Disseminated histoplasmosis

Young female with high-risk exposure to HIV presenting with constitutional symptoms (fever and malaise), GI sx (diarrhea, vomiting) and intermittent confusion found to have oral thrush, cholestatic liver injury diagnosed with HIV/AIDS with 1) CMV colitis with viremia; 2) disseminated histoplasmosis (blood, bone marrow, colon) likely leading to HLH vs macrophage activation syndrome. Her ferritin on admission was >100,000 which improved to normal with treatment of underlying disease. Bone marrow biopsy showed hemophagocytosis and histoplasmosis. She was treated with 2 weeks Ambisome IV to treat histoplasmosis before starting abacavir 600 mg/dolutegravir 50 mg/lamivudine 300 mg therapy. Discharged with PO itraconazole 200 BID. Treatment with valganciclovir and then foscarnet for CMV colitis. Atovaquone for PJP ppx. 

Opportunistic infection by CD4 count

Disseminated histoplasmosis
Our patient worked in a food factory with live chickens. Remember, it starts off as mold in soil from animal droppings (birds) and turns into yeast in the host. Aerosolized particles are inhaled and spread though our lymph nodes. HIV/AIDS is a risk factor to develop disseminated histoplasmosis. The most common complication is GI tract involvement . Histoplasmosis itself is shown to induce HLH. Treatment of disseminated histoplasmosis is 14 days of IV Amphotericin followed by PO itraconazole. 

Starting HAART
Start HAART therapy as soon as possible except if there is CMV retinitis, cryptococcal meningitis, TB meningitis, new pulmonary TB or disseminated MAC. 

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