{
  "abstract": "Most histoplasmosis infections are asymptomatic or present as a self-limiting pulmonary illness; however, disseminated disease can occur in immunocompromised patients. Lower gastrointestinal (GI) bleeding (haematochezia) without other GI-related symptoms is an uncommon manifestation of disseminated histoplasmosis, posing a diagnostic challenge.We describe a renal transplant recipient in his 70s on chronic immunosuppressive therapy (tacrolimus and mycophenolate mofetil) who initially presented with progressive bilateral lower-extremity weakness and later developed haematochezia during hospitalisation. A colonoscopy was performed for worsening anaemia and haematochezia and revealed a localised ulcerated lesion. Histopathology demonstrated necrotising granulomatous inflammation with intracellular yeast forms on H&E staining, with Grocott methenamine silver stain highlighting oval budding yeast consistent with Histoplasma capsulatum. Serum Histoplasma antigen was positive (5.2 ng/mL).MRI demonstrated multifocal enhancing lesions involving the brain and spinal cord. Cerebrospinal fluid analysis revealed lymphocytic pleocytosis (27 cells/µL, 90% lymphocytes), elevated protein (88.2 mg/dL) and low glucose (48 mg/dL; serum 101 mg/dL), concerning for fungal meningitis in the setting of disseminated histoplasmosis.He was treated with liposomal amphotericin B followed by itraconazole, with a reduction in his tacrolimus dosing from 3 mg in the morning and 2 mg in the evening to 1 mg two times per day to reduce drug-drug interactions and risk of nephrotoxicity. At his 6-week follow-up, his neurologic deficits had significantly improved, and he was ambulating independently.",
  "authors": [
    {
      "affiliations": [
        "Medical School, University of North Dakota School of Medicine & Health Sciences, Grand Forks, North Dakota, USA",
        "Sanford Health North, Fargo, North Dakota, USA"
      ],
      "name": "Peyton Frolek"
    },
    {
      "affiliations": [
        "Sanford Health North, Fargo, North Dakota, USA"
      ],
      "name": "Rita Ahmad"
    },
    {
      "affiliations": [
        "Sanford Health North, Fargo, North Dakota, USA"
      ],
      "name": "Fadel Nammour"
    },
    {
      "affiliations": [
        "Sanford Medical Center Fargo, Fargo, North Dakota, USA"
      ],
      "name": "Recep Nigdelioglu"
    },
    {
      "affiliations": [
        "Sanford Medical Center Fargo, Fargo, North Dakota, USA"
      ],
      "name": "Avish Nagpal"
    }
  ],
  "title": "Lower gastrointestinal bleeding (haematochezia) as the initial clue to disseminated histoplasmosis with central nervous system involvement in a renal transplant recipient",
  "uid": "a3ecc44a-ed1c-5bb1-acf1-f9a53aa5741a"
}