A Tricky Pain in the Neck: Histoplasmosis Masquerading As Thyroglossal Duct Cyst

1Virginia Commonwealth University, Richmond, VA

Meeting: Hospital Medicine 2014, March 24-27, Las Vegas, Nev.

Abstract number: 681

Case Presentation:

A 63‐year‐old male nonsmoker with monoclonal gammopathy of undetermined significance and prostate cancer presented with 2.5 months of dysphagia, odynophagia, hoarseness, and midline neck swelling. Computed tomographic (CT) scan of the neck revealed a cystic mass extending inferiorly from the tongue base to the level of the thyroid cartilage, without lymphadenopathy. Fine‐needle aspiration of the cystic mass yielded 5 mL of acutely inflamed mucoid fluid. Imaging and pathologic findings were felt consistent with thyroglossal duct cyst. Three weeks later, he underwent excision of the presumed thyroglossal duct cyst and excisional biopsy of submental lymph nodes. Eight days following surgery, pathology reported histoplasmosis, with associated granulomatous inflammation, involving both the excised cyst and lymph nodes. Subsequent evaluation revealed evidence of disseminated histoplasmosis, with a cavitary right lower lung lesion, multiple calcified hilar and mediastinal lymph nodes, and numerous ring‐enhancing lesions throughout the brain. For treatment of disseminated histoplasmosis with central nervous system (CNS) involvement, he received 6 weeks of liposomal amphotericin B, followed by 12 months of oral itraconazole.

Discussion:

Histoplasmosis is a common endemic mycosis, caused by inhalation of Histoplasma capsulatumspores found in soil contaminated with bird or bat droppings. In the United States, infection is most common in the states located in the Ohio and Mississippi River valleys. Histoplasmosis is usually asymptomatic but can present as an acute, influenza‐like illness. In patients who are immunocompromised or at the extremes of age, infection can progress to disseminated, life‐threatening disease. Most cases of histoplasmosis are associated with hilar or mediastinal lymphadenitis confined within the thorax. Clinical presentation within the neck has been reported only rarely and is felt likely due to the spread of infection from the mediastinum to cervical lymph nodes via lymphatics or tissue planes, followed by coalescence into a cervical equivalent of a mediastinal granuloma. Treatment of CNS histoplasmosis is difficult because of the poor penetration of most antifungal agents into cerebrospinal fluid. Induction therapy with 4‐6 weeks of liposomal amphotericin B is followed by at least one year of itraconazole to prevent relapse.

Conclusions:

The purpose of reporting this case is to describe histoplasmosis infection in the neck, a rare presentation of a common infection. Hospitalists, especially those practicing in states within the Ohio and Mississippi River valleys, should maintain awareness of this condition and vigilance for the potential of severe, disseminated disease with protean presentations in elderly and immunocompromised patients.

To cite this abstract:

Wixted D. A Tricky Pain in the Neck: Histoplasmosis Masquerading As Thyroglossal Duct Cyst. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 681. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/a-tricky-pain-in-the-neck-histoplasmosis-masquerading-as-thyroglossal-duct-cyst/. Accessed September 16, 2019.

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