P3923 - Granulomatous Hepatitis Due to Histoplasma Capsulatum While on Treatment With Adalimumab

Jefferson Tran, , Nhat Nguyen, MD, Hashem Elgouhari, MD, Thomas Tran, MD
TMC, Denison, TX

Introduction: Histoplasmosis is a common fungal infection of the respiratory tract in endemic areas. However, extrapulmonary hepatic histoplasmosis is extremely rare. There is only one case of granulomatous hepatitis due to histoplasmosis in a patient on infliximab in the medical literature. We report the first case of granulomatous hepatitis due to histoplasmosis in a patient on adalimumab.

Case Description/Methods: The patient is a 55-year-old man with a history of psoriatic arthritis on adalimumab. He presented with 2 weeks of right upper quadrant pain, nausea, weight loss, and intermittent fever. Labs were significant for elevated liver enzymes (bilirubin 5.8, AST 111, ALT 85, alkaline phosphatase 312). An extensive hepatic work up, including serology and ultrasound, was unrevealing. Chest XR was normal. The patient underwent an MRCP for possible biliary obstruction which showed a normal liver, mildly distended gallbladder and normal bile duct at 4 mm in diameter. EGD showed duodenitis and gastritis, confirmed by biopsies. EUS showed a normal pancreas, gallbladder and bile duct. There was moderate diffuse hyperechoic infiltration of the liver. FNAs were performed. Pathology showed widespread hepatic inflammation with granulomas and ductal injury. Grocott methenamine silver stain showed yeast forms consistent with Histoplasma capsulatum. Acid-fast bacilli stain was negative for tuberculosis. Immunohistochemical stain for CMV was negative. The patient was diagnosed with granulomatous hepatitis due to histoplasmosis while taking adalimumab. Adalimumab was discontinued, and the patient was started on IV amphotericin B while being hospitalized. At discharge, the antifungal agent was changed to oral itraconazole. He did well with gradual resolution of symptoms and normalization of liver enzymes.

Discussion: Histoplasma capsulatum is a dimorphic fungus found in soil. The spores can become airborne and can be inhaled into the alveoli. Immunocompetent patients typically eliminate the infection with no or minimal respiratory symptoms. Immunosuppressed patients including those on anti-TNF agents are susceptible to severe respiratory symptoms and disseminated histoplasmosis. Granulomatous hepatitis due to histoplasmosis without pulmonary involvement is extremely rare. We report the first case of granulomatous hepatitis due to histoplasmosis in a patient on adalimumab. As biologics become more commonly used, clinicians should have a high index of suspicion of opportunistic infections including histoplasmosis.


Disclosures:


Jefferson Tran, , Nhat Nguyen, MD, Hashem Elgouhari, MD, Thomas Tran, MD. P3923 - Granulomatous Hepatitis Due to Histoplasma Capsulatum While on Treatment With Adalimumab, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.