European Journal of Internal Medicine 77 (2020) 119–120

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European Journal of Internal Medicine

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Internal Medicine Flashcard

A 44-year-old man with cough, arthralgia, and fever T

a,⁎ b
Priyanka Bhugra , Abhishek Maiti
a
Department of Internal Medicine, Houston Methodist Hospital, 6565 Fannin St, Houston, TX, 77030, United States
b
Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, United States

1. Case description 3. Discussion

A 44-year- old man presented with dry cough, diffuse joint pain,
fevers, and night sweats for one month and poor appetite and weight
loss for three months. Physical examination showed hepatosplenome-
galy. A chest computed tomogram (Panel A and B) showed diffuse
miliary nodules. Sputum for acid fast bacilli was negative. Testing for
HIV-1 was positive with a high viral load and a low CD4 count of 4/µL.
Bronchoscopy with bronchoalveolar lavage was performed. Gomori
methenamine-silver stain of the bronchoalveolar lavage specimen
showed intracellular yeasts within macrophages with narrow-based
budding (Panel C).
What is the diagnosis?
Fig. 1.
2. Diagnosis
Together with the clinical presentation, findings on imaging studies
and bronchoalveolar lavage, a diagnosis of disseminated histoplasmosis
with acquired immunodeficiency syndrome (AIDS) was established.
The patient also tested positive for urine histoplasma antigen.
Histoplasma capsulatum is a thermally dimorphic fungus transmitted
via inhalation of spores from the soil in endemic areas which causes
acute infection [1]. Some patients can develop disease many years after
travel to an endemic area, consistent with reactivation of latent foci. T-
cell immunity plays the predominant role in the recovery from histo-
plasmosis. Cytokines including IL-12 and interferon (IFN) gamma arm
macrophages to kill the fungus and halt the progression of disease.
Individuals with underlying conditions like AIDS with impaired de-
fences are at risk for developing more severe and disseminated infec-
tion. Patients with AIDS frequently develop progressive disseminated
histoplasmosis characterized by fever, night sweats, weight loss and
hepatosplenomegaly [2]. Urinary Histoplasma antigen has a high sen-
sitivity of more than 90% for diagnosing disseminated disease in im-
munocompromised patients [2]. Monitoring urinary Histoplasma an-
tigen can also help with assessing treatment response, failure, and
relapse [3]. Most common radiographic abnormalities are diffuse in-
terstitial or reticulonodular infiltrates.
Induction therapy with liposomal Amphotericin B for one to two
weeks followed by maintenance therapy with itraconazole for a

Figure 1. Figure 1 A an B. Computed chest tomogram showing diffuse miliary nodules, and C. Intracellular yeastswithin macropahges with narrow-based budding on
Gomori methanamine-silver stain of bronchoalveolar lavage.

⁎
Corresponding author.
E-mail address: pbhugra@houstonmethodist.org (P. Bhugra).

https://doi.org/10.1016/j.ejim.2020.04.054
Received 22 February 2020; Accepted 20 April 2020
Available online 14 May 2020
0953-6205/ © 2020 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
P. Bhugra and A. Maiti European Journal of Internal Medicine 77 (2020) 119–120

minimum of one year is recommended to prevent relapse. Anti-retro- Informed consent

viral therapy should be initiated as soon as possible to improve cellular
immunity. The patient was treated with liposomal amphotericin B for written consent to publication was obtained.
two weeks and is currently doing well on oral itraconazole and highly
active anti-retroviral therapy. Declaration of Competing Interest

There are no competing interests.

Contributors
References
AM provided care for the patient. All authors wrote and revised the
manuscript. [1] Wheat LJ, Freifeld AG, Kleiman MB, et al. Clinical Practice Guidelines for the
Management of Patients with Histoplasmosis: 2007 Update by the Infectious Diseases
Society of America. Clin Infect Dis 2007;45(7):807–25.
Funding information [2] Limper AH, Adenis A, Le T, Harrison TS. Fungal infections in HIV/AIDS. Lancet Infect
Dis 2017;17(11):e334–43.
[3] Azar MM, Hage CA. Laboratory diagnostics for Histoplasmosis. J Clin Microbiol
This report received no specific funding. 2017;55(6):1612–20.

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