A sixty-four-year-old renal transplant recipient woman presented at the hospital six years after transplantation. She had had a history of fever, hypotension, and asthenia with 36 hours of evolution associated with seven kilograms of weight loss in three months. Physical examination revealed white spots in the mouth and a rash on the back (Figure 1). The patient had anemia (Hb 8.4 g/dL, Ht 23.0%), leukopenia (2.3x109/L), C reactive protein (10.8 mg/dL) and ferritin (13.253 ng/mL) above the normal range, and acute graft dysfunction (Cr 3.0 > 4.0mg/dL). Liver function was not compromised (albumin 3.7g/dL, aspartate aminotransferase 32 U/L, alanine aminotransferase 29 U/L). Her immunosuppression regimen at admission was prednisone (5 mg/day) and azathioprine (2 mg/Kg/day), and the basal serum creatinine (Cr) value was 3.0 mg/dL.
On the day of her admission, hemocultures were performed to search for fungus and mycobacterium. Polymerase chain reaction (PCR) for CMV and Epstein Barr virus (EBV), latex agglutination test for cryptococcus, and serology for Histoplasma capsulatum and Trypanosoma cruzi were also done. From that day, an empiric treatment with vancomycin, meropenem, and ganciclovir was started aiming to treat a possible bacterial infection or a viral opportunistic one.
CMV antigenemia was negative but PCR unveiled 546 copies of the virus. A decision was made to perform a biopsy of the cutaneous lesion and cultivate fungi and mycobacteria. For further investigation, image tests such as a thoraco-abdominal computerized tomography scan (CT) and an echocardiogram were done, which did not reveal any abnormality. A myelogram showed erythroid hyperplasia and an upper digestive endoscopy showed an ulcerative esophagitis with intranuclear inclusions and some esophageal candidiasis lesions. Fluconazole was associated with the current antimicrobial and antiviral regimen (vancomycin, meropenem and gancyclovir).
The clinical condition of the patient declined, she had melena and mucocutaneous bleeding with hemodynamic instability, which evolved to disseminated intravascular coagulation (DIC). We empirically started liposomal amphotericin B to cover histoplasmosis and a four-drug treatment for tuberculosis. The patient did not improve and became unstable, needing mechanical ventilation and vasopressor support. She had acute hepatitis due to liposomal amphotericin B hepatotoxicity and died 7 days after starting the treatment for histoplasmosis.
The diagnosis of sepsis-like histoplasmosis was done after laboratory results obtained post-mortem. Histoplasma capsulatum was found in blood cultures and serology by double immunodiffusion and immunoblotting (band H and M). The microbiology of the skin biopsy also isolated H. capsulatum.