Introduction: Histoplasmosis is an endemic mycosis most commonly seen around the Ohio and Mississippi River Valleys, particularly in the state of Tennessee. Patients are exposed to the dimorphic fungus, Histoplasma capsulatum, through inhalation of fungal spores from the soil. Exposure to bird habitats, bat caves, demolition, outdoor gardening, and old buildings can increase the risk of acquisition. In immunocompromised patients, disseminated histoplasmosis can result in a complicated, life-threatening course of infection with high morbidity and mortality.

Disseminated Histoplasmosis most commonly presents with pulmonary infection. It is not unusual for infection to present in the eye, characterized by involvement of the retina and choroid with scarring and peripapillary atrophy. However, what is particularly rare, is the presentation of histoplasmosis in an immunocompromised patient only involving the eyelid, with no ocular infection or deficits.

Case Presentation and Final Diagnosis: A 74-year-old Caucasian woman with a history of rheumatoid arthritis presented to clinic with an acute onset of eyelid swelling and redness. At the time of presentation, the left eye lesion appeared as an erythematous mass surrounding the entire eyelid, which was tender and warm to touch. She denied any eye pain, blurry vision, proptosis, or ophthalmoplegia symptoms. An eyelid biopsy with Grocott’s methenamine silver(GMS) stain returned positive for histoplasmosis. She also had a positive urine histoplasma antigen, confirming the diagnosis of disseminated histoplasma infection. She denied other symptoms including fever or respiratory complaints. Her RA was previously controlled with infliximab, which was promptly discontinued. Other daily medications included methotrexate, folic acid and prednisone. HIV testing was negative.

Management and Outcome: Treatment was promptly initiated with itraconazole for 12-months with close monitoring. By treatment discontinuation, the symptoms involving her left eyelid were completely resolved and urine histoplasma antigen was negative. 12-month follow up confirmed no long-term complications.

Outcome/Conclusion: Disseminated histoplasmosis can be a challenging diagnosis due to its variety of presentations. It requires a high index of suspicion in order to confirm the diagnosis and initiate treatment immediately. This patient presents a unique and delicate case of controlled, localized infection of the eyelid that was appropriately treated without any long-term complications.

References and Resources

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