Enlarged hilar lymph node due to Histoplasma

A 13-year-old boy from Northeastern Brazil presented with a 12-month history of productive cough. Physical examination revealed small cervical and epitrochlear lymph nodes. He denied contact with bats, but stated that pigeons were located near his school. Red blood cell, leukocyte, and C-reactive protein levels were normal. Chest radiography showed a radiopaque nodule on the left inferior lobe (Figure 1; white arrow) and an amorphous image of a lobulated lineament on the left inferior hilum (5.5×3.5cm), suggesting an adenomegaly. Computed tomography (Figure 2) revealed a 5.6×3.1×3.2-cm lymph node at the left hilum with a necrotic center, peripheral calcification, and splenic granulomas. Bronchoalveolar lavage disclosed a small amount of leukocytes with negative stain and culture results. The tuberculin test and Cytomegalovirus [immunoglobulin M/immunoglobulin G (IgM/IgG)] and Toxoplasma serologies were negative. The Histoplasma serology (immunodiffusion) was positive. Following initiation of itraconazole (400mg/day), the cough remarkably diminished. Disseminated histoplasmosis is frequently diagnosed in patients with acquired immunodeficiency syndrome (AIDS) in Brazil. However, the acute pulmonary form is rarely diagnosed due to its self-limiting nature and unawareness of local physicians regarding its manifestations and complications, including mediastinal or hilar lymphadenitis¹. The diagnosis of acute pulmonary histoplasmosis in patients with no history of intense exposure to this fungus is difficult. Tuberculosis and malignancies are frequently the main hypotheses^{2) (3}. The elapsed time from symptom onset until seeking medical assistance may suggest an infectious agent. The positive serology for Histoplasma combined with the remarkable response to itraconazole may corroborate the presumptive diagnosis of this mycosis.

References

• ¹
  Fischer GB, Mocelin H, Severo CB, Oliveira FM, Xavier MO, Severo LC. Histoplasmosis in children. Paediatr Respir Rev 2009; 10:172-177.
• ²
  Aide MA. Chapter 4: histoplasmosis. J Bras Pneumol () 2009; 35:1145-1151. http://dx.doi.org/10.1590/S1806-37132009001100013
  » http://dx.doi.org/10.1590/S1806-37132009001100013
• ³
  Deus Filho A, Wanke B, Cavalcanti MAS, Martins LMS, Deus ACB. Histoplasmose no Nordeste do Brasil: Relato de três casos. Rev Port Pneumol () 2009; 15:109-114.

Publication Dates

• Publication in this collection
  Sep-Oct 2016

History

• Received
  27 Jan 2016
• Accepted
  26 Apr 2016