Disseminated histoplasmosis with oral involvement and co-infection with Pneumocystis in a patient with HIV: A case report

Oral manifestations of disseminated histoplasmosis are rare but can present in immunocompromised individuals. We report a case of disseminated Histoplasmosis presenting with presumed oral involvement and Pneumocystis jirovecii pneumonia in a seropositive HIV individual. A 32-year-old male with HIV presented to the emergency department for a two-week history of abdominal pain and a tongue ulcer in the setting of significant weight loss, blood-tinged sputum, and non-adherence with antiretroviral therapy for three years. Physical exam revealed a verrucous ulcer on the lateral aspect of the tongue. CT scan of the chest revealed diffuse bilateral pulmonary nodules and ground glass opacities. At presentation, his CD4 + count was 12 cells/mm3. During his hospitalization, he developed acute hypoxic respiratory failure requiring non-invasive ventilation. His urine histoplasma antigen was positive at greater than 25 ng/mL and liposomal amphotericin was started. Shortly thereafter, Pneumocystis jirovecii PCR on bronchoalveolar lavage returned positive prompting additional therapy with trimethoprim-sulfamethoxazole. At discharge, the patient had no respiratory symptoms and near-resolution of his tongue ulcer.