Disseminated Histoplasmosis in a Patient With HIV Infection Untreated for 23 Years

Histoplasmosis is a potentially life-threatening opportunistic fungal infection in patients with advanced human immunodeficiency virus (HIV), particularly in endemic regions such as the Ohio and Mississippi River valleys. Despite advances in antiretroviral therapy, delayed diagnosis, lack of linkage to care, and treatment nonadherence continue to contribute to severe opportunistic infections in individuals with untreated HIV. We present the case of a 43-year-old woman with a 23-year-long history of untreated HIV infection who presented with fever, weight loss, diarrhea, and malaise. Laboratory evaluation revealed a viral load of 327,000 copies/mL and severe immunosuppression with a Cluster of Differentiation (CD4) count of 8 cells/µL, hyponatremia, and elevated liver transaminases. Computed tomography imaging demonstrated extensive mesenteric and retroperitoneal lymphadenopathy. Biopsy of a retroperitoneal lymph node revealed granulomas containing fungal organisms consistent with disseminated histoplasmosis. The patient was initially treated with empiric broad-spectrum antibiotics and intravenous amphotericin B, followed by long-term itraconazole therapy and initiation of antiretroviral treatment, resulting in clinical and immunologic improvement. This case highlights the direct relationship between prolonged untreated HIV infection, advanced immunosuppression, and disseminated histoplasmosis, while underscoring the impact of stigma and barriers to care on delayed diagnosis and disease severity. Early HIV diagnosis, timely linkage to care, and sustained patient engagement remain essential to preventing severe opportunistic infections.