Travel related histoplasmosis – a diagnostic challenge in a patient with tumor necrosis factor alpha (TNF-α) inhibitor therapy

• Published in: Tropical Diseases, Travel Medicine and Vaccines
• Main Authors: Eveline Hofmann, Konrad Mühlethaler, Matthias Pollak, Daniel Ott, Nora Bienz, Stefan Zimmerli, Cédric Hirzel
• Format: Article in Journal/Newspaper
• Language: English
• Published: BMC 2022
• Subjects: Histoplasmosis; Immunocompromised; TNF-α inhibitor; Returning traveler; Hemophagocytic lymphohistiocytosis; Arctic medicine. Tropical medicine; RC955-962; Arctic
• Online Access: https://doi.org/10.1186/s40794-022-00178-2; https://doaj.org/article/47b47bd26d614519bd0204af3c1968cb

Abstract Introduction In a non-endemic setting, disseminated histoplasmosis is a rare travel-related health problem of immunosuppressed returnees from endemic regions. Methods We describe the case of a 68-year-old man with rheumatoid arthritis and tumor necrosis factor alpha (TNF-α) inhibitor treatment-related immunodeficiency, who suffered from disseminated histoplasmosis after traveling to Brazil. Based on this case, we discuss challenges and pitfalls associated with the diagnosis of disseminated histoplasmosis in a non-endemic setting. Results The disease mimicked a hemophagocytic lymphohistiocytosis (HLH) like syndrome. Histoplasma capsulatum was microscopically detected in bronchoalveolar fluid and bone marrow aspirate smears, but was initially misclassified as Leishmania spp., another class of pathogens, which may cause HLH like syndromes in immunocompromised individuals. Discussion Since the clinical symptoms of histoplasmosis are nonspecific and physicians in non-endemic regions might not be familiar with this disease pattern, there is a risk of delayed diagnosis of travel related cases. Taking a thorough travel history is key in unclear cases of illness in immunocompromised patients.