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Case Reports
. 2024 Sep 28;16(9):e70398.
doi: 10.7759/cureus.70398. eCollection 2024 Sep.

Histoplasma capsulatum Infection With Both Granulomatous Features and Fibrosing Mediastinitis Presenting as Shortness of Breath: A Case Report

Ryan M Kozloski  1 , Alec K Donohue  2 , Preston J Sparks  3 , Janelle L Robertson  4 , David C Hostler  5
Affiliations
Case Reports

Histoplasma capsulatum Infection With Both Granulomatous Features and Fibrosing Mediastinitis Presenting as Shortness of Breath: A Case Report

Ryan M Kozloski et al. Cureus. .

Abstract

It is known that Histoplasma capsulatum can cause chronic granulomatous disease or fibrosing mediastinitis, but both presentations occurring in the same patient is exceedingly rare and difficult to diagnose. The patient is a 24-year-old female with a past medical history of asthma, who presented for worsening shortness of breath. Thoracic imaging revealed a large paratracheal mass with a significant mass effect. Endobronchial ultrasound (EBUS) was attempted unsuccessfully, and the patient underwent video-assisted thoracoscopic surgery, which established the diagnosis of fibrosing mediastinitis. Extensive infectious disease workup confirmed Histoplasma infection. She was treated with a course of Itraconazole, pulmonary artery stenting, and rituximab.

Keywords: asthma; fibrosing mediastinitis; granulomatous disease; hilar fullness; interdisciplinary; lack of response to therapy; video assisted thoracoscopic surgery.

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Conflict of interest statement

Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Pulmonary function testing data
Baseline spirometry identified an isolated decreased FEV1 with a significant bronchodilator response which normalized airflow. There was a mild restrictive defect by plethysmography and a Mild reduction in DLCO. F/V ex: flow rate of expiration divided by volume of air expired, PRE: prebronchodilator testing, VOL: volume, V: volume, T: time, CH4: methane, CO: carbon monoxide, Ref: age, gender, and size-controlled reference values, LLN: lower limit of normal, Pre%Ref: percentage of reference value from prebronchodilator testing, FVC: forced vital compacity, FEV1: forced expiratory volume exhaled in the first second, FEF25-75%: forced mid-expiratory flow, PEF: peak expiratory flow, FET100%: forced expiratory time, EOTT: end of test time, TLC: total lung compacity, VC: vital compacity, IC: Inspiratory compacity, FRCpl: functional residual compacity, ERV: expiratory reserve volume. RV: residual volume, DLCO_SB: diffusion compacity of the lungs for carbon monoxide, VA_SB: alveolar volume, BHT: breath hold test
Figure 2
Figure 2. Computed tomography scan
A. Axial image demonstrating a 7-millimeter upper lobe nodule. B and C. Coronal and axial images showing perihilar fullness concerning for mediastinal adenopathy and large soft tissue mass in the left paratracheal space with extrinsic compression of the mass on the left main bronchus.
Figure 3
Figure 3. Images from diagnostic VATS
A. Extensive adhesions were found and lysed. B. Scanlan forceps were used to biopsy the mass in the hilum. VATS: video-assisted thoracoscopic surgery
Figure 4
Figure 4. Pathology results
A. (Hematoxylin and Eosin 10X): Biopsy of the fibrotic mass in the hilum showed fibrosis infiltrating the mediastinal adipose tissue with thickened collagen and inflammatory infiltrate composed primarily of lymphocytes and plasma cells with rare eosinophils, findings characteristic of fibrosing mediastinitis. B. (Grocott’s Methenamine Silver 40X): Caseating granuloma that highlights abundant yeast-like organisms within the central necroinflammatory debris. These organisms were morphologically consistent with Histoplasma capsulatum.
See this image and copyright information in PMC

References

    1. Fibrosing mediastinitis. Clinical presentation, therapeutic outcomes, and adaptive immune response. Peikert T, Colby TV, Midthun DE, Pairolero PC, Edell ES, Schroeder DR, Specks U. Medicine (Baltimore) 2011;90:412–423. - PubMed
    1. Clinical manifestation of mediastinal fibrosis and histoplasmosis. Mathisen DJ, Grillo HC. Ann Thorac Surg. 1992;54:1053–1057. - PubMed
    1. Fibrosing mediastinitis complicating prior histoplasmosis is associated with human leukocyte antigen DQB1*04:02 - a case control study. Strock SB, Gaudieri S, Mallal S, et al. BMC Infect Dis. 2015;15:206. - PMC - PubMed
    1. Feasibility and efficacy of percutaneous pulmonary vein stenting for the treatment of patients with severe pulmonary vein stenosis due to fibrosing mediastinitis [Article in Chinese] Zhou X, Li YJ, Cao YS, et al. https://pubmed.ncbi.nlm.nih.gov/31648464/ Zhonghua Xin Xue Guan Bing Za Zhi. 2019;47:814–819. - PubMed
    1. Percutaneous vascular stent implantation as treatment for central vascular obstruction due to fibrosing mediastinitis. Albers EL, Pugh ME, Hill KD, Wang L, Loyd JE, Doyle TP. Circulation. 2011;123:1391–1399. - PMC - PubMed

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