Subacute disseminated histoplasmosis in a psoriatic arthritic patient with predominant hepatobiliary symptomatology: The vital role of outpatient labs

Abstract

Infection with Histoplasma capsulatum, a dimorphic fungus endemic to the Midwest, most commonly manifests as fever, cough, and fatigue. In immunocompetent individuals, histoplasmosis infection is often asymptomatic or mild and self-limited; however, infection can become disseminated and more severe in immunocompromised patients. Here, we present a case of a sixty-year-old female with a history of psoriatic arthritis on adalimumab and azathioprine with delayed diagnosis of disseminated histoplasmosis. The patient had an indolent presentation that consisted primarily of fatigue, mild respiratory symptoms, and gastrointestinal issues, including elevated liver enzymes and biliary inflammation. While previous reports have shown acute presentations of primary gastrointestinal histoplasmosis, here we illustrate the importance of outpatient labs and maintaining a broad differential in a patient with subacute disseminated histoplasmosis, with primarily hepatobiliary symptoms.