Title : A case of disseminated histoplasmosis presenting as fever of unknown origin in a patient with diabetes mellitus
Abstract:
Background: Histoplasmosis is an endemic mycosis that is usually asymptoma c but occasionally results in severe illness. While it is endemic in some regions of the world, including America, Africa, and parts of Asia, it is considered rare in India. Most pa ents who develop disseminated histoplasmosis are immunosuppressed (eg, AIDS, solid organ transplanta on, treatment with tumor necrosis factor-alpha inhibitors) or are at the extremes of age. Here, we present a case of disseminated histoplasmosis in pa ent with diabetes mellitus.
Case presentation: A man in his 40s presented with fever and cough for one month dura on. The fever was high grade, predominantly in the evening hours and not associated with any periodicity or rhythmicity. He also had minimally produc ve cough with a mucoid sputum and occasional hemoptysis. His past medical history is notable for Alcoholic Chronic liver disease (Child Pugh grade B) and Type 2 diabetes mellitus. He also had history of treated pulmonary tuberculosis in his childhood. He frequently visits a nearby forest and had significant exposure to bird droppings. Physical examina on revealed pallor and features of volume overload. Examina on of the respiratory system showed coarse inspiratory crepts in the the right mammary, infraaxillary and infrascapular areas. Pa ent was clinical diagnosed with Fever of unknown origin with a respiratory focus. His lab reports showed pancytopenia with a high Erythocyte Sedimenta on Rate (ESR). HRCT thorax revealed minimal bronchiectasis in right lower lobe and subpleural fibro c nodule. Bone marrow biopsy showed non casea ng granulomas and yeast forms of fungi, as evidenced by posi ve Groco 's methenamine silver staining. Meanwhile his urine histoplasma an gen turned posi ve. The pa ent was diagnosed with disseminated Histoplasmosis and received a 14 day course of Amphotericin B, followed by a plan for oral itraconazole for one year. He became afebrile of Day 5 of an fungal treatment and is currently doing well.
Discussion: Histoplasmosis is a disease usually seen in immunocompromised individuals in endemic areas. The incidence of the disease is increasing in India, mainly due to be er recogni on of the disease. In a place where tuberculosis is endemic, the diagnosis of Histoplasmosis which has overlapping clinical features remains challenging. Hence early suspicion and prompt inves ga ons help in the recogni on of this deadly disease. Moreover there are increasing case reports, where diabetes has been the sole risk factor for the disease. Our pa ent too, didn’t have the classical risk factors associated with Histoplasmosis. Hence further research into the possible rela onship between diabetes and incidence of Histoplasmosis is also warranted.
