Abstract
ISOLATED INTRAMEDULLARY HISTOPLASMOSIS/BLASTOMYCOSIS OF THE THORACIC CORD WITHOUT PULMONARY INVOLVEMENT: A RARE INITIAL PRESENTATION IN AN IMMUNOCOMPROMISED ADULT
Chest, v 168(4), pp 1566A-1567A
2025
Abstract
INTRODUCTION: Histoplasma capsulatum and Blastomyces dermatitidis, typically presents as a pulmonary infection that may subsequently disseminate to other organs. When confined to the lungs, they commonly manifest as a fungal ball, a chronic granulomatous lesion that can mimic malignancy. Given that most patients with a fungoma are asymptomatic, it's crucial to consider it as a differential diagnosis when encountering a solitary pulmonary nodule in immunocompromised individuals with possible exposure living in or passing through endemic areas. Fungoma within the Central nervous system, particularly within the spinal cord without pulmonary involvement is a very rare manifestation of the infection, with limited cases documented.
CASE PRESENTATION: A 44-year-old female with a history of sarcoidosis on Azathioprine, hypertension, GERD, iron deficiency anemia, and prediabetes presented with progressive neurological symptoms. The patient initially experienced midline thoracic pain radiating to the left chest for two months. History suggested an immunocompromised state. Incidentally patient mentioned traveling through areas known to be higher concentration for fungal exposures (Ohio and Mississippi river valley). An MRI of the thoracic spine revealed a large centrally necrotic soft tissue mass compromising the T3 and T4 vertebral bodies with extension into the epidural space.A complete bilateral laminectomy of T3-4 was performed, along with a subtotal bilateral laminectomy of T2, revealing a mass with thick yellow fluid oozing out. Samples were sent for testing with a frozen section initially confirming histoplasmosis however, cultures eventually grew blastomycosis. Both being dimorphic fungi with similar histological appearance.After surgical removal of the mass and clean out, patient was returned to the ICU and initiated medical therapy with long term IV antifungals. Patient recovered well with aggressive PT and was discharged to rehab with very frequent outpatient follow up.
DISCUSSION: Histoplasmoma/Blastomycosis pathogeneses involves inhalation of fungal microconidia, which are phagocytosed by alveolar macrophages and subsequently disseminate hematogenously or via lymphatic routes to the CNS and other organs Diagnosis involves a combination approach using imaging, such as MRI, CT scans, using anti-histo/anti-blasto antibody detection in the CSF, bloodwork and having a high clinical suspicion. Surgical resection with pathology would be most definitive for diagnosis and treatment. Other treatment includes 2 phase medical therapy, first for the acute infection using Liposomal amphotericin B (AMB-L), 5.0 mg/kg daily administered intravenously over a period of 4-6 weeks, targeting a cumulative dose of 175 mg/kg. Course may be extended in immunosuppressed individual whom cannot be reversed. Followed by maintenance phase where itraconazole becomes the primary therapeutic agent, 200 mg 2-3 times daily for a minimum duration of one year, with continuation until CSF abnormalities, including Histoplasma/Blastomyces antigen levels, demonstrate complete resolution.
CONCLUSIONS: CNS histoplasmoma/blastomycosis particularly of the spine is a very rare manifestation of fungal infection generally seen in immunocompromised individuals but can be seen in immunocompetent persons as well. CNS fungal infections should be considered highly in immunocompromised individuals presenting with central cord symptoms and especially with imaging findings of possible mass. Patient will require close follow up and monitoring lab work sometimes for an additional year post treatment given high risk of re-infection.
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- Title
- ISOLATED INTRAMEDULLARY HISTOPLASMOSIS/BLASTOMYCOSIS OF THE THORACIC CORD WITHOUT PULMONARY INVOLVEMENT: A RARE INITIAL PRESENTATION IN AN IMMUNOCOMPROMISED ADULT
- Creators
- MANNU ShergillLAN ShenJOHN GoldmanAkshay Avula
- Publication Details
- Chest, v 168(4), pp 1566A-1567A
- Number of pages
- 2
- Resource Type
- Abstract
- Language
- English
- Academic Unit
- College of Medicine; General Internal Medicine
- Other Identifier
- 991022146957604721