Non-resolving pneumonia: A rare presentation of progressive disseminated histoplasmosis
A 17-year-old male patient, student and nonsmoker, consulted a local physician at Murshidabad, West Bengal with high grade intermittent fever with chills but no rigors, cough with scanty mucoid expectoration, dull aching chest pain, and generalized weakness for 5 days. The patient's chest X-ray postero-anterior (PA) view at that time showed middle lobe consolidation []. The patient was treated as CAP with oral amoxicillin + clavulanic acid (625 mg) 8 hourly and levofloxacin (500 mg) daily was added afterwards. As the patient's condition deteriorated with documented weight loss of 5 Kg in 2 weeks, his father brought him to our hospital. On examination, the patient was very toxic with blood pressure 90/60 mmHg, pulse rate 130/min regular, respiratory rate 32/min with moderate pallor. Examination of the respiratory system revealed crepitations in the right mammary area. Examinations of other systems were normal. We treated the case as non-resolving pneumonia and did antibiotics adjustment with the intravenous cefoperazone-sulbactam (1.5 g) 8 hourly and oral clarithromycin (500 mg) twice daily along with the other supporting treatment. The investigations revealed hemoglobin 6.4 g%, total white cell count 15200/mm3 with 94% neutrophils; fasting blood sugar 86 mg/dl, urea 45 mg/dl, creatinine 0.8 mg/dl, total bilirubin 0.96 mg/dl, alanine transaminase 78 U/L, aspartate transaminase 82 U/L and alkaline phosphatase 238 U/L. Routine urine examination was normal and culture revealed no growth after 72 h of incubation. Blood culture (two samples) was negative for bacteria. His sputum smear was negative for acid-fast bacilli for 3 consecutive days. Enzyme-linked immunosorbent assay (ELISA) for HIV 1 and 2 was non-reactive. Mantoux test with 5 T.U. was negative. HBsAg and anti-HCV were negative. USG whole abdomen showed hepatosplenomegaly. The patient's condition deteriorated further with appearance of right-sided pleural effusion [] and hepatosplenomegaly. Examination of pleural fluid showed cell count of 560/mm3 with 70% lymphocytes, protein 3.4 gm/dl, sugar 46 mg/dl, lactate dehydrogenase 600 U/L and adenosine deaminase 36 U/L. The patient's contrast enhanced computed tomography (CECT) of thorax showed organization of right middle lobe consolidation with enlargement of right paratracheal and subcarinal lymph nodes with central necrosis []. Fibre-optic bronchoscopy revealed pus coming from the right main bronchus and a gelatinous mass in the posterior wall of trachea and a widened carina with constricted right main bronchus []. Bronchoscopic biopsy from the mass showed inflammatory granulation tissue with proliferation of capillaries and infiltration of a large number of inflammatory cells. Gomori's methenamine silver stain showed fungal spores morphologically resembling Histoplasma capsulatum []. Bronchoalveolar lavage (BAL) and transbronchial needle aspiration (TBNA) from subcarinal lymph node also showed the presence of capsulated round microorganism on a background of inflammatory exudates compatible with Histoplasma capsulatum. Post-bronchoscopic sputum for fungal culture showed a growth of Histoplasma capsulatum. The patient did not have any past history suggestive of exposure to Histoplasma capsulatum. The patient was treated with intravenous amphotericin B 50 mg/day for 1 week followed by oral itraconazole 200 mg twice daily. Significant clinical improvement was noticed by 7 days and follow-up chest X-ray after one month showed a significant radiological resolution [].