8 October 2009 Case of the Week #159


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Thanks to Alia Albawardi, McGill University Health Center, Montreal, Quebec (Canada) for contributing this case. To contribute a Case of the Week, email khpathology@gmail.com with the clinical history and your diagnosis.  Please also email us diagnostic microscopic images (textbook quality) in JPG, GIF or TIFF format (send as attachments, we will shrink if necessary), and include any other images (gross, immunostains, etc.) that may be helpful or interesting.  We will write the discussion (unless you want to), list you as the contributor, and send you $35 (US dollars) by check or PayPal for your time after we post the case. Please only send cases with high quality images and a diagnosis that is somewhat unusual (or a case with unusual features).


Case of the Week #159


Clinical History


An otherwise healthy 31-year-old woman presented to a hospital in Montreal, Canada with an enlarged stomach lesion by endoscopy. A gastric biopsy was performed.


Micro images:





What is your diagnosis?



























Histoplasmosis of the stomach




Histoplasma capsulatum is a fungus commonly found throughout the world. In the U.S., it is endemic in the Ohio and Mississippi River valleys (eMedicine), particularly in caves and bat and bird droppings. It is frequently found in the lungs, but can affect any site. In the G.I. tract, it may cause nausea, vomiting, diarrhea, hepatosplenomegaly and possibly perforation and peritonitis. Histoplasma often infects patients with AIDS or other immunosuppressive disorders (Dis Col Rect 1991;34:185) and is often severe or fatal (Microbes Infect 2008;10:973).


Patients may present with mucosal ulceration, hemorrhage or submucosal plaques or nodules, but 25% of patients have no endoscopic findings. Microscopically, there are intracellular spores up to 4 microns with rigid walls and retracted cytoplasm. The organisms have a clear zone around a central blue nucleus, which gives the cell membrane the appearance of a capsule - hence the name of the organism.


Diagnosis is based on histology and culture, as well as rapid antigen / antibody tests of blood, urine or tissue (Curr Opin Infect Dis 2008;21:421). Skin tests confirm exposure, but not infection. A bone marrow biopsy may be helpful in early diagnosis, which is particularly important in disseminated disease (Arch Pathol Lab Med 2006;130:120).


Histoplasmosis of the stomach may clinically resemble a gastric ulcer (Rev Gastroenterol Peru 2003;23:221). The microscopic differential diagnosis includes Candida glabrata, the second most common Candida species in U.S. hospitalized patients. In tissue, it present as yeasts, 3-5 microns in size, which are difficult to visualize on H&E stained slides but can be detected with GMS. Typically no hyphal elements are found (Dermatol Online J 2008;14:15). It can differentiated from Histoplasma based on H&E appearance (histoplasma spores are identifiable) and culture. Other disorders that may appear similar include Leishmania infection, Mycobacterium avium-intracellulare, Whipples disease, Cryptococcosis and malakoplakia.


Treatment for Histoplasmosis is generally a course of antibiotics from 3 to 18 months. Relapses are common.


Additional references: Am Surg 1996;62:369, Am J Med 1985;78:203, Bone Marrow chapter - PathologyOutlines.com, AFIP Atlas of Nontumor Pathology, Fascicle 5, 2007.



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