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A difficult diagnosis: acute histoplasmosis.

Singh N, Pizanis C, Davis J - Clin Kidney J (2012)

Bottom Line: A 43-year-old male with deceased donor kidney transplantation presented with fever of unknown etiology and underwent an extensive workup.The diagnosis of histoplasmosis was made after biopsy of a positron emission tomography-positive subcarinal lymph node showed non-caseating granulomas with a positive stain for yeast.The diagnosis was confirmed when fevers remitted with initiation of appropriate anti-fungal therapy.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, The Ohio State University College of Medicine and Public Health, Columbus, OH, USA.

ABSTRACT
A 43-year-old male with deceased donor kidney transplantation presented with fever of unknown etiology and underwent an extensive workup. The diagnosis of histoplasmosis was made after biopsy of a positron emission tomography-positive subcarinal lymph node showed non-caseating granulomas with a positive stain for yeast. The diagnosis was confirmed when fevers remitted with initiation of appropriate anti-fungal therapy.

No MeSH data available.


Related in: MedlinePlus

The epithelioid non-necrotizing granulomas with giant cells (arrows) in the lymph node. Please see the additional color image (hemotxylin & eosin stain) as Supplementary material online.
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fig2: The epithelioid non-necrotizing granulomas with giant cells (arrows) in the lymph node. Please see the additional color image (hemotxylin & eosin stain) as Supplementary material online.

Mentions: Based on the findings on chest imaging, a bronchoscopy and bronchoalveolar lavage (BAL) were performed and sent for cell count, bacterial culture, respiratory viral pathogen nucleic acid testing and general viral culture and fungal and acid-fast bacillus analysis. Cytology of the BAL fluid showed 71% macrophages, 12% neutrophils and 16% lymphocytes but other tests were reported to be negative. Other negative diagnostic workup included a CT scan of abdomen and pelvis, whole body WBC scan and a bone marrow biopsy. As fever continued, we also entertained the possibility of malignancy or lymphoma. It was important to figure out whether the single large necrotic-looking subcarinal lymph node seen on chest CT scan in absence of other lymphadenopathy was significant or not and whether we were dealing with a more systemic process. A PET scan (Figure 1) was subsequently obtained. It showed increased [18F]-fluorodeoxyglucose (FDG) uptake in mediastinal, hilar, supraclavicular, retroclavicular and periaortic lymph nodes. Thus, the PET scan confirmed the systemic disease and showed that necrotic-looking subcarinal lymph node enlargement was significant’. A media stinoscopy with subcarinal lymph node biopsy was then performed to better characterize the etiology of lymphadenopathy. Pathology revealed non-caseating granulomas (Figure 2) with small yeast forms suggestive of Histoplasma capsulatum (Figure 3). The patient was initiated on itraconazole capsule 200 mg bid but as the serum itraconazole level 10 days later was detected to be low at 0.6 mcg/mL, he was switched to the liquid formulation (to allow better absorption) at the same dose. With the liquid form, the patient achieved a target level of ∼1 mcg/mL, and hence, he was continued on the same regimen. The patient defervesced within a week after initiation of itraconazole. Cultures of the nodes confirmed the diagnosis of histoplasmosis. So far, the patient has completed 8 months of itraconazole for a total of 12 months and has remained afebrile. He required reduction in the dose of sirolimus at the beginning of the therapy because the drug–drug interaction between itraconazole and sirolimus resulted in a significant increase in the drug level of the sirolimus. The patient has maintained a stable graft function till the time of last follow-up.


A difficult diagnosis: acute histoplasmosis.

Singh N, Pizanis C, Davis J - Clin Kidney J (2012)

The epithelioid non-necrotizing granulomas with giant cells (arrows) in the lymph node. Please see the additional color image (hemotxylin & eosin stain) as Supplementary material online.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4400496&req=5

fig2: The epithelioid non-necrotizing granulomas with giant cells (arrows) in the lymph node. Please see the additional color image (hemotxylin & eosin stain) as Supplementary material online.
Mentions: Based on the findings on chest imaging, a bronchoscopy and bronchoalveolar lavage (BAL) were performed and sent for cell count, bacterial culture, respiratory viral pathogen nucleic acid testing and general viral culture and fungal and acid-fast bacillus analysis. Cytology of the BAL fluid showed 71% macrophages, 12% neutrophils and 16% lymphocytes but other tests were reported to be negative. Other negative diagnostic workup included a CT scan of abdomen and pelvis, whole body WBC scan and a bone marrow biopsy. As fever continued, we also entertained the possibility of malignancy or lymphoma. It was important to figure out whether the single large necrotic-looking subcarinal lymph node seen on chest CT scan in absence of other lymphadenopathy was significant or not and whether we were dealing with a more systemic process. A PET scan (Figure 1) was subsequently obtained. It showed increased [18F]-fluorodeoxyglucose (FDG) uptake in mediastinal, hilar, supraclavicular, retroclavicular and periaortic lymph nodes. Thus, the PET scan confirmed the systemic disease and showed that necrotic-looking subcarinal lymph node enlargement was significant’. A media stinoscopy with subcarinal lymph node biopsy was then performed to better characterize the etiology of lymphadenopathy. Pathology revealed non-caseating granulomas (Figure 2) with small yeast forms suggestive of Histoplasma capsulatum (Figure 3). The patient was initiated on itraconazole capsule 200 mg bid but as the serum itraconazole level 10 days later was detected to be low at 0.6 mcg/mL, he was switched to the liquid formulation (to allow better absorption) at the same dose. With the liquid form, the patient achieved a target level of ∼1 mcg/mL, and hence, he was continued on the same regimen. The patient defervesced within a week after initiation of itraconazole. Cultures of the nodes confirmed the diagnosis of histoplasmosis. So far, the patient has completed 8 months of itraconazole for a total of 12 months and has remained afebrile. He required reduction in the dose of sirolimus at the beginning of the therapy because the drug–drug interaction between itraconazole and sirolimus resulted in a significant increase in the drug level of the sirolimus. The patient has maintained a stable graft function till the time of last follow-up.

Bottom Line: A 43-year-old male with deceased donor kidney transplantation presented with fever of unknown etiology and underwent an extensive workup.The diagnosis of histoplasmosis was made after biopsy of a positron emission tomography-positive subcarinal lymph node showed non-caseating granulomas with a positive stain for yeast.The diagnosis was confirmed when fevers remitted with initiation of appropriate anti-fungal therapy.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, The Ohio State University College of Medicine and Public Health, Columbus, OH, USA.

ABSTRACT
A 43-year-old male with deceased donor kidney transplantation presented with fever of unknown etiology and underwent an extensive workup. The diagnosis of histoplasmosis was made after biopsy of a positron emission tomography-positive subcarinal lymph node showed non-caseating granulomas with a positive stain for yeast. The diagnosis was confirmed when fevers remitted with initiation of appropriate anti-fungal therapy.

No MeSH data available.


Related in: MedlinePlus