Introduction: Histoplasmosis is the most common mycosis in the United States with peak incidence in the Midwest region.
In ~21% of patients with systemic histoplasmosis hyperbilirubinemia can be detected. However, cholestatic presentation of histoplasmosis infection is very rare.
Here we present a case of immunocompromised patient with predominant cholestatic liver disease caused by Histoplasma Capsulatum.
Case Description/Methods: This is the case of 56-years-old female who presented with– sided abdominal pain, shortness of breath, chills, hot flushes, nausea, vomiting and diarrhea. She is suffering from rheumatoid arthritis. Her medications are adalimumab, celecoxib, hydroxychloroquine. She denied alcohol intake.
Her initial workup including liver function tests (LFTs) was positive for a total bilirubin 3.5 mg/dl, conjugated bilirubin 2.7 mg/dl, alkaline phosphatase – 547 U/L, AST – 152 U/L, ALT-142 U/L, and platelet count – 55 k/ul.
During hospitalization her abdominal pain was getting progressively worse, and her LFTs continued to trend up. Eventually liver biopsy was performed.
The results showed multiple granulomas with central necrosis, and associated portal and lobular inflammation. The fungal stain highlighted yeasts suggestive of histoplasma. Her urinary histoplasma Ag Quantitative EIA eventually came back positive -8.87 ng/ml.
Viewing the normal chest x-ray and ongoing hypoxia, chest CT scan with IV contrast was performed showing 1.1 cm lung nodule in the left lower lobe. A subsequent bronchoscopy revealed budding yeasts. Patient was started on liposomal amphotericin B, and her LFTs trended down. The patient was treated with amphotericin B for 21days subsequently changed to twice-daily oral Itraconazole 200mg.
At the outpatient follow up visit, patient admitted a complete resolution of her abdominal pain and improvement of her breathing status.
Discussion: Liver histoplasmosis is a rare cause for cholestatic liver disease. Over the past two decades, a limited number of cases with similar clinical scenario were described.
Despite of the rarity of this condition, hepatic histoplasmosis should be considered in a selected population of immunocompromised patients living in an endemic area (ex: Ohio). Inclusion of urine antigen testing for histoplasma in early workup can potentially prevent diagnostic delay.
