Subacute Histoplasmosis with Focal Involvement of the Epiglottis: Importance of Differential Diagnosis

Histoplasmosis is an endemic mycosis of the Americas, Africa, and Asia. In Spain, it is the most common imported endemic mycosis appearing in the literature, and its incidence is on the rise. Proper differential diagnosis of the disease must be taken into consideration by otorhinolaryngologists, as the clinical manifestations of histoplasmosis may simulate more prevalent diseases such as cancer or tuberculosis. We present the case of a Spanish patient with focal involvement of the larynx and offer a review of the relevant literature. 1. Introduction Histoplasma capsulatum, the etiologic agent of histoplasmosis, causes more infections in humans than any other endemic mycosis. As with other fungal diseases, initial exposure to the fungus occurs through inhalation. Cases of the disease have been described worldwide, although it is endemic to North America, Latin America, and particular regions of Africa and Asia. Over 80% of the people who live in the areas around the Ohio and Mississippi River Valleys present serological signs of infection [1]. Clinical manifestation is varied and may affect all the organs and tissues in the body. When the inoculum is small in size, most infections are asymptomatic. Immunodeficient patients and patients infected by large inoculums of fungal organisms may develop more severe or disseminated infections. Firm diagnosis is reached by isolating the fungus in special cultures, while alternate methods include searching for yeast forms in diseased tissues or detecting serum antibodies or specific antigens. Treatment consists of intravenous amphotericin B antifungal therapy for 10 days in addition to oral itraconazole for 9 to 12 months. It is important for ENT specialists to take into account the differential diagnosis of this illness, as the clinical manifestations of histoplasmosis in the oropharynx and larynx may resemble malignant neoplasia or tuberculosis [2]. 2. Clinical Case A 71-year-old male patient from Madrid, Spain, presented to our department with dysphonia that had been present for 2 months. He reported a 30-year history of smoking and had received a liver transplant 8 years before as a result of liver cirrhosis, for which he was undergoing chronic immunosuppressant treatment with mycophenolate mofetil. The patient presented manifestations of dysphonia, dysphagia, odynophagia, and a sensation of autophony, together with fatigue, anorexia, and a loss of over 20？kg of body weight in the previous 6 months. A fiber-optic laryngoscopy (Figure 1) revealed a vegetative lesion on the lingual surface of the epiglottis.