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Infliximab-induced disseminated histoplasmosis in a patient with Crohn's disease

Abstract

Background A 56-year-old female with a 30-year history of ileocolic Crohn's disease presented with a 1-month history of bloody diarrhea and decreased caliber of stools; physical examination revealed a broad indurated anal fissure. The patient had been receiving antimetabolite therapy with 6-mercaptopurine and maintenance therapy with infliximab for over a year.

Investigations Physical examination; proctoscopy; perianal and anal canal biopsy; chest CT; blood and stool analysis, measurement of serum histoplasmosis antibodies and urine histoplasmosis antigen levels; fungal culture and Gomori's methenamine silver staining of resected tissue specimens.

Diagnosis Disseminated histoplasmosis.

Management Proctocolectomy and end ileostomy followed by treatment with liposomal amphotericin and then oral itraconazole. A palmar space abscess required multiple debridements, and a muscle flap to cover the defect.

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Figure 1: Image of a fissure in ano suspicious for squamous cell carcinoma in a 56-year-old female patient with ileocolic Crohn's disease.
Figure 2: Image of suspected necrotizing perianal infection in the case patient showing destruction of the posterior anal canal.
Figure 3: A resected perianal tissue specimen from the case patient stained with Gomori's methenamine silver stain shows Histoplasma capsulatum yeast cells in the muscularis propria (magnification × 1,000).
Figure 4: Histologic image of a resected specimen from the anal canal of the case patient.

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Acknowledgements

Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Correspondence to Susan Galandiuk.

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The authors declare no competing financial interests.

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Galandiuk, S., Davis, B. Infliximab-induced disseminated histoplasmosis in a patient with Crohn's disease. Nat Rev Gastroenterol Hepatol 5, 283–287 (2008). https://doi.org/10.1038/ncpgasthep1119

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