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Resident PGY 1
Henry Ford Hospital
Case: A 41-year-old male from Michigan with a past medical history significant for ulcerative colitis presented to the emergency department with fevers and chills in November 2019. He had been experiencing recurrent daily fevers at home, reaching temperatures of 102-103 F. Previously, the patient had been experiencing abdominal pain and loose, bloody stool since January 2019. A colonoscopy in June 2019 showed pancolitis and biopsy was consistent with ulcerative colitis. After an episode of pancreatitis attributed to mesalamine, he was started on vedolizumab in November 2019 and tolerated two infusions. Other than the recent diagnosis of UC, the patient had no other pertinent past medical history. In terms of the patient’s social history, he lived his entire life in Michigan and had no recent travel outside the state. At home, the patient was exposed to a rabbit, dog and gecko and he worked as a construction worker. He did endorse frequently chopping wood in the forest and multiple other outdoor activities. A few weeks after the patient’s last vedolizumab infusion, he presented to the Emergency Department endorsing home temperatures of 102-103°F. He was febrile and workup revealed abnormal LFT’s (AST: 266, ATL: 232, T. Bili: 1.6, ALP: 70). He was started empirically on vancomycin, cefepime, and metronidazole given his immunocompromised state from the recent vedolizumab use and suspicion for infectious process and transferred to a hospital tertiary care center for further management. Throughout his admission, the patient had cyclic nightly fevers with temperatures reaching 102-103°F. Infectious workup to rule out atypical opportunistic infections was done, including HSV, HIV, Hep B, Hep C, Hep A, C diff. CMV, Giardia, Syphilis and Cryptosporidium. MRCP was performed given his transaminitis and was suggestive of possible small duct primary sclerosing cholangitis (PSC). Liver biopsy was done to further characterize and confirm the PSC, but the pathology report showed granulomas, encapsulated yeasts, and no evidence of PSC. Test results eventually revealed positive urine histoplasma antigen and positive blood beta-d-glucan. With suspected disseminated histoplasmosis, the patient was started on IV liposome amphotericin B for one week after which he was transitioned to oral itraconazole for 3-6 months. His fevers resolved, and his LFT’s returned to normal.
Impact/Discussion: Histoplasmosis is one of the four known systemic mycoses known to be endemic in the Ohio and Mississippi River valleys in the United States. Sources of exposure to H capsulatum include farming, cutting down trees, and remodeling or demolition of old buildings. Without any immunocompromising factors, the infection resolves via the body’s cell-mediated immunity. If immunocompromised, H capsulatum can disseminate and cause a variety of systemic symptoms including fever, fatigue, weight loss, lymphadenopathy, hepatomegaly, and splenomegaly. According to the literature, only two cases of histoplasmosis after vedolizumab treatment have been reported, among which only one was characterized as disseminated histoplasmosis. This is a rare case of a clinical presentation of disseminated histoplasmosis in a region in the United States not known to be endemic of Histoplasma capsulatum. However, in our patient, the history of immunomodulation therapy combined with a fondness of vigorous outdoor activities produced an optimal setting for the development of histoplasmosis.
Conclusion: It is evident that a proper history of present illness with a detailed social history becomes essential in the diagnosis of uncommon infections in immunocompromised individuals as our patient endorsed two risk factors for Histoplasma capsulatum. Histoplasmosis can present in a variety of ways, and along with other systemic mycoses, should be considered in patients presenting with non-specific systemic symptoms.
Murskyj, Ivanna O., "Disseminated Histoplasmosis after Vedolizumab Treatment for Ulcerative Colitis" (2020). Case Reports. 45.