Reactivation of Histoplasmosis Disseminated into the Central Nervous System Presenting as a Stroke

Abstract

Histoplasmosis is one of the most prevalent endemic mycosis in the United States. Patients with a previous history of histoplasmosis have a risk of reinfection in the future. Individuals with impaired immunity and those who have massive re-exposure to H. capsulatum, their defenses against this organism can be overwhelmed and diseases can recur. We present a unique case of reactivation disseminated histoplasmosis in an immunocompetent patient. We present a case of a 75-year-old male who presented to the ER on two separate occasions for stroke-like symptoms with progressive falls, impaired speech, hand tremor, confusion and generalized weakness. CT of the head without contrast on both occasions showed chronic atrophy and microvascular changes but no acute abnormalities. MRI could not be performed due to pacemaker incompatibility. EKG showed paced rhythm. The only abnormal lab was a creatinine level of 1.6. Neurology was consulted and they ordered an EEG and lumbar puncture during his second hospitalization. EEG showed generalized slowing, suggestive of diffuse brain dysfunction. Lumbar puncture showed WBC: 103, protein: 172, lymphocytes: 88%, neutrophils: 11%, monocytes: 1%. Following the lumbar puncture, Infectious Disease was consulted. On further investigation, it was discovered that the patient was previously treated for oral histoplasmosis with itraconazole for three months. Cerebrospinal fluid (CSF) was positive for histoplasmosis antigen titer 1:64. Serology was positive for histoplasmosis antibody complement fixation titer of 1:32. The patient was treated with liposomal amphotericin B for six weeks. With treatment, his serology titers continued to improve. The patient was discharged home on itraconazole 200 mg for lifetime, due to his previous history of oral histoplasmosis. On his three-month follow-up, his serology titer was <1:8. Histoplasmosis should be considered in the differential diagnosis of patients who present with chronic meningitis, cerebral vascular accident, focal brain or spinal cord lesions, and encephalitis.

Clinical, radiological and laboratory characteristics of central nervous system histoplasmosis: A systematic review of a severe disease

“…We found 1159 studies and included 108 manuscripts published between 1962 and 2022, totaling 298 patients 7–10,12–115 . We excluded 38 articles that could not be retrieved.…”

Histoplasmosis: An Overview Treatment of Histoplasmosis

“…Aggressive and prolonged antifungal therapy is indicated in all cases of CNS histoplasmosis. However, there is no definitive treatment for CNS histoplasmosis [42].…”

Reactivation of Disseminated Histoplasmosis With Central Nervous System Involvement Following a Primary Gastrointestinal Histoplasmosis Infection: A Case Report

“…We present a case of reactivation of CNS histoplasmosis following a primary diagnosis of seronegative gastrointestinal histoplasmosis in an immunocompetent patient. To the best of our knowledge, there are very few reports of reactivated disseminated histoplasmosis presenting as CNS histoplasmosis [3], and none with corresponding imaging findings.…”

“…Histoplasmosis can progress to be disseminated in patients with acute infection. In patients with a previous history of infection, there is a risk of future re-infection, primarily among those with impaired immunity [2,3]. Central nervous system (CNS) histoplasmosis is a rare manifestation seen in 5% to 10% of patients with disseminated histoplasmosis [4].…”

“…Once diagnosed, the recommended guideline for the treatment of CNS histoplasmosis is amphotericin B, followed by itraconazole for at least one year. Upon review of the literature via a PubMed search for "reactivated disseminated histoplasmosis in the CNS," one prior report of reactivated disseminated histoplasmosis in the CNS was identified [3].…”