Sarcoidosis possibly predisposing to disseminated histoplasmosis.

In Europe most authors consider that histoplasmosis due to Histoplasma capsulatum is a rare imported fungal disease that is only diagnosed when it appears in the disseminated form. Such a presentation is very unusual in areas where it is endemic.' This paradox is explicable because in most cases infection is localised, so that in endemic areas cases of dissemination represent a very small proportion of the total; where histoplasmosis is not endemic but is seen among those who have lived or travelled in regions where it is endemic, disseminated disease may present many years after their return and represents a large proportion of confirmed cases. Underlying immunosuppression has been reported in 44% of patients with disseminated disease2: predisposing factors include haematological malignancy, use of immunosuppressive drugs (corticosteroids, cytotoxic drugs), or immunologically depressive disease such as AIDS,3 systemic lupus erythematosus, and diabetes mellitus.4 When dissemination occurs it predominantly affects the lungs, the adrenal glands, and the reticuloendothelial system, but may also affect other organs, such as the pharynx, liver, and the central nervous system, leading to the peculiar aspects that have been described.5 The effects may be confused with those of other systemic diseases, such as tuberculosis and connective tissue diseases. The diagnosis becomes particularly difficult when systemic diseases such as these predispose to dissemination of histoplasmosis. We report a case of fatal subacute histoplasmosis developing in a patient with probable sarcoidosis.