A diagnostic predicament: activated sarcoidosis or pulmonary histoplasmosis. A case report

Abstract

We report a case of a 41-year-old man presenting with persisting fevers over 2 weeks. The patient had spent 4 weeks in Central America. He was in control of a stable stage II sarcoidosis. Laboratory and various microbiological tests as well as chest radiography led to no diagnosis. Activated sarcoidosis was hypothesized as the most likely diagnosis. However, we considered an infectious process as a differential diagnosis, in detail, the travel history imposed histoplasmosis. Chest-CT documented localized interstitial consolidations. Bronchoscopy with bronchoalveolar lavage (BAL) and biopsy was performed. Results of BAL fluid, biopsy, distinct sarcoidosis serum markers and a borderline positive histoplasmosis-serology yielded in a diagnostic dilemma as no distinct diagnosis was drawable. After the patient was already started on a prednisolone trial, the final diagnosis - pulmonary histoplasmosis - could be achieved via positive culture and PCR out of the BAL fluid. This case shows the difficult differentiation between an acute exacerbation of a chronic pulmonary disease and a concomitant infection, which was especially aggravated in this case as the histoplasmosis masqueraded an acute picture of sarcoidosis.

Histoplasmosis Diagnosed in Europe and Israel: A Case Report and Systematic Review of the Literature from 2005 to 2020

“…The countries reporting the most cases were France (8, 28.6%), Spain (6, 21.4%), and The Netherlands (5, 17.8%). Sixteen patients had progressive disseminated histoplasmosis (57.1%), which was revealed by a picture of haemophagocytic lymphohistiocytosis (HLH) in five cases [76,83,84,88,92]; two had intestinal histoplasmosis [89,91], one of whom was initially misdiagnosed as having Crohn's disease leading to HLH following treatment with infliximab [91]; the remaining ten had apparently localised disease with cerebral involvement [72], endocarditis [77], pyomyositis [63], or pulmonary [87], oral [78], laryngeal [80], liver [44], osteoarticular [89] or skin diseases [39]. Seven cases (25%) were characterised by ulcerated lips or the involvement of the oropharyngeal mucosa [70][71][72]74,81,84,88].…”

Clinical features and endemic trend of histoplasmosis in China: A retrospective analysis and literature review

“…10 Patients with suspicious diagnosis of histoplasmosis without finding these fungi in bone marrow or other tissues would be excluded. Immunocompromise was defined as a prior in the presence of one of the seven criteria: (1) neutropenia, (2) solid organ or hematopoietic stem cell transplantation, (3) immunosuppressive medications (chronic glucocorticoids, antirejection medications, antineoplastic, et al), (4) cirrhosis, (5) human immunodeficiency virus (HIV), (6). diabetes and (7) advanced cancer.…”

“…Histoplasmosis is a systemic fungal infectious disease caused by Histoplasma capsulatum ( H. capsulatum ), a dimorphic fungus that mostly distributes in moist and warm regions, and occurs when the soil is disrupted thereby releasing fungal spores which are inhaled and deposited in alveoli . Progressive disseminated histoplasmosis is a serious disease that mainly involves monocyte‐macrophage system, such as liver, spleen, bone marrow and lymph nodes and is common in immunocompromised patients presenting with severe organic systemic damage . However, histoplasmosis is usually a self‐limited disease in immunocompetent people.…”

“…1,2 Progressive disseminated histoplasmosis is a serious disease that mainly involves monocyte-macrophage system, such as liver, spleen, bone marrow and lymph nodes and is common in immunocompromised patients presenting with severe organic systemic damage. [3][4][5] However, histoplasmosis is usually a self-limited disease in immunocompetent people. This mycosis is an opportunistic infection in individuals with innate or acquired cellular immune dysfunction that could be caused by acquired or iatrogenic factors.…”

Disease Detection with Molecular Biomarkers: From Chemistry of Body Fluids to Nature-Inspired Chemical Sensors

“…), in vitro medical assay (urine, blood, stool, etc. ), and pathological and clinical microbiological examinations (for tuberculosis, , chlamydia infection, , rotavirus, , malaria histoplasmosis, , etc.). However, these are clinical services needing professional skills at considerable cost.…”