CRA14 FATAL DISSEMINATED HISTOPLASMOSIS IN A RENAL TRANSPLANT RECIPIENT: A REMINDER OF OPPORTUNISTIC FUNGAL INFECTION

Xiao Rou Tan, Suat Yee Lim, Rozanah Abd Rahman
Hospital Sultanah Aminah, Johor Bahru, Malaysia

Introduction
Histoplasmosis is a fungal infection caused by the dimorphic fungus Histoplasma capsulatum, which is infrequently isolated in Malaysia. In immunocompromised individuals, such as organ transplant recipients, it can progress to disseminated disease, which may be life-threatening if not diagnosed and treated promptly.

Case presentation
A 63-year-old man with a history of renal transplantation in 2006 presented with a one-week history of fever, left iliac fossa pain, and lethargy. Physical examination revealed tenderness in the left iliac fossa, erythema nodosum on the right lower limb, and a left gluteal abscess. Laboratory investigations showed persistent hypercalcemia, mildly elevated serum ACE levels, and a normal intact PTH. Colonoscopy revealed pancolonic diverticulitis. PET-CT imaging demonstrated hypermetabolic lymphadenopathy in the left supraclavicular and retroperitoneal regions, along with bilateral ground-glass opacities in the lungs. A skin biopsy showed septal panniculitis containing fungal elements while bronchoscopy and fungal PCR confirmed the presence of Histoplasma capsulatum. A diagnosis of disseminated histoplasmosis was made, affecting the skin, lungs, gastrointestinal tract, and soft tissue. The patient initially showed improvement with intravenous amphotericin B therapy. Unfortunately, his condition later worsened, and he succumbed to a bleeding diverticulum, suspected to be a complication of the disseminated infection.

Discussion & Conclusion
This case highlights its diverse clinical manifestations, including pulmonary, cutaneous, gastrointestinal, and soft tissue involvement. The presence of hypercalcemia and elevated ACE levels should raise suspicion for underlying granulomatous disease. Despite initial improvement with amphotericin B, the patient succumbed to a fatal gastrointestinal bleed, likely related to histoplasmosis-induced colonic involvement. Clinicians must remain vigilant for opportunistic infections like histoplasmosis in high-risk populations, as early diagnosis and treatment are crucial for improving outcomes.