Histoplasmosis hepatitis after orthotopic liver transplantation

Histoplasmosis is an endemic mycosis in the Ohio and Mississippi River valleys and can cause disseminated infection in immunocompromised hosts. Disseminated histoplasmosis is often respiratory in nature and most cases in transplant patients occur within 2 years post-transplantation. A 32-year-old male on mycophenolate and tacrolimus who underwent an orthotopic liver transplantation 10 years prior presented with generalized body aches, fevers, mild congestion, dysuria and elevated transaminases. Liver biopsy revealed epithelioid granulomas with narrow-based budding yeast, suggesting histoplasma. Liver involvement in disseminated histoplasmosis is well characterized however the disease is usually pulmonary in origin. Only three other case reports describe isolated granulomatous hepatitis, and this is the first to our knowledge to occur in a liver transplant allograft. A high index of suspicion is essential for diagnosis and prompt treatment of histoplasmosis in transplant patients considering their immunocompromised state.