Histoplasma-Induced Esophageal Ulcers in HIV/AIDS Patient: A Case Report

BACKGROUND Patients with HIV/AIDS can develop opportunistic infections of the esophagus. While Candida frequently causes infectious esophagitis in this population, other opportunistic infections, like cytomegalovirus and herpes simplex virus, can cause esophagitis, and in some cases, esophageal ulcers. Less frequent opportunistic infections of the esophagus include histoplasmosis. CASE REPORT A 58-year-old man with a history of HIV presented to the hospital with esophageal dysphagia. He had a history of disseminated histoplasmosis and was on itraconazole. Upper endoscopy done for the dysphagia revealed large, deeply cratered esophageal ulcers, a common cause of esophageal dysphagia. Ulcer biopsies were obtained, with routine staining negative for HIV, cytomegalovirus, yeast, or fungal organisms. He was started on acid suppressive therapy, with no improvement in dysphagia. Laboratory test results were significant for subtherapeutic levels of itraconazole therapy and positive urine Histoplasma antigen. These new findings raised concern for histoplasmosis being the cause of the patient's esophageal ulcers. Therefore, the team conducted specialized Grocot-Gomori methenamine silver staining on tissue from the esophageal ulcers, which revealed Histoplasma. For disseminated histoplasmosis treatment, he was admitted for intravenous amphotericin, and his outpatient dose of itraconazole was adjusted. Dysphagia subsequently improved, and follow-up upper endoscopy revealed esophageal ulcers had resolved. CONCLUSIONS This case underscores Histoplasma capsulatum as a rare but significant cause of esophageal ulceration in patients with HIV/AIDS. Proper diagnostic approaches, including specialized staining techniques, are critical when routine examinations fail to identify a pathogen. In patients with HIV/AIDS, clinicians should be keen to consider alternate, less common, causes of esophageal ulcers.