|
|
|
Video Endoscopic Sequence 1 of 12.
Gastrointestinal Histoplasmosis
Third part of the duodenum
This is a 50 year-old female with weight loss of 20 lbs and epigastric pain.
Of the few case reports of duodenal histoplasmosis described in the literature, most have presented with nonspecific symptoms, such as weight loss or abdominal pain, or no symptoms at all.
The differential diagnosis for the inflammatory lesions of gastrointestinal histoplasmosis includes idiopathic inflammatory bowel disease (ulcerative colitis and Crohn disease), lymphoma, sarcoidosis, and other infections.
For more endoscopic details download the video clips by
clicking on the endoscopic images.
All endoscopic images shown in this Atlas contain video
clips.
|
|
|
Video Endoscopic Sequence 2 of 12.
Gastrointestinal Histoplasmosis in Patient with AIDS
Endoscopy of Duodenal Histoplasmosis
Third part of the duodenum
Intestinal involvement is most common, particularly of the terminal ileum because of its abundant lymphoid tissue, although lesions may occur anywhere from the mouth to the anus. Patients may present with hematochezia, melena, intestinal obstruction or perforation, and peritonitis. Gastrointestinal bleeding is more common in patients with AIDS.
|
|
|
Video Endoscopic Sequence 3 of 12.
A nodule at the pre-pyloric antrum that resemble a heterotopic pancreas,
Nodule with a central dimple. The biopsies also display histoplasmosis.
On endoscopy, GI lesions may appear as segments of inflamed or thickened bowel, ulcerations, strictures, polyps, or tumor-like lesions . This variation in gross appearance makes GIH a great imitator of other GI disorders, most notably inflammatory bowel diseases and GI malignancies.
|
|
|
Video Endoscopic Sequence 4 of 12.
Gastrointestinal Histoplasmosis
Other findings include ulcerations, polypoid lesions, and masses mimicking carcinoma. Ulcerative lesions may be mistakenly diagnosed as inflammatory bowel disease. Biliary tract involvement has been rarely reported. Peritonitis is distinctly rare, with only a few reports described in the literature. Serological tests for antibodies are useful for diagnosis, but may be falsely negative in immunocompromised individuals. Antigen detection is sensitive in this population. Although histopathology and tissue cultures are specific, limitations include insensitivity and need for invasive procedures. Antifungal options include intravenous amphotericin B for severe or unstable disease and oral itraconazole for stable disease.
While the clinical presentation of GIH is often vague and nonspecific, it should be considered on the differential diagnosis in patients with a variety of different upper or lower GI symptoms.
|
|
|
Video Endoscopic Sequence 5 of 12.
Gastrointestinal Histoplasmosis
In patients with disseminated histoplasmosis, the gastrointestinal (GI) tract is one of the most commonly affected.organ systems with approximately 70% of patients demonstrating some GI involvement at autopsy. While gastrointestinal histoplasmosis (GIH) may involve any portion of the GI tract, nearly 90% of lesions involve the lower GI tract, most commonly the ileocecal region or colon
This is thought to be due to the abundance of gutassociated lymphoid tissue (GALT) in these areas, such as Peyer’s patches in the terminal ileum, which may serve as entry sites for macrophages filled with H. capsulatum yeasts.
Given the discrepancy between autopsy data and clinically reported data, the incidence of GIH is underestimated and clinicians should consider this diagnosis in AIDS patients at risk, specifically those with advanced immunosuppression (i.e., CD4+ cell counts <100 cells/mm3).
|
|
|
Video Endoscopic Sequence 6 of 12.
Gastrointestinal Histoplasmosis
Although common at autopsy, GIH is rarely recognized clinically with GI symptoms being reported in <10% of cases of disseminated infection. This may be due, in part, to the nonspecific manifestations of GIH, namely, fever, weight loss, diarrhea, and abdominal pain. In aminority of cases.
|
|
|
Video Endoscopic Sequence 7 of 12.
Duodenal Histoplasmosis
|
|
|
Video Endoscopic Sequence 8 of 12.
Duodenal Histoplasmosis
Multiple biopsies were taken which showed duodenal
mucosa with granulomatous inflammation. Gomori’s
methenamine silver (GMS) stain identified macrophages
with small intracellular yeasts consistent with disseminated
histoplasmosis.
|
|
|
Video Endoscopic Sequence 9 of 12.
Duodenal Histoplasmosis
Histologically, GIH first appears as focal lesions in the submucosa and lamina propria, but the gross appearance of these lesions is highly variable.
|
|
|
Video Endoscopic Sequence 10 of 12.
Duodenal Histoplasmosis
PAS Staining.
|
|
|
Video Endoscopic Sequence 11 of 12.
Duodenal Histoplasmosis
|
|
|
Video Endoscopic Sequence 12 of 12.
Duodenal Histoplasmosis
|
|
|
|
|
|