A 21-Year-Old Woman With Persistent Fever and Malaise

Muralikrishna Gopalakrishnamoorthy, MBBS, PGY-1; Archana Bhaskaran, MBBS, PGY-1; Rajeswari Anaparthy, MBBS, PGY-1; Ted T. Lin, MS3; Syed Hasan, MBBS


September 30, 2015

Intravenous amphotericin B is the drug of choice for the initial treatment of patients with disseminated histoplasmosis who are severely ill or immunosuppressed or whose infection involves the CNS. The conventional or the lipid formulation can be used, but the lipid formulation is preferred because of a lower incidence of adverse effects. This regimen can be changed to itraconazole (200 mg twice daily) once clinical improvement is evident, and the latter regimen can be used as the initial therapy in less severely ill patients.

Patients with AIDS whose disseminated histoplasmosis has responded to 10 weeks of therapy should receive itraconazole (200 mg/d) for life to prevent relapse. Lifelong maintenance therapy may not be necessary for HIV-infected patients who have received prolonged itraconazole treatment, who have had a sustained response to highly active antiretroviral therapy (HAART), and who no longer have detectable Histoplasma antigen in the serum.

If left untreated, disseminated histoplasmosis is progressive and can lead to death within a few weeks.[1,3,8,9]

After a sputum culture and an acid-fast bacilli smear were noted to be negative, the diagnosis in this patient was subsequently confirmed by an elevated urine Histoplasma antigen value of 42.5 U (upper limit of normal, 2 U), as well as blood cultures that were positive for H capsulatum. She was treated with a 10-day course of intravenous liposomal amphotericin at a dose of 4 mg/kg body weight (usual dose, 3-5 mg/kg body weight); after she showed signs of clinical improvement, therapy was switched to oral itraconazole at a dose of 200 mg twice a day for 1 year.

The patient was not started on antiretroviral therapy at presentation because of concern about immune reconstitution syndrome; however, HAART was initiated at the time of discharge. At the time of the writing of this case report, the patient is doing well on HAART therapy, with recovery of her CD4 count and adequate viral suppression.


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