Histoplasmosis-a great invader, even in immunocompetent patient

Disseminated histoplasmosis (DH) is a rare deep fungal infection caused by Histoplasma capsulatum and it usually occurs in immunocompromised patients like in acquired immunodeficiency syndrome (AIDS) or patients getting any immunosuppressive therapy. Histoplasmosis usually remains unrecognized in immunocompetent individuals. Here we are reporting a case of a 55-year-old immunocompetent man with DH who presented to us with dysphagia, occasional vomiting, slurred speech with left sided hemipaeresis, weight loss and after hospital admission he developed fever, but no cough. On investigations, he was found to have bilateral adrenal mass, rim enhancing lesion in the brain, nodular lesions in duodenum and soft tissue mass in lung. DH was confirmed by the presence of Histoplasma capsulatum in the cytopathology of adrenal mass and histopathology of tissue from duodenum which revealed PAS positive yeasts. He was treated with itraconazole rather than recommended choice of liposomal amphotericin B as he could not afford this expensive drug. After getting itraconazole on subsequent follow up at 4 months, he was found to be clinically improving, gained weight about 10 kg with disappearance of other symptoms. DH may present with atypical symptoms like dysphagia, slurred speech with hemiparesis rather than common presentation with fever, cough or weight loss. Though DH is more common in immunocompromised patients, if multisystem involvement occurs in immunocompetent patients, we should always consider deep fungal infection as one of the differentials.