|Year : 2015 | Volume
| Issue : 1 | Page : 61-62
Siva M Sridhar, Manjula Sridhar, Sai D Raghavendra
Department of Radio Diagnosis, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
|Date of Web Publication||8-May-2015|
Siva M Sridhar
Plot No. 202, Orchid Apartments, Ocean View Layout, Pandurangapuram, Visakhapatnam 530 003, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Histoplasmosis is a worldwide fungal infectious disease caused by inhalation of spores of Histoplasma capsulatum. It may present as chronic pulmonary infection or in disseminated form. Disseminated histoplasmosis frequently affects the adrenal gland; however, unilateral involvement in immunosuppressed patients is the usual presentation. We report a case of an immunocompetent old male with history of weight loss, fever and bilateral adrenal masses. Computed tomography (CT)-guided biopsy of adrenal mass revealed histoplasmosis. This case report emphasizes the importance of considering fungal infection as differential diagnoses of mass lesions involving bilateral adrenals even if the patients are immunocompetent, along with the commoner lesions at these sites.
Keywords: Adrenal mass, disseminated histoplasmosis, suprarenal mass
|How to cite this article:|
Sridhar SM, Sridhar M, Raghavendra SD. Disseminated histoplasmosis. Niger J Basic Clin Sci 2015;12:61-2
| Introduction|| |
Histoplasmosis is an infectious disease caused by the dimorphic fungus Histoplasma capsulatum. Inhalation of H. capsulatum spores produces a lung infection with widely varying symptoms. In elderly, debilitated, diabetic and immune-compromised patients, it may cause chronic pulmonary disease or disseminated disease. Cases of disseminated and extra pulmonary histoplasmosis are uncommon; however, there is high incidence of liver, spleen, lymph node, bone marrow and adrenal involvement. The clinical presentation of the disseminated disease includes pyrexia, anorexia, nausea, vomiting, weight loss and fatigue. These symptoms are nonspecific and may resemble other chronic infections and malignancies.
| Case report|| |
A 60-year-old non-diabetic, non-hypertensive male presented with progressive loss of weight and appetite, low-grade fever, of 3 months duration. General examination of the patient was normal. On systemic examination, no signs/symptoms related to respiratory/gastrointestinal/renal involvement are noted except for mild Hepato splenomegaly. Routine blood tests [haemoglobin, random blood sugar (RBS), total count (TC), differential count (DC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), blood urea, serum creatinine, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), alkaline phosphatase] and urine tests (glucose, protein and microscopy) revealed no abnormality. Blood culture was negative. The tests done for malaria [Quantitative buffy coat (QBC)], tuberculosis [polymerase chain reaction (PCR), Quantiferon-TB Gold], human immunodeficiency virus (HIV) (TRIDOT-Rapid HIV test and Western Blot), were negative. Ultrasonography of the abdomen revealed hepatosplenomegaly without any focal lesion. Both adrenal glands were enlarged and hypoechoic. Contrast-enhanced computed tomography (CT) of the abdomen showed hepatosplenomegaly with both adrenal glands enlarged. The right adrenal measured 52 × 41 mm and the left measured 46 × 38 mm, hypo-dense bilateral adrenals showing heterogeneous enhancement and poorly enhancing internal septations[Figure 1]a and b]. There was no internal necrosis/calcification seen. Adrenal hormone profile tests (serum cortisol-23 μ g/dL, sodium-140 mmol/lt, pottasium- 4 mmol/lt, chloride-98mmol/lt and calcium-9.6 mmol/lt) did not revealed any abnormality. With a provisional diagnosis of secondary metastases, tuberculosis and lymphoma, a CT-guided biopsy was done from the left adrenal mass, [Figure 1]c and d] which revealed numerous yeast forms in a necrotic background which was positive on Periodic Acid Schiff staining consistent with histoplasmosis. The sabourauds agar culture grown few colonies of histoplasma capsulatum. The patient was treated with amphotericin B 3mg/kg for two weeks and oral itraconazole, 200 mg three times daily for 3 days, followed by 200 mg twice daily for 6 weeks.
|Figure 1: (a) Plain computed tomography (CT) abdomen showing uniformly bilateral hypo dense adrenal masses (*) with no calcifications, (b) Contrast enhanced computed tomography (CT) demonstrating heterogeneously enhancing bilateral adrenal masses (arrows) with no necrosis, (c) Computed tomography (CT)-guided biopsy from left adrenal mass|
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| Discussion|| |
There are three major clinical presentations of histoplasmosis: Pulmonary, progressive disseminated and primary cutaneous histoplasmosis.
Disseminated histoplasmosis is a rare and potentially fatal disease. The clinical manifestations of chronic disseminated histoplasmosis in an immunocompetent patient resemble those of other chronic infections like tuberculosis or malignancies. Non-immunocompromised patients usually presents with low-grade fever, weight loss, anorexia, night sweats with the features of adrenal insufficiency, like nausea, vomiting, diarrhoea, myalgia, orthostatic hypotension, hypoglycemia, dehydration, weight loss, disorientation, especially in the endemic areas.
It is more common in males with male to female ratio of 3-10:1.
Incidence is 2-5% in immunocompromised patients and <0.05% in immunocompetent patient. The incidence of histoplasmosis is more in infants and elderly patients of 60 years and above. 
Ultrasonography may show hepatosplenomegaly and bilateral adrenal enlargement. Adrenal masses are usually hypoechoic and can have homogenous or heterogonous echotexture. Most characteristic feature is maintenance of the triangular shape of the adrenal gland.  CT may show hepatosplenomegaly, adrenal enlargement with heterogonous density and varied enhancement. Enlarged adrenals with deformed shape, peripheral enhancement, calcifications and necrosis have been described but no features to specifically diagnose histoplasmosis.
Fine-needle aspiration (FNA)/biopsy of the adrenal gland may reveal cluster of macrophages with abundant cytoplasm containing yeast forms of Histoplasma capsulatum.
The differential diagnoses of bilateral adrenomegaly are metastasis, lymphoma, adrenal haemorrhage, sarcoidosis and infections which include histoplasmosis, tuberculosis, cryptococosis, coccidioidomycosis and blastomycosis.  However, central hypo-density and peripheral rim enhancement of the adrenals may narrow down the differentials to only tuberculosis or histoplasmosis.
Fine-needle aspiration biopsy (FNAB) of adrenal gland in is an effective method in the diagnosis of these unusual infectious diseases.
| References|| |
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