A case of Histoplasma capsulatum causing granulomatous liver disease and Addisonian crisis

A 56-year-old man with persistently elevated liver enzyme levels, fatigue, lethargy and a 9.0 kg weight loss over six months underwent a percutaneous liver biopsy that demonstrated multiple granulomas. Screening serologies we re positive for histoplasmosis, and he was started on itraconazole treatmen t. He returned to hospital the same night with coffee-ground emesis and in Addisonian crisis requiring parenteral steroids and intensive care unit sup port. An abdominal computed tomography scan revealed bilaterally enlarged, nonenhancing adrenal glands suggestive of infarcts, presumed secondary to h istoplasmosis. Treatment was initiated with amphotericin B, and Histoplasma capsulatum. was cultured from his urine and cerebrospinal fluid. A serum i mmunodiffusion test was also positive for both H and M hands, indicating ac tive infection with Histoplasmosis species. His serum and urine samples wer e also weakly positive for the antigen. Despite complications of renal fail ure, pneumonia and congestive heart failure, he recovered with medical ther apy and was discharged home to complete a prolonged course of itraconazole therapy. While hepatic granulomas often reflect an occult disease process, the cause may remain undiscovered in 30% to 50% of patients despite exhaust ive investigations. H capsulatum is an uncommon cause of granulomatous live r disease, and with its protean clinical presentation, a high index of susp icion is needed to make the diagnosis and avoid the potentially high fatali ty rate associated with disseminated infection.