A silent aggressor: disseminated histoplasmosis with laryngeal and adrenal involvement in a diabetic patient

Summary: A 65-year-old male with poorly controlled type 2 diabetes mellitus presented with 7 months of progressive hoarseness of voice, fever, anorexia, cough, and weight loss. Just before admission, he developed drowsiness and memory impairment. Examination showed a drowsy but stable patient without meningeal signs and hyperpigmentation. Persistent hoarseness prompted laryngoscopy, which revealed a vocal cord nodule. Imaging demonstrated bilateral adrenal enlargement with hypodense lesions in liver, pancreas, spleen, and kidney. Hormonal evaluation showed preserved adrenal function. Histopathological examination of vocal cord tissue and an adrenal biopsy confirmed the diagnosis of disseminated histoplasmosis. The patient was treated with antifungal therapy. Over 18 months of therapy, adrenal function remained normal, renal function stabilized, and urinary histoplasma antigen became undetectable. Glycemic control improved on oral hypoglycemic agents, vocal recovery occurred with therapy, and the patient achieved long-term clinical stability. Learning points: Disseminated histoplasmosis can present with hoarseness, fever, weight loss and multi-organ involvement. Adrenal enlargement is common but may not always cause insufficiency. Histopathology and fungal stains (PAS, GMS, and LPCB) are diagnostic gold standards. High clinical suspicion is needed in endemic regions or immunocompromised hosts.