Disseminated histoplasmosis in an HIV patient with CD4 count of 1 cell/µL

We report a case of a young woman with advanced HIV/AIDS who presented with a short duration of fever and shortness of breath, with no recent travel history or previous hospitalisation, accompanied by non-specific abdominal symptoms and suspicious upper gastrointestinal bleed. Her CD4 count was 1 cell/μL raising the suspicious for various opportunistic aetiologies. The initial suspicion was for pneumocystis pneumonia (PCP) and the patient was treated empirically with antimicrobials. Peripheral smear findings, urinary antigen tests and bronchoalveolar lavage (BAL) were suggestive of disseminated histoplasmosis. PCP was ruled out in BAL. Transabdominal imaging was concerning for periaortic lymphadenopathy raising the suspicion of occult malignancy. Endoscopic evaluation of her digestive tract was unrevealing. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) confirmed histoplasmosis. She received a liposomal amphotericin B for 10 days followed by itraconazole with significant improvement. Her CD4 count was found to be the lowest reported count with a single opportunistic pathogen.