title: A diagnostic predicament: activated sarcoidosis or pulmonary histoplasmosis. A case report.
abstract: We report a case of a 41-year-old man presenting with persisting fevers over 2 weeks. The patient had spent 4 weeks in Central America. He was in control of a stable stage II sarcoidosis. Laboratory and various microbiological tests as well as chest radiography led to no diagnosis. Activated sarcoidosis was hypothesized as the most likely diagnosis. However, we considered an infectious process as a differential diagnosis, in detail, the travel history imposed histoplasmosis. Chest-CT documented localized interstitial consolidations. Bronchoscopy with bronchoalveolar lavage (BAL) and biopsy was performed. Results of BAL fluid, biopsy, distinct sarcoidosis serum markers and a borderline positive histoplasmosis-serology yielded in a diagnostic dilemma as no distinct diagnosis was drawable. After the patient was already started on a prednisolone trial, the final diagnosis - pulmonary histoplasmosis - could be achieved via positive culture and PCR out of the BAL fluid. This case shows the difficult differentiation between an acute exacerbation of a chronic pulmonary disease and a concomitant infection, which was especially aggravated in this case as the histoplasmosis masqueraded an acute picture of sarcoidosis.
authors.affiliation: Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
authors.forename: Tilman
authors.initials: T
authors.lastname: Lingscheid
authors.affiliation: Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
authors.forename: Marie
authors.initials: M
authors.lastname: von Heinz
authors.affiliation: Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
authors.forename: Birgit
authors.initials: B
authors.lastname: Klages
authors.affiliation: FG16 Mycotic and Parasitic Agents and Mycobacteria, Robert Koch Institute, Nordufer 20, 13353, Berlin, Germany.
authors.forename: Volker
authors.initials: V
authors.lastname: Rickerts
authors.affiliation: FG16 Mycotic and Parasitic Agents and Mycobacteria, Robert Koch Institute, Nordufer 20, 13353, Berlin, Germany.
authors.forename: Kathrin
authors.initials: K
authors.lastname: Tintelnot
authors.affiliation: Department of Pathology, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
authors.forename: Manuela
authors.initials: M
authors.lastname: Gerhold
authors.affiliation: Department of Radiology, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
authors.forename: Jörg-Wilhelm
authors.initials: JW
authors.lastname: Oestmann
authors.affiliation: Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
authors.forename: Markus
authors.initials: M
authors.lastname: Becker
authors.affiliation: Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
authors.forename: Bettina
authors.initials: B
authors.lastname: Temmesfeld-Wollbrück
authors.affiliation: Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
authors.forename: Norbert
authors.initials: N
authors.lastname: Suttorp
authors.affiliation: Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
authors.forename: Ralf-Harto
authors.initials: RH
authors.lastname: Hübner
mesh_terms: D000328:Adult; D000935:Antifungal Agents / Q000008:administration & dosage / Q000627:therapeutic use; D018893:Bronchoalveolar Lavage / Q000379:methods; D001992:Bronchoalveolar Lavage Fluid / Q000276:immunology* / Q000382:microbiology; D001999:Bronchoscopy / Q000379:methods; D015704:CD4 Antigens / Q000276:immunology; D016827:CD8 Antigens / Q000276:immunology; D003937:Diagnosis, Differential; D019353:Endemic Diseases; D005938:Glucocorticoids / Q000008:administration & dosage / Q000627:therapeutic use; D006658:Histoplasma / Q000302:isolation & purification / Q000378:metabolism; D006660:Histoplasmosis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000382:microbiology / Q000473:pathology; D006801:Humans; D017964:Itraconazole / Q000008:administration & dosage / Q000627:therapeutic use; D008172:Lung Diseases, Fungal / Q000097:blood / Q000000981:diagnostic imaging / Q000382:microbiology* / Q000473:pathology*; D008297:Male; D011239:Prednisolone / Q000008:administration & dosage / Q000627:therapeutic use; D011859:Radiography / Q000379:methods; D012507:Sarcoidosis / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy / Q000276:immunology*; D014057:Tomography, X-Ray Computed / Q000379:methods; D014195:Travel
chemical_list: D000935:Antifungal Agents; D015704:CD4 Antigens; D016827:CD8 Antigens; D005938:Glucocorticoids; D017964:Itraconazole; D011239:Prednisolone
keywords: CD4/CD8 - Histoplasma capsulatum - histoplasmosis - sarcoidosis