Disseminated Histoplasmosis in an Immunocompetent Patient After COVID-19 Pneumonia

Abstract

Disseminated histoplasmosis can occur in immunocompromised patients such as in HIV disease and patients with medication-induced immunosuppression. Most of these patients present with fever, weight loss, hepatosplenomegaly, lymphadenopathy, and pancytopenia. There are increasing reports of coronavirus disease 2019 (COVID-19) pneumonia associated with fungal infections including aspergillus and mucormycosis. It is not typical for immunocompetent patients to present with disseminated fungal disease. We herein report a case of a 50-year-old immunocompetent male with a recent recovery from COVID-19 pneumonia who presented with fever and pancytopenia. Chest computed tomography (CT) demonstrated new-onset right upper lobe lung mass, subcarinal lymphadenopathy, and splenomegaly. Mediastinal lymph nodes and bone marrow biopsies were performed, and the patient was diagnosed with disseminated histoplasmosis. The association between COVID-19 pneumonia and fungal infections is increasingly reported. Diagnosis requires a high index of suspicion, especially in immunocompetent patients.

Disseminated histoplasmosis in an immunocompetent patient with COVID-19 pneumonia

“…Furthermore, by the time this article was written, there were only two cases of histoplasmosis and COVID-19 in patients with HIV/ AIDS 6 7 and four cases of coinfection in immunocompetent patients found. [8][9][10] The two patients with HIV/AIDS diagnosed with histoplasmosis and COVID-19 presented to the emergency room with cough, dyspnoea with decreased oxygen saturation and fever. Common chest CT findings were mediastinal lymph node enlargement and pulmonary ground-glass opacities.…”

“…8 As for the third patient, fine-needle aspiration of the subcarinal node revealed budding yeast; finally, positive bronchoalveolar lavage, tissue biopsy and urine antigen confirmed the diagnosis. 9 Pancytopenia was present in one of the patients. 9 Outpatient management with oral itraconazole was the choice for two patients; they recovered successfully after 3 months of treatment.…”

“…8 9 One of these patients also received a 5-day course of remdesivir at the time of the viral infection. 9 Later on, these three patients followed up with their providers due to persistent dry cough and fever. Repeated chest CT demonstrated reduction in ground-glass opacities and new nodular densities with mediastinal lymph node enlargement.…”

“…Further history interrogation revealed risk factors for histoplasmosis including bat and dust exposure 8 and living in the Ohio River valley. 9 Sputum analysis, urine antigen and serology were used to diagnose histoplasmosis in two patients. 8 As for the third patient, fine-needle aspiration of the subcarinal node revealed budding yeast; finally, positive bronchoalveolar lavage, tissue biopsy and urine antigen confirmed the diagnosis.…”

“…4 5 Only a few cases have been reported worldwide in immunocompromised patients, and such presentation is unusual in immunocompetent patients. [6][7][8][9][10] This case presents a 61-year-old immunocompetent man, affected by obesity, hypertension, hypothyroidism and type 2 diabetes mellitus, who was initially admitted to the medical floors on highflow nasal cannula due to acute hypoxic respiratory failure secondary to COVID-19 pneumonia. Despite appropriate COVID-19-directed therapy with dexamethasone, baricitinib and empirical antibiotic coverage for bacterial coinfection, the patient remained critically ill and eventually required transfer to the intensive care unit (ICU) for intubation and mechanical ventilation.…”