A 74‐year‐old woman resides in Ohio presented with intermittent dyspepsia, 30‐ lbs. weight loss and decreased appetite for 1 month duration. She denied any fever. EGD revealed duodenal ulcer and biopsy was positive for H. pylori. Colonoscopy exam was unremarkable. She was treated with omeprazole, amoxicillin and clarithromycin. Her condition improved partially, but 6 weeks later she was readmitted to the hospital with severe abdominal pain. On physical exam, she was febrile of 102.4, HR 110, BP 100/60 mm hg and RR of 22. She had vague abdominal tenderness, with peritoneal signs. Her WBC was 12.6 k/ul with a neutrophil of 86%. Chemistry and liver function tests were normal. CT abdomen revealed ileocecal hypoechoic mass and signs of perforated viscous. A presumptive diagnosis of GI malignancy with bowel perforation was suspected. Exploratory laparotomy with small bowel resection was performed. Biopsy of the ileum demonstrated diffuse collections of large histiocytes associated with a mixed inflammatory infiltrate in the lamina propria with rounded intracytoplasmic structures (2‐4 μm, oval, narrow‐based budding yeast) morphologically consistent withHistoplasma capsulatum. She was found to be negative for HIV. Fungal serologies and Blood cultures were negative. Chest radiography did show evidence of histoplasmosis. The patient was subsequently treated with IV amphotericin for 2 weeks followed by itraconazole for 6 months.
Histoplasmosis has been reported both in immunocompetent as well as immunocompromised patients with disseminated forms being more common in the latter group. In HIV positive patients the prevalence of histoplasmosis varies from 5% to 32% depending on the endemicity of the disease. Weight loss and fever were found to be the most common symptoms, while on physical examination; oropharyngeal ulcers, hepatosplenomegaly and lymphadenopathy were the most common signs. Due to varied and non‐specific clinical manifestations of systemic histoplasmosis and low index of suspicion, most of the infections are either misdiagnosed or underdiagnosed. The diagnosis of GIH can be challenging as in the present case where the presentation was with localized ileum involvement and no immunocompromised state was documented at the time of presentation.
This case increases the practitioners’ general awareness of Gastrointestinal histoplasmosis (GIH) and its complications. A particular high index of suspicion is required in individuals who presents with significant weight loss and gastrointestinal symptoms. GIH should be considered in the differential diagnosis of inflammatory bowel disease and suspected carcinoma even if the history of immunocompromised state is lacking. Diagnosis of GIH is important as if left untreated can lead to lethal complications. On the other hand, timely and appropriate treatment can result in long term survival.
To cite this abstract:Dinary B, Dinary F, Shaheen K, Altaqi B, Eghobamien D. Weight Loss and Ileal Mass in Immune‐Competent Female. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 406. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/weight-loss-and-ileal-mass-in-immunecompetent-female/. Accessed April 1, 2020.