Classical presentation of Histoplasma infection includes fever and respiratory symptoms. Opportunistic microorganisms must be suspected on immunocompromised patients who develop bizarre symptoms. We present a case of a female patient with rheumatoid arthritis who received treatment with Infliximab during one and a half year; she developed granulomatous hepatitis secondary to Histoplasma infection. The patient was admitted with acute hepatitis and thrombocytopenic coagulopathy. A liver biopsy was performed revealing granulomatous hepatitis, microvesicular steatosis, isolated apoptotic cells, and parenchyma microabscesses. PAS and G？m？ri stains revealed areas with mycotic microorganisms morphologically compatible with Histoplasma spp. and confirmed by culture. 1. Introduction Histoplasma capsulatum (HC) is a dimorphic fungus classified as an opportunistic microorganism; it can affect patients treated with infliximab, which is a monoclonal antibody against tumor necrosis factor alpha (TNFα). On the literature we found only 13 reported cases of Histoplasma infection (HI) in patients treated with anti-TNFα therapy (9 with Infliximab and 4 with Etanercept) [1–7]. The use of these drugs has been associated with increase in the frequency of granulomatous infections [2]. However we present the first case of granulomatous hepatitis (GH) associated with HI in a patient with Rheumatoid Arthritis (RA) treated with Infliximab. Granulomas are found in 2 to 35% of liver biopsies and up to 30% of these cases remain idiopathic biopsies [8–10]. Its etiology is diverse and is not established in almost half of the cases [11]; therefore histological evaluation of granulomas on liver specimens necessarily needs clinical correlation and the use of special stains for microorganisms including Ziehl-Neelsen, Periodic acid-Schiff (PAS), Grocott's Methenamine Silver Stain (or G？m？ri), Giemsa, and Mucicarmine. Case. A 58-year-old female patient was admitted with previous extrainstitutional one-week hospitalization due to 3 weeks of multiple emesis episodes, weakness, progressive jaundice, and abdominal distention, associated with choluria, acholia, and hyporexia. Suspicious biliary tract obstruction was made and submitted reports informed; abdominal Magnetic Resonance Imaging (MRI) and Retrograde Endoscopic Cholangiography both with evidence of hepatomegaly with normal biliary tree, fatty change, and perihepatic fluid scan, with no focal lesions nor vascular thrombosis, Abdominal Computed Axial tomography (CT) with hepatosplenomegaly (Images not available). Obstruction was ruled
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