S3141 Rare Late Disseminated Histoplasmosis in a Liver Transplant Patient

Introduction: Histoplasmosis capsulatum is a dimorphic fungus found throughout the world and in the United States is particularly endemic to the Ohio and Mississippi river valleys. It is often found in soil and associated with bat guano and bird droppings. Disseminated histoplasmosis infection is rare, but commonly associated with immunosuppressed states. However, disseminated histoplasmosis infection is particularly rare in patients who underwent orthotopic liver transplantation (OLT) and most commonly occurs within 1 to 2 years post transplantation. Case Description/Methods: A 63-year-old male with history of OLT (21 years prior to presentation) from hepatitis C virus cirrhosis presents with complaints of fevers, chills, fatigue, & abdominal distention for three months. On presentation he was febrile but hemodynamically stable. Physical exam was notable for abdominal distention and scleral icterus. Laboratory data was notable for elevated alanine aminotransferase (71 U/L), aspartate aminotransaminase (98 U/L), total bilirubin (6.2 mg/dL), and alkaline phosphatase (300 U/L). A magnetic resonance cholangiopancreatography was performed which demonstrated cirrhotic changes in the graft liver and a 4.4 cm right adrenal mass and 3 cm left adrenal mass. A biopsy of the adrenal mass showed fungal forms consistent with histoplasma species, background necrosis, and acute inflammation. A liver biopsy showed granulomatous hepatitis with fungal forms consistent with histoplasma species and advanced bridging fibrosis. Further imaging demonstrated bilateral ground glass opacities in the lungs but no abnormalities elsewhere. The patient was treated with amphotericin B and transitioned to itraconazole with 12 months of therapy planned with surveillance of urine histoplasma antigen levels. Discussion: In this case, we present a unique case of disseminated histoplasmosis with histoplasmosis hepatitis in a patient who underwent OLT greater than 20 years prior. While any immunosuppressed patient is at a higher risk of disseminated histoplasmosis, it remains relatively rare among patients who have undergone solid organ transplantation. This case highlights the need to remain vigilant against all opportunistic infections in the post-transplant patients at any time post transplantation and particularly those that are endemic to the patient’s area of residence.