthritis and interstitial lung disease. Apollo Med [serial online] 2022 [cited 2022 Jul 1];19:113-4. Available from: https://www.apollomedicine.org/text.asp?2022/19/2/113/344873


  Introduction Top


Histoplasmosis is an uncommon fungal infection, caused by the dimorphic fungus, named Histoplasma capsulatum. It is generally self-limiting in immunocompetent individuals, but it gets disseminated in immunocompromised individuals. It is endemic in the Central and South-central regions of the United States. Although it is relatively rare in India it is endemic in the eastern regions of the country.


  Case Report Top


Our patient, a 54-year-old female, was a known case of rheumatoid arthritis with interstitial lung disease-nonspecific interstitial pneumonia pattern (on Hydroxychloroquine HCQs, methylprednisolone 8 mg, leflunomide 10 mg, and long-term oxygen therapy). She also had systemic hypertension and was on regular medication. Since July 2020, she had developed generalized weakness and low-grade fever associated with mild shivering which was relieved on taking paracetamol. She was evaluated outside for the same. Blood counts showed bicytopenia (hemoglobin – 7.8, total leukocyte count – 4.8, and platelets – 2.12). The malarial antigen and typhi dot, HIV 1, 2, HBs antigen, anti-hepatitis A virus antibody, and anti-hepatitis C virus antibody were nonreactive. Thyroid profile was within normal limits. All cultures including blood, urine, and sputum were sterile. Ultrasonography whole abdomen was done which was within normal limits. Procalcitonin was also within normal limit (<0.05). COVID-19 reverse transcription–polymerase chain reaction (RT-PCR) done twice was negative. Chest X-ray did not show any new infiltrates. Despite taking an oral antibiotic course, the patient's fever persisted. Bone marrow biopsy was done that showed multiple small granulomas along with Langerhan's cell type of giant cells studding the marrow. Periodic acid–Schiff and Grocott's silver methenamine for fungi showed presence of capsulated yeast-like structures, both intracellularly and extracellularly, which were identified as H. capsulatum on fungal culture after 3 weeks of incubation. Bone marrow biopsy was also tested for acid-fast bacillus (AFB) stain, AFB culture, GeneXpert for Mycobacterium tuberculosis, and aerobic culture, which were all sterile. As the patient was on immunosuppressants, immunological profile was done which showed absolute CD3, CD4, and CD8 counts of 375, 257, and 123 cells per microliter, respectively, with a CD4:CD8 ratio of 2.09.

The patient was started on intravenous liposomal amphotericin B after which she became afebrile after 3 days. Her oxygen requirement decreased and weakness improved. The patient was given iv amphotericin B for 14 days after which she was discharged on oral itraconazole 200 mg twice a day, which was continued for 6 weeks. It is pertinent to note that she was on 2–3 L per minute of continuous oxygen to maintain an oxygen saturation of 90%–93%, and was wheelchair bound for the past 3 years. However, after antifungal therapy, her oxygen supplement reduced to less than 1 L per minute and was able to walk without support in her room.


  Discussion Top


Histoplasmosis is caused by H. capsulatum, which is a thermally dimorphic fungus.[1],[2] It is a granulomatous fungal infection involving the reticuloendothelial system. It is mostly self-limiting, but can prove lethal in debilitated, immunocompromised patients, those on cytotoxic drugs, and those with hematologic malignancies.[1],[2],[3] In India, there are sporadic case reports of this infection. It is known to be endemic in few areas of East India.[3] The infective organism resides in soil containing the droppings of birds and chicken feathers. Inhalation of microconidia and mycelial fragments from the contaminated soil is the route of this infection. It can be either a pulmonary histoplasmosis or progressive disseminated histoplasmosis.[1],[2] The common symptoms of this infection include fever, night sweats, tiredness, and breathing difficulty. Hepatosplenomegaly and lymphadenopathy are common on physical examination.[4] The risk of the infection as well as its dissemination is more in HIV patients with CD4 count of <150 cells/μl. It resembles other ailments such as tuberculosis (TB), lymphoma, and malignancies. A high index of suspicion of rare opportunistic infections such as histoplasmosis is essential in the current scenario of acquired immunodeficiency syndrome (AIDS) pandemic, even in nonendemic regions. A timely diagnosis and medical management leads to a good prognosis. Disseminated histoplasmosis is rare in nonendemic regions of India. Bone marrow aspiration is an important diagnostic tool. The response of the infection to antifungal agents is very good. Patients with AIDS (especially if CD4 counts remain <150 cells/μl) may require lifelong maintenance therapy. Histoplasmosis should be considered in patients with pyrexia of unknown origin, loss of weight, hepatomegaly, and pulmonary findings, especially if these are not responding to anti-TB drugs.[5] The sensitivity of bone marrow examination is 75% for diagnosing fungal infections in HIV patients.[5]

The other differential diagnoses to be considered include leishmaniasis; other fungal pathogens such as candidiasis, cryptococcosis, blastomycosis; pneumocystis infection; or systemic cancers.[4]


  Conclusion Top


Awareness of the histoplasmosis disease is essential as it is still rare in nonendemic areas of India and the clinical features are similar to other common systemic illnesses such as TB and malignancy. Early diagnosis and early initiation of treatment with the antifungal agents help to have better prognosis. Our patient who was on long-term oxygen therapy and wheelchair bound improved considerably with antifungal treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Acknowledgment

Informed consent was obtained from all patients for being enrolled in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Agarwal VK, Prusty BS, Pereira KR. An uncommon presentation of progressive disseminate histoplasmosis. Ann Trop Med Public Health 2016;9:279-82.  Back to cited text no. 1
  [Full text]  
2.
Ganesan N, Sharma R, Phansalkar MD, Varghese R. Disseminated histoplasmosis in an immunocompetent patient diagnosed on bone marrow aspirate – A rare presentation from a non-endemic area. J Clin Diagn Res 2015;9:ED07-8.  Back to cited text no. 2
    
3.
Sane SY, Patel MG, Patel BM, Kokal KK. Disseminated histoplasmosis (a case report). J Postgrad Med 1983;29:270-3.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Lunardi LW, Wagner R, Dos Santos CC, Severo AT, Ferreira JA. Complete blood count alterations in disseminated histoplasmosis. Rev Bras Hematol Hemoter 2015;37:263-5.  Back to cited text no. 4
    
5.
Mukherjee A, Tangri R, Verma N, Gautam D. Chronic disseminated histoplasmosis bone marrow involvement in an immunocompetent patient. Indian J Hematol Blood Transfus 2010;26:65-7.  Back to cited text no. 5
    




 

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