Published in:
01-09-2017 | Clinical Practice: Clinical Images
Fever, Splenomegaly, and Pancytopenia: Histoplasma-Associated Hemophagocytic Lymphohistiocytosis
Published in: Journal of General Internal Medicine | Issue 9/2017
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A 26-year-old man with acquired immunodeficiency syndrome (AIDS) taking no medications presented with fever and anorexia. Examination showed a febrile cachectic man with splenomegaly. Laboratory analysis revealed pancytopenia (white cell count 2.1 × 103/μL, hemoglobin 8.1 gm/dL, platelet count 49 × 103/μL) and CD4 count 2/μL. Serum ferritin (8312 mcg/L) and fasting triglycerides (312 mg/dL) were elevated. Urinary Histoplasma antigen was positive. Bone marrow biopsy demonstrated histiocytes with intracellular yeast and ingested red blood cells (Figs. 1 and 2). The patient was diagnosed with disseminated histoplasmosis that manifested as hemophagocytic lymphohistiocytosis (HLH) and was treated with antiretroviral therapy, intravenous amphotericin B for 2 weeks, and oral itraconazole for 1 year.
Figure 1
Several enlarged histiocytes containing numerous yeast forms which are surrounded by a clear zone, characteristic of Histoplasma (red arrows). One histiocyte (at the top) also contains an engulfed red blood cell (black arrow). Bone marrow, Wright-Giemsa stain, ×1000.
Figure 2
GMS stain highlights numerous fungal organisms identified as capsulated yeast (red arrows). Bone marrow, Gomori methenamine silver (GMS) stain, ×50.
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