An adolescent with asthma presenting with worsening cough

The diagnosis of systemic histoplasmosis may be delayed due to underlying pulmonary conditions in patients from an endemic area. An adolescent White male from the Midwestern United States with a history of moderate persistent asthma presented to the pulmonary clinic with a 10-day's history of cough. The patient had no response to modifications of his asthma treatment regimen and proceeded to experience worsening symptoms, including pleuritic chest pain and dysphagia. Chest imaging revealed multiple pulmonary nodules, right mainstem bronchus narrowing, bilateral hilar adenopathy, and esophageal thickening. Ophthalmologic examination revealed an ocular "histo spot", but the patient denied any ocular symptoms. Despite negative initial histoplasmosis antibody testing, the patient began oral itraconazole therapy for presumed histoplasmosis infection. Follow-up histoplasmosis antibody titers were positive, and the patient responded well to itraconazole. Disseminated histoplasmosis can have a wide range of presenting symptoms, which may delay its diagnosis among patients with pre-existing asthma.