LAUSR

CASE A69-year-old male with no known significant past medical history presented with 2 months of shortness of breath, dry cough, subjective fevers, and an unintentional 20-pound weight loss. Review of symptoms was also notable for constant, diffuse headaches and nausea without vomiting or abdominal pain. In 1986, the patient moved from El Salvador to Texas, where he worked in construction until the time of presentation. While in El Salvador, the patient noted multiple female sexual partners, although he was now monogamous with one female partner. On physical examination, he was afebrile and saturating 100% on room air. He was frail and appeared chronically ill. His lungs were clear upon auscultation bilaterally. Lab results were most notable for pancytopenia, with a white blood cell count of 3.82 109/liter (4.22 109 to 10.33 109/liter), hemoglobin of 8.1 g/dl (13.2 to 16.9 g/dl), and a platelet count of 31 109/liter (160 109 to 383 109/liter), as well as hyponatremia, with a sodium concentration of 124 mmol/liter (135 to 145 mmol/liter) and an elevated ferritin level of 57,180 ng/dl (30 to 400 ng/ml). Although not previously known to have human immunodeficiency virus (HIV), the patient’s 4th-generation HIV screening test for HIV type 1 (HIV-1) and HIV-2 antibodies and p24 antigen was positive. He was subsequently found to have a CD4 count of 29 cells/ l (365 to 1,437 cells/ l) and an HIV load of 720,440 copies/ml. A chest X ray was unremarkable, but a computerized tomography (CT) scan of the chest showed numerous tiny nodules measuring up to 5 mm in size. The dry cough and pancytopenia in concert with nodules upon CT chest exam in the setting of AIDS was concerning for disseminated histoplasmosis, and thus a bone marrow biopsy specimen with fungal culture was obtained. Microscopic examination of Giemsa-stained bone marrow aspirate smears revealed numerous oval intracellular yeast cells (2 to 4 m) in macrophages (Fig. 1A), consistent with the suspected diagnosis of disseminated Histoplasma capsulatum infection. The patient’s urine Histoplasma antigen test returned a level of 20 ng/ml. After 8 days, both his fungal blood culture and fungal bone marrow culture grew H. capsulatum. He was treated with liposomal amphotericin B for 2 weeks, followed by itraconazole indefinitely. Antiretroviral agents were held upon discharge, and he moved to another state with plans to follow up with an outside provider.