Korean J Transplant.  2023 Nov;37(Suppl 1):S100. 10.4285/ATW2023.F-6821.

Histoplasmosis masquerading as hemophagocytic lymphohistiocytosis in renal allograft recipient: a case report

• Tiwari V
• Kumar T
• Bhalla A
• Rana D

• KMID: 2551687
• DOI: http://doi.org/10.4285/ATW2023.F-6821

Abstract

Histoplasmosis, caused by Histoplasma capsulatum, is a dimorphic fungal infection prevalent in soil contaminated with pigeon and bat droppings. Most commonly it presents as pulmonary histoplasmosis and disseminated histoplasmosis with involvement of bone marrow in up to one third cases presenting as anemia, leukopenia and refractory thrombocytopenia. Only a few cases of histoplasmosis are reported from the Gangetic plains in India. Due to rarity of the entity and nonspecif-ic symptoms early diagnosis can be challenging. It can be easily misdiagnosed as tuberculosis in Indian setting due to high endemicity of tuberculosis which my lead to delay in treatment. A 44-year-old male with posttransplant status of 1 year with stable graft function presented with low-grade fever, weakness, ecchymotic patches all over his body, and oral mucosal bleed. He had pancytopenia with hemoglobin of 6.8 mg/dL, total leucocyte count of 3,150/cu mm, platelet count of 1,000/mcL, with normal creatinine (1.01 mg/dL). Three weeks prior to this presentation, the patient had a history of mild coronavirus disease 2019 (COVID-19) infection. Various infectious causes were ruled out. In view of pancytopenia, high serum ferritin of 4,025 ng/mL, serum triglyceride of 165 mg/dL, patient was started on intravenous immunoglobulin and intravenous steroids suspecting hemophagocytic lymphohistiocytosis secondary to post-COVID-19 infection. Further, a bone marrow biopsy was done which showed histoplasmosis. To rule out disseminated infection, a chest computed tomography scan was done which was normal. However, the urinary antigen for histoplasmosis was positive. Subsequently, treatment with liposomal amphotericin B (4 mg/ kg/day) led to a gradual improvement in pancytopenia. The patient was discharged on oral itraconazole, with reduced immu-nosuppression using steroids and tacrolimus. Currently, the patient’s condition is stable with normal blood counts, and graft function. This case highlights the importance of considering opportunistic infections, such as histoplasmosis, in immunosuppressed patients, especially after organ transplantation. Early diagnosis and prompt treatment are crucial for better outcomes in such cases.