Progressive Disseminated Histoplasmosis Mimicking as Anal Carcinoma – Look at the Mountain, Not at Stone: A Case Report

Abstract

Disseminated histoplasmosis is a systemic disease caused by the dimorphic fungus Histoplasma capsulatum . Here, we are presenting a case of shock who was diagnosed to have primary adrenal insufficiency. This 68-year-old man had bilateral adrenal mass and later presented with chronic fever and ulcerated anal mass in the oncology clinic. The oncologist made a provisional diagnosis of anal carcinoma with adrenal metastasis. He was suspected of having an adrenal crisis and was admitted to the intensive care unit. He also had granulomatous hepatitis and acute kidney injury. The working diagnosis was changed to systemic inflammatory/infective pathology. The biopsy of the anal tissue done to look for the aetiology showed Histoplasma . He was started on oral itraconazole therapy. He improved symptomatically (resolution of fever, improvement in pain) when assessed after seven days. His anal ulcer healed after 21 days of itraconazole therapy.

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 ,…”

“…Thus, when an individual, especially in the setting of an immunocompromised state, presents with fever and jaundice, this disease entity should be considered or ruled out. Of the 123 cases, 16 had granulomatous hepatitis with six having coexisting cholecystitis [ 22 , 32 , 34 , 47 , 54 , 56 , 61 , 67 , 68 , 72 , 73 , 76 , 83 , 97 , 114 , 118 ]. Of the 16, 11 were immunocompromised secondary to HIV infection (n = 3) [ 68 , 72 , 114 ], post-transplantation on immunosuppressive therapy (n = 2) [ 61 , 72 ] and some were on immunosuppressive therapy for various ailments (n = 6), azathioprine [ 32 , 76 ], methotrexate [ 34 , 73 , 118 ], steroids [ 32 , 34 , 118 ], infliximab [ 32 , 73 ], fingolimod [ 54 ], mycophenolate, adalimumab [ 76 , 118 ], mesalazine [ 76 ] and the remainder were immunocompetent [ 22 , 47 , 56 , 67 , 97 ].…”

“…Of the 16, 11 were immunocompromised secondary to HIV infection (n = 3) [ 68 , 72 , 114 ], post-transplantation on immunosuppressive therapy (n = 2) [ 61 , 72 ] and some were on immunosuppressive therapy for various ailments (n = 6), azathioprine [ 32 , 76 ], methotrexate [ 34 , 73 , 118 ], steroids [ 32 , 34 , 118 ], infliximab [ 32 , 73 ], fingolimod [ 54 ], mycophenolate, adalimumab [ 76 , 118 ], mesalazine [ 76 ] and the remainder were immunocompetent [ 22 , 47 , 56 , 67 , 97 ]. Investigations revealed markedly elevated liver enzymes with coexisting gall bladder disorder [ 22 , 44 , 54 , 67 , 68 , 118 ] and enlarged liver [ 32 , 34 , 68 , 83 ]. Diagnosis of granulomatous hepatitis was made via liver biopsy, which showed characteristic features of H.capsulatum [ 22 , 32 , 34 , 54 , 56 , 72 , 73 , 97 ].…”

“…Treatment was surgical (cholecystectomy) for individuals with gall bladder involvement [ 22 , 68 , 72 ], in addition to antifungal therapy with itraconazole and amphotericin B. Marked recovery was noted with a resolution of symptoms and marked reduction in liver enzymes [ 22 , 32 , 34 , 56 , 61 , 67 , 76 , 83 , 114 ]; death was recorded in one case due to multiorgan failure [ 72 ]. Histoplasma though an uncommon cause of granulomatous hepatitis is associated with a high mortality rate of 100% [ 34 , 56 ] if not identified and treated.…”