Abstract Introduction Sarcoidosis and histoplasmosis can present with overlapping clinical and radiologic features. We demonstrate the importance of high clinical suspicion for disseminated histoplasmosis diagnosis in an immunocompetent host. Case Presentation A 77-year-old female with a history of primary biliary cholangitis was admitted for a fall and found to have incidental hypercalcemia with computed tomography (CT) evidence of pelvic bony lesions concerning for malignancy. A bone marrow biopsy revealed noncaseating granulomas. She was discharged with planned follow-up but was re-admitted two weeks later for fatigue and altered mental status. Physical exam revealed a parotid mass. Laboratory abnormalities included thrombocytopenia and elevated ACE, CRP, and ESR levels. She tested negative for HIV. A CT chest showed ground-glass opacities, innumerable scattered solid lung nodules, a calcified lung granuloma, and mediastinal lymphadenopathy. There was no family history of rheumatologic or autoimmune disease. Travel history was unknown. Due to a high suspicion for Extrapulmonary Sarcoidosis as well as immune-mediated thrombocytopenia (ITP), the decision was made to initiate empiric corticosteroids. The hospital course was complicated by multiorgan failure, acute renal failure requiring dialysis, and an elevated alkaline phosphatase with hyperbilirubinemia, necessitating ICU level of care. The patient unfortunately declined further, developed worsening shock and progressive encephalopathy, culminating in a transition to comfort care. On autopsy, she was found to have disseminated fungal infection diagnostic of histoplasmosis, with fungal elements identified in the liver, spleen, pancreas, mediastinal lymph nodes, and lungs. Discussion Disseminated histoplasmosis is an endemic mycosis caused by Histoplasma capsulatum, which is often associated with the Mississippi and Ohio river valleys. This disease primarily affects immunocompromised individuals, especially those with advanced HIV or organ transplant recipients. Histoplasmosis in immunocompetent patients is often asymptomatic or self-limited, and disseminated disease in an immunocompetent patient is rare. This case highlights a rare presentation of histoplasmosis in an immunocompetent patient in a nonendemic region, emphasizing the need for high clinical suspicion for histoplasmosis. Immunosuppressive therapy, in this case as empiric corticosteroids ITP and sarcoidosis, can unmask or worsen underlying histoplasmosis. This abstract is funded by: no funding
Cobb et al. (Fri,) studied this question.