Enlarged hilar lymph node due to Histoplasma

Abstract

A 13-year-old boy from Northeastern Brazil presented with a 12-month history of productive cough. Physical examination revealed small cervical and epitrochlear lymph nodes. He denied contact with bats, but stated that pigeons were located near his school. Red blood cell, leukocyte, and C-reactive protein levels were normal. Chest radiography showed a radiopaque nodule on the left inferior lobe ( Figure A; white arrow) and an amorphous image of a lobulated lineament on the left inferior hilum (5.5×3.5cm), suggesting an adenomegaly. Computed tomography ( Figure B) revealed a 5.6×3.1×3.2-cm lymph node at the left hilum with a necrotic center, peripheral calcification, and splenic granulomas. Bronchoalveolar lavage disclosed a small amount of leukocytes with negative stain and culture results. The tuberculin test and Cytomegalovirus [immunoglobulin M/ immunoglobulin G (IgM/IgG)] and Toxoplasma serologies were negative. The Histoplasma serology (immunodiffusion) was positive. Following initiation of itraconazole (400mg/day), the cough remarkably diminished. Disseminated histoplasmosis is frequently diagnosed in patients with acquired immunodeficiency syndrome (AIDS) in Brazil. However, the acute pulmonary form is rarely diagnosed due to its self-limiting nature and unawareness of local physicians regarding its manifestations and complications, including mediastinal or hilar lymphadenitis (1)