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Jornal Português de Gastrenterologia

versão impressa ISSN 0872-8178

J Port Gastrenterol. vol.21 no.4 Lisboa ago. 2014

http://dx.doi.org/10.1016/j.jpg.2013.11.005 

ENDOSCOPIC SPOT

 

Disseminated histoplasmosis - Endoscopic presentation

Histoplasmose disseminada - apresentação endoscópica

 

Pedro Cardoso Figueiredo, Pedro Pinto-Marques, João Freitas

Serviço de Gastrenterologia, Hospital Garcia de Orta, Almada, Portugal

*Corresponding author

 

A 46-year-old woman presented with a 3-month history of malaise and weight loss (20 kg). These symptoms were accompanied by epigastric pain and watery diarrhea in the last 2 weeks before she was admitted. Her past medical history was significant for chronic kidney disease of unknown etiology for which she had received a cadaveric kidney transplant six years earlier. Immunosuppression consisted of tacrolimus, mycophenolate mophetil and prednisone. She had never traveled outside Portugal.

Physical examination was unremarkable. Laboratory tests revealed an elevated C reactive protein (7.3 mg/dL) and found no evidence of HIV, HBV, HCV, CMV, EBV and Leishmania infections.

The patient was submitted in a single session to an upper digestive endoscopy and colonoscopy. In the duodenum, ileum and colon, there were multiple ulcers with raised borders which were biopsied (Figs. 1 and 2). Pathology evaluation revealed intense acute inflammatory infiltrate and numerous intra- and extra-cellular microorganisms identified as Histoplasma spp (Fig. 3).

 

 

 

 

The patient was started on liposomal amphotericin B, but there was rapid clinical deterioration and she died from multiple organ failure.

Histoplasmosis is caused by the fungus H. capsulatum which is found in soil contaminated with bird and bat droppings and is endemic in Southeast Asia, India, Africa and America. Healthy people exposed to H. capsulatum are generally asymptomatic but they may develop acute pulmonar histoplasmosis, a ‘‘flu-like’’ illness.1 Disseminated histoplasmosis is a severe form of infection which mostly occurs in immunosuppressed individuals and frequently involves the gastrointestinal tract, although often asymptomatically.2,3 Endoscopic lesions include ulcerations and polypoid masses, most often involving the colon or ileum.2 Correspondingly, in our patient the most exuberant lesions were found on colonoscopy.

In a non-endemic area such as Europe, most reports stem from immigrants and people returning from highly endemic areas. However, exceedingly rare cases have been diagnosed in Europeans who have never traveled outside their country of origin and are believed therefore to be autochthonous infections.1 This might have been the case in our patient but another hypothesis has to be considered - H. capsulatum transmission by organ transplantation, which has been previously reported.4,5 Whichever may have been the case, the authors present this report, focusing on the endoscopic presentation which provided the diagnosis, due to its rarity in our country.

 

References

1. Ashbee HR, Evans EG, Viviani MA, Dupont B, Chryssanthou E, Surmont I, et al. Histoplasmosis in Europe: report on an epidemiological survey from the European Confederation of Medical Mycology Working Group. Med Mycol. 2008;46:57-65.         [ Links ]

2. Goodwin Jr RA, Shapiro JL, Thurman GH, Thurman SS, Des Prez RM. Disseminated histoplasmosis: clinical and pathologic correlations. Medicine (Baltimore). 1980;59:1-33.         [ Links ]

3. Kahi CJ, Wheat LJ, Allen SD, Sarosi GA. Gastrointestinal histoplasmosis. Am J Gastroenterol. 2005;100:220-31.         [ Links ]

4. Botterel F, Romand S, Saliba F, Reynes M, Bismuth H, Samuel D, et al. A case of disseminated histoplasmosis likely due to infection from a liver allograft. Eur J Clin Microbiol Infect Dis. 1999;18:662-4.         [ Links ]

5. Limaye AP, Connolly PA, Sagar M, Fritsche TR, Cookson BT, Wheat LJ, et al. Transmission of Histoplasma capsulatum by organ transplantation. N Engl J Med. 2000;343:1163-6.         [ Links ]

 

*Corresponding author

Email address: pedro.c.figueiredo@hotmail.com (P. Cardoso Figueiredo).

 

Ethical disclosures

Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data. The authors declare that no patient data appear in this article.

Right to privacy and informed consent. The authors declare that no patient data appear in this article.

Conflict of interest

The authors have no conflict of interest to declare.

 

Received 12 September 2013; accepted 30 November 2013