A Case of Disseminated Histoplasmosis Presenting As Adrenal Insufficiency With Granulomatous Hepatitis

Histoplasmosis is a fungal infection caused by Histoplasma capsulatum. In the United States, histoplasmosis is endemic in the Mississippi River Valley and Ohio. Histoplasmosis is often asymptomatic in immunocompetent individuals, and severe disseminated cases are more often seen in immunosuppressed patients. Disseminated histoplasmosis often affects the reticuloendothelial system, invading specific visceral organs such as the liver, spleen, and pancreas. The current study presents a unique case of disseminated histoplasmosis in a 64-year-old immunocompetent male. The patient's presentation included a 40-lb weight loss over a year, bilateral adrenal nodules, abnormal liver enzymes, and granulomatous hepatitis, which initially raised suspicion of a malignant etiology. An adrenal mass biopsy showed fungal morphology that confirmed an H. capsulatum infection. Further history showed that the patient recently traveled to Bangladesh, which is thought to be a region endemic to histoplasmosis. This case is noteworthy because disseminated histoplasmosis rarely affects immunocompetent individuals, and an infectious etiology for adrenal insufficiency is exceedingly rare, especially in the United States. The treatment regimen included a 14-day induction therapy of IV amphotericin B followed by outpatient itraconazole, leading to symptom resolution. This case highlights the need to consider an infectious etiology for adrenal insufficiency, especially among immunocompetent individuals who may be at risk after traveling to endemic areas.