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HEPATIC HISTOPLASMOSIS IN TWO PATIENTS ON ADALIMUMAB
M Veerasamy1, M Emig2
1Associate, GRMERC/MSU; 2Spectrum Health, Grand Rapids, MI
INTRODUCTION: Patients receiving anti-TNFalpha medications have an increased incidence of disseminated fungal infections. We present two patients on adalimumab who developed histoplasmosis with prominent liver involvement.
Case 1: A 63 yo caucasian male, on adalimumab for 10 months for rheumatoid arthritis, presented with fever, sweats and fatigue, abnormal liver enzymes and anemia. CT demonstrated multiple liver and pulmonary nodules, and was interpreted as consistent with metastatic disease. Bone marrow biopsy showed noncaseating granulomas with probable Histoplasma. He was diagnosed with disseminated histoplasmosis and treated with amphotericin B. Histoplasma capsulatum grew from BAL and blood culture; urine antigen was positive.
Case 2: A 42 yo Hispanic male, on adalimumab for 2 years for severe psoriatic arthritis, presented with nausea, vomiting and epigastric discomfort. He had abnormal liver enzymes and hypercalcemia at 13.4. Liver biopsy showed noncaseating granulomas and grew H capsulatum. He was treated with itraconazole. Both patients had their adalimumab discontinued, improved with treatment, and have had no further relapses.
DISCUSSION: Histoplasmosis is the most prevalent endemic mycosis in United States. Many cases of disseminated histoplasmosis have been reported in patients on infliximab/etanercept; very few cases have been reported with adalimumab. Disseminated histoplasmosis seen with anti-TNFalpha therapy may be due to a defect in the TH1 arm of cellular immunity. Disseminated histoplasmosis may affect lung, liver, bone marrow, spleen and lymph nodes and can present with diverse clinical features and laboratory abnormalities. Treatment includes amphotericin B or itraconazole and discontinuation of anti-TNFalpha therapy.
CONCLUSION: Disseminated histoplasmosis should be considered early in the evaluation of patients developing complications during anti-TNFalpha therapy. With increasing use of these drugs, primary care clinicians must be cognizant of the protean manifestations of this infection and should have a high index of suspicion for histoplasmosis in patients on this class of drugs.