Gastrointestinal Histoplasmosis
Gastrointestinal Histoplasmosis

Video Endoscopic Sequence 1 of 12.

Gastrointestinal Histoplasmosis

Third part of the duodenum

This is a 50 year-old female with weight loss of 20 lbs and epigastric pain.

Of the few case reports of duodenal histoplasmosis described in the literature, most have presented with nonspecific symptoms, such as weight loss or abdominal pain, or no symptoms at all.

The differential diagnosis for the inflammatory lesions of gastrointestinal histoplasmosis includes idiopathic inflammatory bowel disease (ulcerative colitis and Crohn disease), lymphoma, sarcoidosis, and other infections.

Gastrointestinal Histoplasmosis

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Intestinal involvement is most common, particularly of the

Video Endoscopic Sequence 2 of 12.

Gastrointestinal Histoplasmosis in Patient with AIDS

Endoscopy of Duodenal Histoplasmosis

Third part of the duodenum

Intestinal involvement is most common, particularly of the terminal ileum because of its abundant lymphoid tissue, although lesions may occur anywhere from the mouth to the anus. Patients may present with hematochezia, melena, intestinal obstruction or perforation, and peritonitis. Gastrointestinal bleeding is more common in patients with AIDS.

 

 

 

 

 

Duodenal Histoplasmosis

Video Endoscopic Sequence 3 of 12.

A nodule at the pre-pyloric antrum that resemble a heterotopic pancreas,

Nodule with a central dimple. The biopsies also display histoplasmosis.

On endoscopy, GI lesions may appear as segments of inflamed or thickened bowel, ulcerations, strictures, polyps, or tumor-like lesions . This variation in gross appearance makes GIH a great imitator of other GI disorders, most notably inflammatory bowel diseases and GI malignancies.

 

 

Gastrointestinal Histoplasmosis

Video Endoscopic Sequence 4 of 12.

Gastrointestinal Histoplasmosis

Other findings include ulcerations, polypoid lesions, and masses mimicking carcinoma. Ulcerative lesions may be mistakenly diagnosed as inflammatory bowel disease. Biliary tract involvement has been rarely reported. Peritonitis is distinctly rare, with only a few reports described in the literature. Serological tests for antibodies are useful for diagnosis, but may be falsely negative in immunocompromised individuals. Antigen detection is sensitive in this population. Although histopathology and tissue cultures are specific, limitations include insensitivity and need for invasive procedures. Antifungal options include intravenous amphotericin B for severe or unstable disease and oral itraconazole for stable disease.

While the clinical presentation of GIH is often vague and nonspecific, it should be considered on the differential diagnosis in patients with a variety of different upper or lower GI symptoms.

 

 

Gastrointestinal Histoplasmosis

Video Endoscopic Sequence 5 of 12.

Gastrointestinal Histoplasmosis

In patients with disseminated histoplasmosis, the gastrointestinal (GI) tract is one of the most commonly affected.organ systems with approximately 70% of patients demonstrating some GI involvement at autopsy. While gastrointestinal histoplasmosis (GIH) may involve any portion of the GI tract, nearly 90% of lesions involve the lower GI tract, most commonly the ileocecal region or colon

This is thought to be due to the abundance of gutassociated lymphoid tissue (GALT) in these areas, such as Peyer’s patches in the terminal ileum, which may serve as entry sites for macrophages filled with H. capsulatum yeasts.

Given the discrepancy between autopsy data and clinically reported data, the incidence of GIH is underestimated and clinicians should consider this diagnosis in AIDS patients at risk, specifically those with advanced immunosuppression (i.e., CD4+ cell counts <100 cells/mm3).

 

 

Although common at autopsy, GIH is rarely recognized

Video Endoscopic Sequence 6 of 12.

Gastrointestinal Histoplasmosis

Although common at autopsy, GIH is rarely recognized clinically with GI symptoms being reported in <10% of cases of disseminated infection. This may be due, in part, to the nonspecific manifestations of GIH, namely, fever, weight loss, diarrhea, and abdominal pain. In aminority of cases.

 

 

Duodenal Histoplasmosis

Video Endoscopic Sequence 7 of 12.

Duodenal Histoplasmosis

 

 

 

Duodenal Histoplasmosis

Video Endoscopic Sequence 8 of 12.

Duodenal Histoplasmosis

Multiple biopsies were taken which showed duodenal
mucosa with granulomatous inflammation. Gomori’s
methenamine silver (GMS) stain identified macrophages
with small intracellular yeasts consistent with disseminated
histoplasmosis.

 

 

Duodenal Histoplasmosis

Video Endoscopic Sequence 9 of 12.

Duodenal Histoplasmosis

Histologically, GIH first appears as focal lesions in the submucosa and lamina propria, but the gross appearance of these lesions is highly variable.

 

Duodenal Histoplasmosis

Video Endoscopic Sequence 10 of 12.

Duodenal Histoplasmosis

PAS Staining.

 

 

 

 

Duodenal Histoplasmosis

Video Endoscopic Sequence 11 of 12.

Duodenal Histoplasmosis

 

Duodenal Histoplasmosis

Video Endoscopic Sequence 12 of 12.

Duodenal Histoplasmosis

 

 

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