Duodenal Histoplasmosis Presenting with Upper Gastrointestinal Bleeding in an AIDS Patient

Abstract

Gastrointestinal histoplasmosis (GIH) is common in patients with disseminated disease but only rarely comes to clinical attention due to the lack of specific signs and symptoms. We report the unusual case of a 33-year-old Caucasian male with advanced AIDS who presented with upper GI bleeding from diffuse erosions throughout the duodenum. Biopsy of the lesions revealed small bowel mucosa with granulomatous inflammation and macrophages with small intracellular yeasts consistent with disseminated histoplasmosis. The patient demonstrated significant clinical improvement following a two-week course of liposomal amphotericin B. To our knowledge, this is the first case report of duodenal histoplasmosis leading to clinically significant bleeding, manifesting with worsening anemia and melanotic stools. Given our findings, we maintain that GIH should be considered on the differential diagnosis for GI bleeding in AIDS patients at risk, specifically those with advanced immunosuppression (i.e., CD4+ cell counts <100 cells/mm3) who reside in endemic areas (Ohio or Mississippi river valleys) and/or have a prior history of histoplasmosis. For diagnostic evaluation, we recommend checking a urine Histoplasma quantitative antigen EIA as well as upper and/or lower endoscopy with biopsy. We recommend treatment with a two-week course of liposomal amphotericin B followed by indefinite itraconazole.

Case 31-2013

“…Up to 12% of patients with AIDS and disseminated histoplasmosis have gastrointestinal involvement, most commonly in the colon or cecum. 7-9 Smallbowel involvement 10 and upper gastrointestinal bleeding have also been reported in these patients.…”

Upper gastrointestinal bleeding as first manifestation of duodenal histoplasmosis in a patient with systemic lupus erythematosus

“…4 Most cases of histoplasmosis are Aids-related. [1][2][3] In patients with disseminated histoplasmosis, the GI tract is one of the most commonly affected organ systems with approximately 70% of patients demonstrating some GI involvement at autopsy. While GI histoplasmosis may involve any portion of the GI tract, nearly 90% of lesions involve the lower GI tract, most commonly the ileocecal region or colon.…”

“…Initial exposure is via inhalation, and spread occurs within macrophages through the reticuloendothelial system. 3 Disseminated infection occurs via lymphohematogenous spread of yeast-filled macrophages into nearby lymph nodes and multiple organs, most commonly the liver, spleen, bone marrow, adrenal glands, and gastrointestinal (GI) tract. While GI involvement is not uncommon in patients with disseminated disease, GI histoplasmosis rarely comes to clinical attention due to the lack of specific signs and symptoms.…”

“…While GI involvement is not uncommon in patients with disseminated disease, GI histoplasmosis rarely comes to clinical attention due to the lack of specific signs and symptoms. 3 The purpose of this study is to describe the second reported case of upper GI bleeding due to duodenal histoplasmosis in a patient with systemic lupus erythematosus (SLE).…”

Giemsa and Grocott in the recognition of Histoplasma capsulatum in blood smears

“…Even though this methodology does not provide a definitive diagnosis of histoplasmosis, it may be very helpful in those cases in which the presumptive diagnosis has not been established yet and where other more sophisticated methods are not available [12,13] .…”