S4934 A Case of Disseminated Histoplasmosis Calls for Preventive Counseling in Inflammatory Bowel Disease

Introduction: Patients with IBD on immunosuppression are at increased risk for fungal infections, notably with tumor necrosis factor-alpha inhibitor use where an incidence of 34 cases of endemic fungal infections per 100,000 has been observed. These patients are susceptible to severe infection with up to 75% presenting with disseminated disease. Case Description/Methods: A 38-year-old man in Wisconsin with a history of Crohn’s disease controlled on infliximab monotherapy presented with 10 days of fevers, myalgias, abdominal pain, nausea, vomiting, and weight loss following a trip to Tulum, Mexico where he swam in a cenote, a fresh-water sinkhole connected to a cave system. Stool testing revealed norovirus and a borderline elevated fecal calprotectin of 119. Liver enzymes were elevated to 300s with normal synthetic function. He was treated conservatively which led to improvement in his gastrointestinal symptoms. However, he had persistent fevers and computed tomography chest obtained for infectious workup revealed right lower lobe clustered airway nodules. Serologic and bronchoscopy testing revealed histoplasmosis infection. A liver biopsy revealed granulomatous inflammation, concerning for histoplasmosis involving the liver. He was treated with itraconazole for disseminated histoplasmosis with subsequent improvement. Infliximab was held at discharge after a 14-day hospitalization with plans to hold for several months following an anticipated 6-12 month itraconazole course. Discussion: Both the ACG and ECCO recommend prevention of infection for patients with IBD prior to travel with referrals to an infectious disease specialist. However, in 2018 Chan et. al. found that only half of gastroenterologists provided pre-travel advice. Specific recommendations for prevention of endemic fungal infections are lacking despite growing evidence for severe infection in patients with IBD on tumor necrosis factor inhibitors, a black box warning in 2008, and the popularity of certain activities such as cave swimming. Our case illustrates the importance of providing pre-travel guidance to IBD patients to prevent severe disseminated fungal infections.