Case Presentation: A 33 year old male with a very recent diagnosis of HIV presented with a 3 week history of fevers and profuse diarrhea, and a 2 day history of a diffuse rash. His initial physical exam was remarkable for a temperature of 39.9 degrees Celsius, HR 101, tender axillary adenopathy, and an erythematous, papular rash on his face, chest, trunk, and extremities. Initial labs were notable for hemoglobin 11.3, hematocrit 30.8, platelets 62, serum creatinine 1.36, ALT 318, and AST 1281. Subsequent workup was remarkable for serum LDH > 2700, CD4 count 21, and serum ferritin level 70,170. Urinary Histoplasma antigen was positive, and his bone marrow biopsy revealed yeast suggestive of Histoplasma capsulatum. Blood cultures were also positive for this organism. Amphotericin B induction therapy was started, and he improved clinically. After completing two weeks of induction therapy, he was started on Itraconazole for maintenance therapy.
Discussion: The differential diagnosis for diarrhea, rash, and fever in an AIDS patient is broad, and often there is more than one disease process at work. Acute and subacute diarrhea in an AIDS patient is often due to infectious etiologies. In this case, the initial workup for infectious causes was unrevealing. A very serum high ferritin level helped to narrow the differential diagnosis. In the setting of serum ferritin levels > 10,000, diagnostic considerations include Still’s disease, systemic lupus erythematosus, disseminated histoplasmosis, disseminated mycobacterial infection, hemophagocytic lymphangiohistiocytosis, and hemochromatosis. There is considerable overlap between the clinical feaatures of disseminated histoplasmosis and hemophagocytic lymphangiohistiocytosis. For this patient, a bone marrow biopsy and positive urine Histoplasma antigen helped to confirm the diagnosis. The clinical manifestations of histoplasmosis are myriad, and effects can be manifested in the gastrointestinal system, skin, bone marrow, adrenal glands, central nervous system, spleen, and cardiovascular system. Severe cases can result in shock and multi-organ failure. The mainstay of treatment for severe cases is Amphotericin B, but mortality can approach fifty percent, even with appropriate antifungal therapy.
Conclusions: This clinical vignette demonstrates the potential utility of serum ferritin measurement in the workup for fever of unknown origin, and it also reviews the clinical characteristics and management of disseminated histoplasmosis.
To cite this abstract:Clarke K, Gluth A, Ricketts J, Cochi S. Very High Ferritin in an Hiv-Positive Patient with Fever of Unknown Origin. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 489. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/very-high-ferritin-in-an-hiv-positive-patient-with-fever-of-unknown-origin/. Accessed July 16, 2019.