Gastrointestinal Histoplasmosis Presenting as an Acute Abdomen with Jejunal Perforation

Introduction Gastrointestinal histoplasmosis (GH) is a well-described albeit uncommon disease. It is found almost exclusively in the immunocompromised host, especially those with untreated HIV and low CD4 counts. Presentation with intestinal perforation is seen mostly commonly in the colon. We present a patient with jejunal perforation, and there have been only 3 previous cases reported in the literature. Case A 39-year-old male with known, untreated HIV presented to the ED with an acute abdomen after experiencing worsening intermittent abdominal pain for 2 months before that was associated with nausea, vomiting, diarrhea, and weight loss. CT of the abdomen and pelvis revealed evidence of gas in the mesentery, small bowel thickening, edema, and free fluid in the abdomen. Emergency exploratory laparotomy was conducted. Intraoperative findings included a perforated jejunum that was studded with nodular lesions as well as mesenteric masses. Histopathologic exam of these mesenteric masses and jejunal lesions were positive for histoplasmosis. Conclusion Disseminated histoplasmosis is a life-threatening disease that occurs nearly exclusively in immunocompromised hosts. Untreated, mortality is as high as 80%. This rare presentation with jejunal perforation highlights the need for awareness of histoplasmosis involvement throughout the entirety of the GI tract.


Introduction
Gastrointestinal histoplasmosis is a well-described phenomenon, occurring almost exclusively in immunocompromised patients. An estimated 70-90% of patients with disseminated histoplasmosis have GI involvement. Of these, only 3-12% are believed to have GI-related symptoms [1]. e most commonly involved sites are the colon and distal ileum, with weight loss, abdominal pain, fever, and diarrhea being the most frequent symptoms. Several case reports and case series have described bowel obstruction and, rarely, perforation, the most common sites being colon or ileum [2][3][4][5][6][7][8][9]. Jejunal perforation has been reported only three times in our literature review [2,10,11]. We hereby present an HIV patient presenting with an acute abdomen found to have di use jejunal and mesenteric disease. Exploratory laparotomy revealed jejunal perforation.

Case
A 39-year-old HIV-positive male presented to the Emergency Department complaining of severe, sharp pain di usely across the abdomen that had awoken him from sleep at 01 : 30 AM. He had been experiencing milder, intermittent abdominal pain for 2 months before. Additionally, he admitted to chills, weight loss, loss of appetite, nausea, and occasional diarrhea and vomiting for 1 month. ere was no reported hemoptysis, hematochezia, melena, or fevers. He had a cough with green sputum for 2 months as well.
He had a past medical history signi cant for HIV due to IV drug use diagnosed 10 years earlier that he had neglected to treat. He has hepatitis C as well. He previously has abused alcohol but had quit 2 months ago, and quit IV drug use 11 years ago. He has less than 10 pack/year smoking. He has been in a monogamous relationship with his girlfriend for multiple years and denies any history of risky sexual behaviors including having polygamous or homozygous relationship. He has lived in southern Texas his whole life, an area of the US known to be mildly endemic with histoplasma species. He had no signi cant travel history.
CT of the abdomen and pelvis ( Figure 1) revealed gas bubbles scattered throughout the left mesentery, multiple areas of small bowel thickening and edema, evidence of free uid in the abdomen, and mesenteric masses ( Figure 1). ese ndings supported bowel perforation. Additionally, workup included CT angiogram (CTA) of the chest, to exclude the pulmonary embolism. e CTA showed 16 mm right lower lobe nodule (Figure 2), as well as a 6 mm left upper lobe nodule. No hilar or mediastinal adenopathy was seen.
An exploratory laparotomy was performed. is revealed numerous nodular implants throughout the small bowel as well as numerous masses in the mesentery. ere was an obvious perforation in the mid to proximal jejunum associated with a nodular lesion that had caused a stricture. e perforated segment was resected along with a representative mesenteric mass. Primary anastomosis was performed noting that the extent of disease involvement in the small bowel prohibited complete resection of all lesions.
In regard to his pulmonary nodule seen on the CTA, the patient underwent bronchoscopy. Minimal di use in ammatory changes and thick whitish secretions were seen in the right lower lobe and right upper lobe. Bronchoalveolar lavage (BAL) was performed from left upper and right lower lobe. Gram stain of the BAL uid showed 3 + WBCs with rare Gram negative rods, 1+ Gram positive cocci, and few coryneform Gram positive rods which was felt to be consistent with normal upper respiratory ora. Cultures grew rapid growing candida species. Pathological examination of the BAL uid revealed in ammatory debries with yeast forms seen on the silver stain. No biopsies were performed. e patient was started on oral itraconazole, 200 mg orally TID for 3 days, and then changed to 200 mg orally BID anticipating 12 months of treatment. In addition to prophylactic, trimethoprim/sulfamethoxazole 800 mg/160 mg one tablet orally and azithromycin 1500 mg orally once per week were started. He was not immediately started on antiretroviral therapy due to lack of inpatient access to these medications.
His hospitalization was complicated by high output drainage from his surgical JP drain.
is eventually decreased to a more manageable level, and the patient was discharged home with his JP drain in place on day 17 of hospitalization. On discharge, he was referred to a local clinic for treatment of AIDS. He failed to follow-up there, citing nancial hardship. e patient returned to the hospital 1 week after discharge with fever, chills, constipation, and abdominal discomfort with partial small bowel obstruction, which was managed conservatively and good resolution was achieved. Repeat bronchoscopy with BAL was negative except for growing yeast in the BAL. Patient was changed to liposomal amphotericin B intravenously with good clinical response. After 2 weeks of intravenous liposomal amphotericin B, he was switched back to itraconazole 200 mg orally BID, anticipating 12 months of therapy with close follow-up. He was discharged home with an instruction to follow-up at the HIV clinic to be started on antiretroviral therapy and followup CT scan of chest in 4 weeks.   Case Reports in Medicine

Discussion
Histoplasma capsulatum is a dimorphic fungus endemic to the Midwestern and Southeastern United States as well as Central and South America. It is found most readily in soil contaminated with bird or bat guano [12]. It is the most frequent cause of fungal respiratory infections and usually has a self-limited course in immunocompetent hosts. It may also present as a progressive disseminated disease that can be life threatening, especially in the elderly and immunocompromised hosts. HIV-positive individuals with CD4+ cell counts lower than 200 cells/mL are at elevated risk for disseminated histoplasmosis (DH). Gastrointestinal histoplasmosis (GIH) is uncommon, manifesting symptomatically in 3-12% of patients with DH. Much higher rates of GI histoplasmosis have been reported on autopsy review indicating the presence of disease which is asymptomatic [11]. Nevertheless, it is a rare disease and presents almost exclusively in the immunocompromised host. e most common sites of involvement are the colon and ileum. It becomes less common more proximally in the small intestine [2,11,13]. e most common symptoms in those with GIH are weight loss, abdominal pain, fever, and diarrhea. e disease manifests variably as intestinal ulcers, bleeding, strictures, and, rarely, perforation. Several published cases and case series report ileal and colonic perforation. In 2000, Gumbs et al. reported what they believed to be the rst report of jejunal perforation [10]. A 2006 case series by Assi et al. report 18 new cases of GI histoplasmosis. Among these, 1 experienced jejunal perforation [13].

Conclusion
is rare presentation of a jejunal perforation due to disseminated histoplasmosis highlights the need for heightened awareness of this disorder in immunocompromised individuals. e majority of patients of GIH are AIDS patients with low CD4 counts who have not received therapy. e mortality in these patients without therapy is high, approaching 80%. With antifungal therapy, mortality improves to 30%. Our patient was initially treated with itraconazole, but was later changed to liposomal amphotericin B when his pulmonary lesions advanced. With this regimen, he has remained stable, although noncompliance with antiretroviral therapy remains an issue.

Conflicts of Interest
e authors declare that they have no con icts of interest. Case Reports in Medicine 3