Granulomatous Hepatitis Secondary to Histoplasmosis in an Immunocompetent Patient

Abstract

Histoplasma capsulatum is the most common endemic mycosis in the United States and usually occurs in certain geographic areas, such as the Mississippi or Ohio River valleys. Histoplasmosis usually causes a mild disease in the immunocompetent but can progress to disseminated disease in patients with impaired immunity. Granulomatous hepatitis as a manifestation of disseminated histoplasmosis in immunocompetent patients is extremely rare. We report the case of a 62-year-old immunocompetent gentleman with a history of histoplasmosis who presented with abdominal pain, elevated liver enzymes, who was diagnosed with granulomatous hepatitis secondary to histoplasmosis.

Gastrointestinal Histoplasmosis: A Descriptive Review, 2001–2021

“…The non-specific signs and symptoms of GIH, as highlighted in this review, include but are not limited to abdominal pain [ 12 , 18 , 19 , 20 , 20 , 21 , 22 , 25 , 27 , 31 , 33 , 35 , 36 , 37 , 38 , 40 , 41 , 43 , 45 , 47 , 50 , 51 , 54 ], diarrhoea [ 12 , 17 , 19 , 21 , 22 , 36 , 37 , 38 , 39 , 40 , 43 , 53 , 68 , 74 , 75 , 103 , 104 , 105 , 106 ], fever [ 12 , 13 , 17 , 19 , 26 , 27 , 28 , 30 , 31 , 33 , 35 ], weight loss [ 13 , 31 , 77 , 79 , 84 , …”

“…Thus, when an individual, especially in the setting of an immunocompromised state, presents with fever and jaundice, this disease entity should be considered or ruled out. Of the 123 cases, 16 had granulomatous hepatitis with six having coexisting cholecystitis [ 22 , 32 , 34 , 47 , 54 , 56 , 61 , 67 , 68 , 72 , 73 , 76 , 83 , 97 , 114 , 118 ]. Of the 16, 11 were immunocompromised secondary to HIV infection (n = 3) [ 68 , 72 , 114 ], post-transplantation on immunosuppressive therapy (n = 2) [ 61 , 72 ] and some were on immunosuppressive therapy for various ailments (n = 6), azathioprine [ 32 , 76 ], methotrexate [ 34 , 73 , 118 ], steroids [ 32 , 34 , 118 ], infliximab [ 32 , 73 ], fingolimod [ 54 ], mycophenolate, adalimumab [ 76 , 118 ], mesalazine [ 76 ] and the remainder were immunocompetent [ 22 , 47 , 56 , 67 , 97 ].…”

“…Of the 123 cases, 16 had granulomatous hepatitis with six having coexisting cholecystitis [ 22 , 32 , 34 , 47 , 54 , 56 , 61 , 67 , 68 , 72 , 73 , 76 , 83 , 97 , 114 , 118 ]. Of the 16, 11 were immunocompromised secondary to HIV infection (n = 3) [ 68 , 72 , 114 ], post-transplantation on immunosuppressive therapy (n = 2) [ 61 , 72 ] and some were on immunosuppressive therapy for various ailments (n = 6), azathioprine [ 32 , 76 ], methotrexate [ 34 , 73 , 118 ], steroids [ 32 , 34 , 118 ], infliximab [ 32 , 73 ], fingolimod [ 54 ], mycophenolate, adalimumab [ 76 , 118 ], mesalazine [ 76 ] and the remainder were immunocompetent [ 22 , 47 , 56 , 67 , 97 ]. Investigations revealed markedly elevated liver enzymes with coexisting gall bladder disorder [ 22 , 44 , 54 , 67 , 68 , 118 ] and enlarged liver [ 32 , 34 , 68 , 83 ].…”

“…Of the 16, 11 were immunocompromised secondary to HIV infection (n = 3) [ 68 , 72 , 114 ], post-transplantation on immunosuppressive therapy (n = 2) [ 61 , 72 ] and some were on immunosuppressive therapy for various ailments (n = 6), azathioprine [ 32 , 76 ], methotrexate [ 34 , 73 , 118 ], steroids [ 32 , 34 , 118 ], infliximab [ 32 , 73 ], fingolimod [ 54 ], mycophenolate, adalimumab [ 76 , 118 ], mesalazine [ 76 ] and the remainder were immunocompetent [ 22 , 47 , 56 , 67 , 97 ]. Investigations revealed markedly elevated liver enzymes with coexisting gall bladder disorder [ 22 , 44 , 54 , 67 , 68 , 118 ] and enlarged liver [ 32 , 34 , 68 , 83 ]. Diagnosis of granulomatous hepatitis was made via liver biopsy, which showed characteristic features of H.capsulatum [ 22 , 32 , 34 , 54 , 56 , 72 , 73 , 97 ].…”

Histoplasmosis hepática y peritoneal simulando otra patología

“…Los pacientes con compromiso hepático se presentan con síntomas inespecíficos, como fiebre de origen desconocido, náuseas y vómitos, dolor abdominal, ictericia y alteración del hepatogama. [7][8][9] Los hallazgos patológicos…”