Yazan Addasi, MD, Haitam M. Buaisha, MBBCh, Ala Abdel-Jalil, MD; Creighton University School of Medicine, Omaha, NE
Introduction: Histoplasmosis is highly endemic in Ohio and Mississippi river valleys. While it is usually asymptomatic in immunocompetent individuals, sever disseminated infection is mostly seen in patients with impaired cellular immunity. Mediastinal granuloma related to histoplasmosis causing dysphagia is rare, especially in immunocompetent patients.
Methods: A previously healthy 40-year-old male presented with pleuritic-type chest pain and solid-food dysphagia for two months. He was active in military with travel to multiple countries in the Middle East prior to his illness. On exam, he appeared well-nourished, with no palpable lymphadenopathy. Labs showed WBC count 11.3 ×103/μL, negative HIV testing. Chest computed tomography (CT) with showed a 4.5 x 2.3 cm complex, partially cystic-appearing septated lesion, with peripheral solid component in the subcarinal region, inseparable from the esophagus. Esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) showed extrinsic compression on mid-esophagus and a 20 x 50 mm thinly-septated, bi-lobed, hypoechoic structure with some internal debris in subcarinal region, with no calcifications. Patient underwent thoracotomy with excision of multiple purulent matted periesophageal lymph nodes. Biopsies showed reactive lymph nodes with necrotizing and non-necrotizing granulomas with scattered yeast suggestive of histoplasmosis. Considering location of the mass and its symptomatic nature, patient was treated with itraconazole for two months with complete resolution of symptoms. Discussion: Gastrointestinal manifestations of histoplasmosis are recognized clinically in around 10% of cases. Esophageal involvement is rare and can be secondary to extrinsic compression by enlarged lymph nodes or as part of disseminated process. Rarely, dysphagia can be the initial presenting symptom of mediastinal granuloma. CT is helpful in detecting well-defined nodes with central calcification. EUS typical features include matted mediastinal lymph nodes or a mass, with possible calcifications. Mediastinal granuloma secondary to histoplasmosis causing dysphagia is rare, especially in immunocompetent individuals. Detailed history, CT scan, EGD and EUS can help aid the diagnosis. Treatment is usually dictated by patient’s presentation and immune status, and may include anti-fungal therapy, surgery or combination.
A complex, partially cystic appearing septated lesion, with peripheral solid component in the subcarinal region, inseparable from the esophagus (Measures approximately 4.5 x 2.3 cm).
EUS showing a thinly-septated, bi-lobed, para-esophageal hypoechoic structure with some internal debris.
Hematoxylin & Eosin images showing caseating granuloma with inflammatory cells and scattered yeast suggesting histoplasmosis
Disclosures: Yazan Addasi indicated no relevant financial relationships. Haitam Buaisha indicated no relevant financial relationships. Ala Abdel-Jalil indicated no relevant financial relationships.