Disseminated histoplasmosis in erythematosus systemic lupus: A case report and review

Abstract

Histoplasmosis is an endemic mycosis in some regions affecting particularly immunosuppressed individuals. The global prevalence of disseminated histoplasmosis in systemic lupus erythematosus (SLE) patients is <1 %, but rises in endemic areas such as Colombia. Clinical manifestations in those patients are atypical, ranging from non-specific symptoms to severe cases of multi-organ failure. Given its rarity and the nonspecific nature of its symptoms, disseminated histoplasmosis in the context of systemic lupus erythematosus remains a diagnostic challenge.

A 28-year-old female patient with a history of SLE diagnosed in 2009 presented to our clinic in February 2024. The patient reported an acute onset of non-specific symptoms, with a subsequent treatment for a suspected bacterial lung infection and successfully discharged. However, due to persistent fever and ongoing weight loss, she returned for further evaluation. Initially a thoracic computed tomography and fiberoptic bronchoscopy was performed, with negative results for tuberculosis (TB), however TB treatment was empirically initiated according to imagenological findings. During hospitalization, the patient developed gastrointestinal bleeding, prompting further investigations and confirming Histoplasma capsulatum in a biopsy. Despite the antifungal therapy, the patient’s condition deteriorated, culminating in multiorgan failure and death 10 days later.

This case underscores the importance of prompt and accurate diagnosis of disseminated histoplasmosis in patients with SLE. The clinical presentation can mimic a lupus flare or other infectious diseases, potentially delaying the initiation of appropriate therapy. In endemic regions such as Latin America, it is critical to include disseminated histoplasmosis in the differential diagnosis of febrile illness in immunosuppressed patients.