P1935 - Increasing ALP as the Primary Manifestation of Disseminated Histoplasmosis in AIDS Patient Without Pulmonary Disease

Triston Berger, MD, Sebastian Borja, MD, Jaspreet Suri, MD
Norwalk Hospital, Norwalk, CT

Introduction: Histoplasmosis is an infection caused by the dimorphic fungi Histoplasma found in the soil of the central and eastern US. Most immunocompetent hosts present with a self-limited illness, however the immunocompromised may develop disseminated disease. Without initiation of antifungal therapy in these cases, histoplasmosis is fatal. The symptoms are non-specific, making rapid diagnosis and treatment difficult. Hepatic involvement in the setting of disseminated histoplasmosis (DH) from a pulmonary source is documented, however hepatic manifestations as a primary symptom in the absence of pulmonary disease is rare. Specifically, the isolated worsening of ALP as the primary manifestation of DH without pulmonary manifestations has not been reported on review of literature.

Case Description/Methods: 51yo F with PMH of AIDS, DM, IVDU, esophageal candidiasis, Crohn's disease presented with 4 days of weakness, diarrhea, and night sweats. Initial blood work was significant for electrolyte abnormalities, pancytopenia, elevations in ALP and AST, mild DIC, and CD4 of 4cell/mm³. Imaging showed no focal lung disease. Hepatic steatosis, esophageal thickening, splenomegaly, and lymphadenopathy with prior biopsy supporting HIV lymphadenopathy was noted. Pt had negative cultures and resolution of fevers by day 3 and felt at baseline by day 6. Infectious workup returned negative including serum CF for histoplasma yeast and mycelial Abs. ALP levels increased to 1725U/L with AST/ALT/Bili stable. MRCP was non-revealing. Liver biopsy demonstrated yeast forms, and urine histoplasma Ag returned positive day 13. She was started on appropriate antifungal therapy and showed improvement of ALP to baseline 3 months later.

Discussion: Our case presents the workup of DH in an AIDS patient with the primary manifestation of isolated elevations in ALP without pulmonary disease. It is interesting that despite ongoing infection without adequate antifungal therapy she remained afebrile and felt at baseline early in hospital course. Given the critical CD4 count she was not able to mount an immune response to stimulate the formation of antibodies to a detectable level, resulting in negative serum CF for yeast and mycelial Abs and delay in treatment. Given the increased false negative rate of Ab testing in AIDS patients and time it takes for Ag testing to result, it may be beneficial to consider tissue sampling earlier when a source is not identified, especially considering the mortality of disseminated infections without rapid treatment.


Disclosures:


Triston Berger, MD, Sebastian Borja, MD, Jaspreet Suri, MD. P1935 - Increasing ALP as the Primary Manifestation of Disseminated Histoplasmosis in AIDS Patient Without Pulmonary Disease, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.