the diagnosis is usually made by demonstration of antigen in the urine , serum , relevant body fluids or pus and by fungal culture .
herein we are presenting a rare case of genitourinary histoplasmosis where the diagnostic dilemma was resolved by fungal culture of prostatic abscess and histopathological examination of epidydimal tissue .
a 37-year - old male , a renal transplant recipient , with the mother as donor , presented with complaints of pain and swelling in the scrotum and fever of one week duration , three years after the transplant .
post transplantation , he was on triple immunosuppressive therapy with tacrolimus , azathioprim , and prednisolone , and his allograft function was stable .
one - and - a - half years after his renal transplant , he had dysphagia and malena , and was diagnosed with esophageal candidiasis and colonic histoplasmosis on the basis of upper gastrointestinal endoscopy and colonoscopy , respectively .
histoplasmosis was confirmed by demonstrating histoplasma capsulatum on histopathology of the biopsy from colonic ulcers and stool culture .
he responded to itraconazole , which was continued for nine months and was asymptomatic on follow - up . at the time of this presentation ,
three years after the transplant , blood investigations revealed severe anemia , leucopenia , thrombocytopenia , and serum creatinine of 3.0 mg / dl .
urinalysis showed proteinuria ( 300 mg / dl ) with numerous red blood cells ( rbcs ) and pus cells .
digital rectal findings suggested bogginess on the anterior rectal wall with prostatic landmarks not well appreciable .
the ultrasound showed enlarged , heterogenous epididymis , with fluid collection and a thick - walled collection in the prostate and retrotrigonal area .
computerized tomography of the pelvis confirmed the ultrasound findings [ figures 1a , b ] .
ct scan pelvis showing retrotrigonal ( a ) and prostatic location ( b ) of collection the epididymal swelling was explored and tissue biopsy was sent for polymerase chain reaction ( pcr ) for mycobacterium tuberculosis and histopathology .
the prostatic and retrotrigonal collection was drained via the per - rectal route and sent for culture studies .
histopathology diagnosed histoplasmosis [ figure 2 ] and culture of the pus ( obtained from the prostatic / retrotrigonal abscess ) confirmed the growth of histoplasma capsulatum [ figure 3 ] .
a repeat colonoscopy was done , which did not reveal any ulcers or polyps or any other finding suggestive of intestinal histoplasmosis .
the patient was restarted on itraconazole for nine months , to which he responded successfully .
photomicrograph showing sheets of histiocytes with intracytoplasmic pas - positive yeast forms , suggestive of histoplasmosis : pas stain 400 magnification photomicrograph showing saprophytic phase of histoplasma capsulatum with spherical , tuberculate , macroconida ( 8  14 m ) : lactophenol cotton blue stain 40 magnification
the risk of genitourinary tuberculosis is increased in transplant recipients , who are either born or live in areas where tuberculosis is endemic .
the frequency of mycobacterium tuberculosis disease among the recipients of solid organ transplants in most developed countries is 1.2  6.4% , but among transplant recipients living in areas of high endemicity , it can reach 15% .
it is worth noting that diverse , unsuspected , and elusive sites of tuberculosis infection have been described . in this patient , with enlargement of epididymis
coupled with findings of an abscess in the prostatic and retrotrigonal region , tuberculosis was a strong probability . however , tissue pcr and culture for mycobacterium tuberculosis was negative and findings of histopathology and culture were conclusive for histoplasmosis .
even as most cases of histoplasmosis were asymptomatic or self - limiting , they could rarely lead to severe and progressive disseminated infections .
diagnosis of disseminated histoplasmosis required a high index of suspicion.[24 ] only four cases of epididymal histoplasmosis have been reported in literature so far .
two cases were diagnosed from the united states in 1981 , one was presented by kahn dg , et al . , at a conference in the united states in 1992
( international conference on acquired immunodeficiency syndrome ( aids ) 1992 jul 19 - 24 ; 8 : 93 ) , and the fourth case was reported from india in 1995 .
three cases were diagnosed by histopathological examinations and pus cultures , and the fourth case was diagnosed with the help of a seminal culture .
all the cases had a similar clinical presentation : fever , weight loss , and testicular pain and / or swelling .
involvement of the prostate is very rare and only nine cases have been previously reported .
reinfection can occur in patients who have had histoplasmosis in the past , like our patient who had colonic histoplasmosis .
when there is a decline in immunity in such a host , residual host defenses can not combat invasion by histoplasma .
diagnosis of histoplasmosis is made by the demonstration of antigen in the urine , serum , relevant body fluids or pus .
histopathology of the suspected lesion can reveal yeast structures of h. capsulatum via the hematoxylin and eosin stain ; however , the organism is better visualized using methenamine silver or periodic acid schiff stains ( pas ) .
confirmation can be obtained by setting up appropriate cultures , demonstrating the growth and dimorphic properties of the fungus .
a high index of suspicion is needed for the diagnosis of histoplasmosis in immunosuppressed patients .
the tissue , pus , and body fluid available for diagnosis must be subjected to investigations for uncommon infections , too .
 genitourinary histoplasmosis is very rare and to our knowledge only four cases of epididymal histoplasmosis and nine cases of prostatic histoplasmosis have been reported in literature . 
 we hereby report a case of a middle - aged male , who presented three years after renal transplant , with complaints of fever , pain , and swelling in the scrotum . 
 imaging disclosed an enlarged right epididymis with prostatic and retrotrigonal abscess , suggesting tuberculosis infection . 
 however , histopathology of the epididymal biopsy revealed histoplasmosis , and the drained pus on culture confirmed infection with histoplasma capsulatum . 
INTRODUCTION
CASE REPORT
DISCUSSION