Title : Miliary histoplasmosis in a recently transplanted patient
Abstract:
Miliary histoplasmosis is an unusual presentation of pulmonary histoplasmosis and may also represent disseminated disease at onset. Immunocompromised patients remain at high risk for this rare infection - with solid organ transplant patients specifically having an incidence of <0.5%, even in endemic areas. This case study follows a 29-year-old male with a complex medical history, including factor 5 deficiency, end-stage renal disease secondary to glomerulonephritis, and a recent living donor renal transplant.
Initially presenting with respiratory symptoms, he was diagnosed with atypical community-acquired pneumonia, later identified as histoplasmosis. Despite initial treatment, including ceftriaxone and azithromycin, the patient's condition deteriorated due to immunocompromise from anti-rejection medications. Further testing confirmed histoplasmosis, leading to treatment with voriconazole and subsequent complications, including a drug reaction and relapse of infection.
The case highlights challenges in managing fungal infections in immunocompromised hosts and the importance of adjusting treatment based on radiographic findings and laboratory tests. Additionally, it raises questions about the optimal duration of antifungal therapy in solid organ transplant recipients, suggesting the need for longer courses compared to guidelines for other patient populations.
Audience Take Away Notes:
- How to use urine antigen testing to guide ongoing antifungal therapy
- Assessing ongoing multidisciplinary guided therapy for both ongoing antifungal use with immunosuppressants to avoid graft rejection
- Consider how imaging intervals can be further optimized to assess for disease progression/regression when symptoms are atypical
