Gastrointestinal Bleeding: One Complaint, Two Culprits
Article Outline
A 27-year-old Guatemalan man was admitted with a 1-month history of hematochezia associated with abdominal pain, weakness, and exercise intolerance. He denied fever, sweats, chills, melena, and weight loss. He had no previous history of chronic disease or surgery. He was a nonsmoker and moderate drinker. On physical examination, his blood pressure was 108/61 mm Hg, pulse 100 beats per minute, and temperature 36.8°C. The eyes had pale conjunctiva and oral mucosa without ulcers or thrush; there was no lymphadenopathy; lungs were clear, and heart sounds were normal. The abdomen was mildly tender diffusely with no organomegaly or masses, and bowel sounds were normal. Rectal examination showed no masses, but occult fecal blood was positive. Laboratory assessments revealed: hemoglobin 8.8 gr/dL, leukocytes 4.5 × 109/L, with 2.8 × 109/L neutrophils, 1.2 × 109/L lymphocytes, and 336 × 109/L platelets. The liver function tests and prothrombin time were within normal limits. The patient underwent colonoscopy, which revealed multiple 0.5 × 0.5 cm diameter colonic ulcers with surrounding erythema and no hemorrhoids or masses. Biopsy of the colonic ulcers showed lymphoid aggregates and yeast morphologically compatible with Histoplasma species (Figure 1, Figure 2). This finding prompted human immunodeficiency (HIV) testing, which returned positive and was later confirmed by Western blot. The patient's CD4+ count was 0.1 × 109/L. Bone marrow culture was negative, as were serum and urinary Histoplasma antigen assays. Serum cytomegalovirus immunoglobulin M and acid fast staining of the biopsy were negative. Computed tomography scan of the chest was unremarkable and an abdominal computed tomography scan showed diffuse periaortic and mesenteric adenopathy. The patient was started on amphotericin B, with an excellent clinical response and no recurrent bleeding. Two weeks later his therapy was changed to oral itraconazole, antiretroviral therapy was begun, and the patient did well.
Figure 1.
Hematoxylin-eosin staining (×100) of the colon biopsy depicts intracellular organisms compatible with Histoplasma species (arrows).
Figure 2.
Methenamine silver staining (×100) of the colon biopsy revealed organisms compatible with Histoplasma species (arrow).
Lower gastrointestinal bleeding is a relatively common complaint confronted by internists and gastroenterologists. The most common causes are: diverticulosis, angiodysplasia, ischemic colitis, colon cancer, and inflammatory bowel disease.1 Given our patient's young age, most of these diagnoses were considered unlikely, and colonoscopy was deemed necessary. The finding of yeast consistent with histoplasmosis on the biopsy specimen prompted HIV testing, which returned positive. Gastrointestinal manifestations are uncommon in patients with histoplasmosis (3%-12%), and when they do occur, they range from dysphagia, diarrhea, and abdominal pain to obstruction, bleeding, and intestinal perforation. Most cases occur in extremely ill patients with progressive disseminated histoplasmosis.2 In contrast, our case demonstrates isolated gastrointestinal (GI) histoplasmosis, which is typically seen in immunocompromised patients and in those from endemic areas, as was our patient.2 Lower gastrointestinal bleeding in HIV-infected patients is rare, with the most common causes being cytomegalovirus colitis, idiopathic colonic ulcers, hemorrhoids, anal fissures, Kaposi's sarcoma, and only case reports of histoplasmosis.3, 4 Our patient was unique in that his first manifestations of 2 potentially life-threatening conditions were hematochezia and abdominal pain, neither of which is a typical presenting symptom for the responsible infectious disease. The patient's negative urinary histoplasma antigen was to be expected because he had localized disease, which was most likely reactivation of previous infection once his immune status had begun to decline due to the HIV infection. Biopsy of the colonic lesions remains the most accurate diagnostic tool and is positive in 89%-91% of cases.4, 5 Treatment of isolated GI histoplasmosis is highly effective: amphotericin B followed by itraconazole.2 This case illustrates a condition that physicians should keep in their differential diagnosis of lower GI bleeding in immigrants and the immunocompromised: isolated gastrointestinal histoplasmosis.
References
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- Gastrointestinal histoplasmosis in the acquired immunodeficiency syndrome: report of 18 cases and literature review. Diagn Microbiol Infect Dis. 2006;55:195–201
- . Gastrointestinal histoplasmosis in patients with AIDS: case report and review. Clin Infect Dis. 2001;32:483–491
Funding: None.
Conflict of Interest: None.
Authorship: Drs. Valdez and Smalligan performed the literature review and wrote the initial drafts of the manuscript. Drs. Raval, Myers, and Matthews had active roles in caring for the patient and in reviewing, writing, and editing the manuscript. All authors have actively participated in this project and have had access to the necessary data.
PII: S0002-9343(09)00291-5
doi:10.1016/j.amjmed.2009.01.029
© 2009 Elsevier Inc. All rights reserved.
