Histoplasmosis Presenting as a Hypopharyngeal Mass in an Immune Compromised Host

CASE REPORT A31-year-old African-American female presented to a local emergency department with a three week history of dysphagia, odynophagia and twenty pound weight loss in the last month. The patient also reported subjective fevers at home. Review of symptoms was significant for a rash which reportedly began on her face and spread to her arms. The patient’s medical history was remarkable for HIV/AIDS diagnosed eleven years earlier with a most recent CD4 count of 5 mm3 (6.5%). She had been on antiretroviral therapy during two prior pregnancies, but had no consistent follow-up for the last four years. Of note, she was diagnosed with esophageal candidiasis approximately three and a half months prior to this presentation. The patient had no known drug allergies and her only medication was trimethoprim/sulfamethazole double strength once daily. On initial presentation, the patient had a temperature of 993 F and all other vital signs were normal. The patient was cachectic and ill-appearing. She had poor dentition with a foul oropharyngeal odor. On closer examination, she also had a visibly atrophic uvula, multiple erythematous patches in her oropharynx and shotty anterior cervical lymphadenopathy. In addition, a maculopapular rash with lesions of varied sizes was noted on her face and upper extremities with minimal extension to the lower extremities and sparing of the palms and soles. The remainder of the patient’s physical exam was unremarkable. The patient’s initial blood work revealed a white blood cell count of 4.0 × 103/μL with 85% segmented neutrophils, 4% band forms, 5% lymphocytes, 4% monocytes and 2% eosinophils. She had a microcytic anemia with a hemoglobin of 9.1 gm/dL and mean corpuscular volume of 78 fL. The patient’s three AFB sputum smears were negative. In addition, she had a negative cryptococcal antigen & rapid plasma regain (RPR). All other initial laboratory evaluation was unremarkable. Endoscopy was performed and revealed a large, firm, friable mass which distorted most of the hypopharynx in a hemi-circumferential manner. There A CASE REPORT