H. capsulatum: A Not-So-Benign Cause of Pericarditis

Abstract

The common causes of pericarditis and its course are benign in the majority of cases. Thus, further testing is usually not pursued and treatment for a presumptive viral etiology with nonsteroidal agents and steroids has been an accepted strategy. We present a patient with pericarditis who was unresponsive to first-line therapy and was subsequently found to have necrotizing granulomas of the pericardium with extensive adhesions and fungal elements seen on tissue biopsy. Serologic testing confirms active H. capsulatum infection, and he responded well to Itraconazole treatment. In patients with pericarditis who fail standard therapy with NSAIDs and steroids, it is suggested that they undergo thorough evaluation and that histoplasmosis be considered as an etiology, especially in endemic regions.

Figure 1

Chest CT imaging. Coronal view of noncontrast chest CT scan showing hyperattenuated pericardium (arrows). Axial chest CT scan showing the same diffusely thickened pericardium. Enlarged mediastinal lymph node (arrowhead). Note the solitary nodule in the Left lower lobe (encircled).

Figure 2

Histologic images. H&E stain of the atrial appendage showing epithelioid histiocytes (arrows), lymphocytes, and caseating granuloma (high power view of hematoxylin-eosin stain). Fungal elements (arrows) within central necrosis (Grocott methenamine silver stain, 400x magnification).