Gastrointestinal histoplasmosis ileal stricture successfully treated with through-the-scope balloon dilation in a patient with hyperimmunoglobulin M syndrome

Abstract

Gastrointestinal histoplasmosis is common in patients with disseminated disease affecting both immunocompetent and immunocompromised patients. However, it is often unrecognized due to a lack of specific signs and symptoms. It has only rarely been reported to cause small bowel obstruction, during which surgical treatment was nearly always necessary. Little is known about the usefulness of endoscopic therapy in gastrointestinal histoplasmosis associated strictures. We report the case of a 32-year-old man with a history of hyperimmunoglobulin M syndrome who presented with small bowel obstruction secondary to disseminated gastrointestinal histoplasmosis. Treatment was successful with a through-the-scope balloon dilator in combination with medical therapy. This report adds to the limited data available on the benefit of endoscopic therapy in infectious strictures, particularly gastrointestinal histoplasmosis.

Gastrointestinal Histoplasmosis: A Descriptive Review, 2001–2021

“…Analysis of the 123 well-documented cases showed the clinical presentation of GIH was often non-specific and mimicked several other gastrointestinal conditions and pathologies, including abdominal tuberculosis (n = 3, 2.4%) [ 85 , 96 , 102 ], GIH and TB coinfection was reported in four [3.3%] cases [ 78 , 87 , 96 , 98 ], inflammatory bowel disease (n = 9, 7.3%) [ 21 , 33 , 40 , 52 , 69 , 75 , 89 , 105 , 107 ], intestinal obstruction (n = 15, 12.2%) [ 15 , 21 , 39 , 50 , 57 , 64 , 71 , 77 , 81 , 89 , 95 , 102 , 103 , 104 , 117 ], abdominal malignancy (n = 9, 7.3%) [ 14 , 16 , 31 , 80 , 83 , 101 , 102 , 108 , 112 ], GI bleeding (n = 29, 23.6%) [ 17 , 18 , 25 , 26 , 27 , 29 , 30 , 31 , 33 , 37 , 41 , 44 , 53 , 56 ,…”

“…As a result of delay, some patients experienced worsening clinical states [ 33 , 69 , 89 , 105 , 107 , 116 ] and/or death [ 20 , 80 , 100 , 116 , 122 ]. A high index of suspicion in evaluating GIH in patients is needed as this will reduce the incidence of complications, such as lower gastrointestinal bleeding [ 17 , 26 , 27 , 29 , 30 , 31 , 33 , 39 , 44 , 53 , 56 , 59 , 63 , 70 , 84 , 94 , 102 , 103 , 105 , 110 , 119 ], intestinal perforation [ 54 , 73 , 80 , 111 ], ulceration [ 70 , 102 , 103 ], intestinal obstruction [ 15 , 21 , 50 , 57 , 81 , 89 , 95 , 102 , 103 , 104 , 117 ], acute pancreatitis [ 20 , 65 , 75 , 115 ], acute cholecystitis [ 44 , …”

“…Focusing on cases without HIV infection, the findings from our review suggest the need to also evaluate patients without HIV infection with risk factors for GIH including post-transplant patients on immunosuppressants [ 16 , 39 , 46 , 49 , 61 , 62 , 63 , 72 , 84 , 101 , 113 ], patients on immunosuppressants for other disease conditions [ 14 , 15 , 17 , 20 , 25 , 28 , 30 , 69 , 76 , 92 , 103 , 105 ] and patients with immunodeficiency syndrome [ 95 ] presenting with GI symptoms. This should be done regardless of the immune status of an individual as complications associated with GIH, such as acute abdomen [ 70 ], can also develop in immunocompetent patients.…”

Gastrointestinal histoplasmosis presenting as a small bowel obstruction in an immunocompetent patient

“…respiratory illness often in the immunocompetent 3–7 12. In those who are immunocompromised (most commonly due to HIV infection), histoplasmosis infection can become disseminated, affecting extrapulmonary sites including the gastrointestinal tract 1 3–7.…”

“…Prompt diagnosis of gastrointestinal histoplasmosis (GIH) is important as mortality is high if left untreated 1 2. Although GIH is commonly reported in patients who are immunocompromised, particularly patients living with HIV,3–8 it can also occur in patients without underlying HIV infection8 and in the immunocompetent 8 9. A low index of suspicion by the attending clinician or delayed diagnosis can lead to complications and fatal outcomes 1 8.…”