Siemieniak 1

A Case Study of Disseminated

Histoplasmosis in Immunocompetent Patient

Zachary Siemieniak
Andrews University Dietetic Internship
April 26th, 2018
 Siemieniak 2

Introduction

E.C., a 41-year-old female presents to the emergency department on 1/31/18 for

complaints of abdominal pain that has been ongoing since November of 2017. Patient height of
62 inches (5' 2"), weight of 49.5 kg (109 lb 1.6 oz), and ideal body weight of 50 kg (110 lbs).
Her BMI was 19.95 kg/m², which indicates a normal weight for height. Patient reports she was
recently diagnosed with disseminated histoplasmosis in Dec 2017, which was diagnosed via
duodenal biopsy.
This particular patient was chosen as the topic of a major case study because of her
incredibly unique disease state, one that is not commonly taught in nutrition related courses.
Histoplasmosis is disease caused by an infection with a fungus, Histoplasma capsulatum. Since
this case is quite complicated, and is still ongoing (after multiple admissions and discharges,
patient remains admitted to the ICU since 4/15/18, is vented/sedated, and continues to receive
extensive medical care), it would be particularly useful to provide additional investigation for
dietitians to modify their nutrition therapy to better improve the overall care of the patient being
studied. The study began on 1/31/18, and has yet to be completed. The focus of this study is to
review the diagnosis, treatment and physiology of disseminated histoplasmosis, as well as
provide current medical nutrition therapy to best facilitate the recovery of said patient being
studied.
Social history

E.C. has been married for 3 years, has no children and identifies with the Catholic
religion. She works as a court clerk at the Berrien County courthouse who handles driver ticket
offenses. E.C. is originally from Pennsylvania and has since lived in Michigan for 7 years. She
lives near Paw Paw Lake in Berrien County, MI, in a generally suburban setting. History was
obtained from patient's mother, father, as well as husband. All three are clueless as to how the
patient was infected with Histoplasma capsulatum, the fungus responsible for Histoplasmosis.1
They report to not frequenting areas where Histoplasma capsulatum is typically transmitted.
Upon admission to the emergency department, the family was questioned as to how E.C. could
have contracted the fungus. The patient is an avid runner who for the past 3 years has woken up
around 0530 to run 8 miles. She also weight trains at Planet Fitness multiple days per week upon
leaving work. When progressive shortness of breath developed as she ran, limiting her ability to
 Siemieniak 3

physical perform, E.C. and her husband began to question her state of health. E.C. is an
otherwise immunocompetent and healthy individual, with no history of smoking or using
smokeless tobacco, with the occasional few alcoholic drinks per week.

Per husband report, he suspected something was wrong at the end of November 2017, but
was unsure of his opinions, due to lack of education on disseminated histoplasmosis. He
explained that she had an incident where she broke or damaged a tooth, and was seeing her
dentist to have it treated. Around the same time (late November 2017), he noticed her breath
began to become unbearable, shortly after brushing her teeth and using mouth wash. He wanted
her to check back with her dentist to assess any infections pertaining to her damaged tooth, or to
see if it was a dead tooth (a dead tooth can result in an abscess, and unrecognized gum disease is
a major cause of bad breath). Looking back, he suspects fungus growth originating in the lungs
(inhalation of fungus is #1 cause of histoplasmosis) could be the cause of her unbearable breath.
When the histoplasma became disseminated, or widely dispersed from the lung tissue throughout
the body and into the blood stream, her tainted breath miraculously went away. This was all his
theory, but comparing the condition she is currently in (mechanically ventilated, sedated,
receiving TPN to meet 100% of needs), if he had known then what he knows now, maybe there
could have been an opportunity to prevent the disease from progressing to such a severe degree.
E.C. husband has visited her every day after work since her latest admission on 4/15/18.

Normal Anatomy & Physiology of Applicable Body Functions

Histoplasmosis is an infection caused by a fungus, called Histoplasma.1 The fungus lives

in the soil, and is breathed in through a person’s lungs.2 Most people with histoplasmosis have no
symptoms and may never know they are infected. The disease can’t be transmitted from person
to person. A small number of people may develop flu-like symptoms that last about 10 days.2
But histoplasmosis can be serious for people with weakened immune systems or who have
chronic diseases, or for infants.3 Rarely, it can lead to death. About 500,000 people are exposed
to H. capsulatum each year in the United States.3 Many people living in the Ohio and Mississippi
river valleys of the United States have been infected with the fungus, called H. capsulatum.4 It
grows in moist soil that is rich in nitrogen, or in places contaminated with bird or bat droppings,
 Siemieniak 4

such as attics, barns, caves, and city parks.4 When other organs are affected, the disease is called
disseminated histoplasmosis, which can be life-threatening if left untreated.

People breathe the spores of fungus into the lungs, where they grow. In people with
healthy immune systems, they usually do not spread to other parts of the body. In those with
weakened immune systems, however, the spores may spread to the lymph nodes, liver, spleen,
bone marrow, adrenal glands, and digestive system.5 Many people living in mild climates can
become infected with histoplasmosis. Those most at risk of becoming infected include:

 Farmers and poultry farmers

 Construction workers
 Spelunkers (cave explorers)
 Geologists and archeologists
 Landscapers and gardeners
 People who have contact with bats

Those at risk of severe infection include:

 People with weakened immune systems (from HIV, corticosteroid therapy, organ
transplantation, and chemotherapy).5
 Very young children
 Senior adults
 People with chronic diseases, such as lung disease

Because most people with histoplasmosis have no symptoms, it can be hard to diagnose. In
addition to a physical exam, your doctor may do the following tests:

 Fungal culture -- can take several weeks to confirm diagnosis, so this test is not used if
someone needs immediate treatment.6
 Fungal stain or blood test.6
 Chest x-ray or computerized tomography (CT) scan.6

Mild cases of histoplasmosis may not need to be treated. Doctors treat more serious cases, with
symptoms that include high fever, trouble breathing, loss of appetite, and malaise, with
 Siemieniak 5

antifungal medications.6 Medications stop the fungus from growing in the body. Doctors often
use these medications in severe cases when the infection has spread to other organs and tissues
throughout the body.

 Amphotericin B (Fungizone IV, Abelcet) -- given intravenously (IV). Your doctor may
start with this drug, then switch to itraconazole.7
 Itraconazole (Sporanox) -- taken by mouth.

Because the drug [Amphotericin] can be very toxic to the kidneys and liver, the function of
these organs needs to be monitored with regular blood tests during treatment.7 As soon as
feasible, patients should be switched to a less toxic oral drug, such as itraconazole.

Past Medical History

E.C. was recently dx with Disseminated Histoplasmosis as an outpatient, diagnosed via

duodenal biopsy, on itraconazole prior to admission. She presented on 1/31 with abdominal pain
and nausea/vomiting which had been going on for several months but has become worse more
recently. From 1/31/18 to 2/26/18 the following findings were discovered: Abdominal X-ray/CT
scan showed ileus likely due to diffuse lymphadenopathy from histoplasmosis. Also noted to
have ascites. GI/General Surgery were consulted. Patient kept NPO, started on TPN and placed
on liposomal amphotericin B per recommendations from infectious disease consultation. She
completed 17 days of amphotericin B and subsequently transitioned back to itraconazole. Patient
has had improvement in symptoms and diet was able to be advanced to soft diet, however patient
would still have intermittent abdominal pain and she was not felt to be taking in enough nutrition
by mouth to support nutritional needs. As such, plan is to discharge with TPN home care visits as
an outpatient.

Regarding ascites, paracentesis done on 2/2 and again on 2/5 with fluid studies negative
for infection. Etiology of ascites likely secondary to severe malnutrition/hypoalbuminemia. TPN
should help address malnutrition until she is able to meet her nutritional requirements by mouth.
Patient also had biopsy of skin lesion on 2/1 with path results showing results consistent with
histoplasmosis.
 Siemieniak 6

On 3/8/18 E.C. presented to the emergency department with shortness of breath and
chills. Patient states that she was at the potassium infusion center earlier that day and had
shortness of breath as she was receiving IV infusion. A rapid response was called and the patient
was examined. Patient was found to be hemodynamically stable, however, the patient was sent to
the watervillet ER for further evaluation. Patient states that she has been feeling fatigued and
short of breath the whole week. Patient admits to nausea and vomiting with TPN. Klebsiella
Bacteremia was positive and most likely secondary to aspiration pneumonia. E.C. was instructed
to continue Ceftriaxone 2 g daily through till 3/25/2018 thereby completing a 14 day antibiotic
course after the last negative blood culture. Bilateral pleural effusions were performed status post
thoracentesis on 3/9 with fluid cultures negative. Patient instructed to continue spironolactone
(which will also help with hypokalemia). Hypokalemia/Hypomagnesemia were repleted via PO/
IV riders. Patient indicated of severe protein calorie malnutrition with prealbumin of 5. TPN
resumed 3/13 with full diet. Diuretic provided to resolve ascites. Patient experienced abdominal
pain due to hepatomegaly and ascites. Pain controlled while on Morphine + Neurontin
combination. E.C. discharged on 3/16/18.

E.C. admitted on 4/1/18 with post prandial vomiting for over 1-2 weeks with every meal
in the setting of anorexia. She was evaluated by GI - had multiple studies which ruled out any
acute process. She was transitioned to oral Reglan for presumed gastroparesis which was
effective. She was discharged in stable condition with outpatient follow up. Her prior
documented Klebsiella bacteremia was resolved as blood cultures were negative. She was
discharged in stable condition on 4/5/18.

Present Medical Status and Treatment

Pt re-admitted to the hospital on 4/15/18 due to increased lethargy, and "weakness while
trying to type" at the computer. She has had nausea and vomiting with associated watery diarrhea
at home. Husband reports she has vomited up some of the Itraconazole prior to admission.
Patient was transferred from floor to PCU to ICU overnight for increasing respiratory distress,
persistent hypoglycemia, sepsis, AKI, and abdominal pain. Prior to admission, patient was
receiving TPN from 2100 to 0900 due to malnutrition and inability to tolerate any other form of
nutrition. Recent events are as follows:
 Siemieniak 7

4/16/18: Patient transferred to ICU for further management. Patient intubated in the am
of 4/16/18 for hypoxic respiratory failure with tachypena. She remains on dopamine and
levophed. Consults were placed to infectious disease and general surgery. Overnight with
movement the patient removed her tunneled R IJ central line. The ICU placed a right femoral
central line.

4/17/18: Patient had R sided paracentesis 4/16 with approximately 2 L turbid fluid
removed. Many nucleated cells seen, no organisms, no yeast. Culture pending. She developed
leukocytosis overnight but is afebrile. She remains on dopamine and levophed. ID and Surgery
following. Et tube advanced again overnight. Will wean sedation and pain meds as appropriate
today. US to rule out DVT today. Tube feeds to start today in consult with GI. Plan for
thoracentesis tomorrow.

4/19/18: Febrile overnight with T-max of 101.1F, patient continues to demonstrate

significant high residuals, proximally 800 mL, nasogastric tube switched to low intermittent
suction due to concerns of aspiration. Increased O2 requirement overnight, from FI O2 of 60%
up to 70%. Call today for neck equal fluid balance, 20 mg of Lasix given. Plan gradual,
incremental reduction and sedation. Interval chest x-ray reveals some right sided interstitial
opacities and slight worsening from previous day in the perihilar area on the right. Goal to wean
dopamine to off.

4/23/18: TPN infusing at goal rate via right femoral CVC. Peptamen infusing at 10ml/hr
with attempt to titrate again today. Residuals have been between 10ml-100 ml. Nutrition-related
Meds being administered include: senna, miralax, reglan, zofran, relistor 4/22, magnesium
sulfate rider 4/23, lasix, hydrocortisone, nimbex, diprivan 6.8ml/hr. E.C. continues to remain on
mechanical ventilation to protect her airway from aspiration risk. Patient currently receiving
Clinimix 5/15 E @ 60ml/hr, Peptamen Intense @ 10ml/hr, 50ml water Q 4 hours. At 60 ml/hr,
TPN provides: 1022 + 240= 1262 kcals/day, 94 g protein/day, 1940 ml fluid/day (TPN + free
water from EN + flushes) + 163 kcals diprivan = 1425 kcals. Patient continues to be followed
daily by RD's to ensure TPN notes are properly written and to keep electrolytes within
manageable limits. E.C. has been hospitalized since 4/15/18 and remains on the CCU.
 Siemieniak 8

Medical Nutrition Therapy

E.C. consumes a primarily plant-based/vegetarian diet with chicken as the only meat
source in her diet; she sometimes eats fish and shellfish. She denies consumption of red meat,
poultry (with exception of chicken), pork, ham, deep fried foods, processed meats such as
hotdogs. Patient reports to drinking a minimum of 64 oz of water daily, in which she measures at
the beginning of every morning, to track her intake. She does not keep sugary foods in the house
Once per week, typically on Sunday, she dedicates one free day, to consume whatever she feels
like. Such days consist of less desirable food choices such as chips, crackers, cheese pizza, etc.
She eats at home for breakfast and dinner alongside her husband, and typically eats lunch out or
at the workplace. E.C. enjoyed cooking and up until her condition became worsened, limiting her
involvement in preparing foods.

Patient 24-hour dietary recall is as follows:

Breakfast - 8 oz glass of Gatorade

- medium pear/banana
- banana
Lunch - water
- chicken teriyaki sub from Jimmy Johns
- Rice
- Pasta
Dinner - Chicken
- Veggie burgers
- Gatorade
- Skim milk
- Large mixed salad
Snacks - Carrots, bananas, and other fruits

Estimated daily calorie intake could not be determined, as the patient was unable to
decipher the exact portions of the food she consumes. As a dedicated runner, she typically
consumes larger portions of food towards dinner time, and lesser portions early on in the day.
She does not monitor food intake as she is typically very lean and needs as much fuel as possible
to maintain her physical fitness.
 Siemieniak 9

E.C.'s diet order has changed multiple times throughout her medical care over
consecutive admissions/discharges. Initially she was prescribed clear liquids for gastrointestinal
testing, with the end goal of being placed on a general diet to improve overall intake. Abdominal
X-ray/CT scans showed ileus likely due to diffuse lymphadenopathy from histoplasmosis. E.C.
also noted to have ascites. GI/General Surgery were consulted. Patient kept NPO, started on TPN
to meet estimated needs. Patient has had improvement in symptoms and diet was able to be
advanced to soft diet, however patient would still have intermittent abdominal pain and she was
not felt to be taking in enough nutrition by mouth to support nutritional needs. As such, plan is to
discharge with TPN home care visits as an outpatient. Etiology of ascites likely secondary to
severe malnutrition/hypoalbuminemia. TPN should help address malnutrition until she is able to
meet her nutritional requirements by mouth. TPN resumed 3/13 with full diet. E.C. admitted on
4/1/18 with post prandial vomiting for over 1-2 weeks with every meal in the setting of anorexia.
She was evaluated by GI - had multiple studies which ruled out any acute process. She was
transitioned to oral Reglan for presumed gastroparesis which was effective. Prior to admission on
4/15/18, patient was receiving TPN from 2100 to 0900 due to malnutrition and inability to
tolerate any other form of nutrition. Tube feeds to begin 4/17/18 after consult with GI. 4/19/18
patient continued to demonstrate significant high residuals, proximally 800 mL, nasogastric tube
switched to low intermittent suction due to concerns of aspiration. 4/23/18 TPN infusing at goal
rate via right femoral CVC. Peptamen infusing at 10ml/hr with attempt to titrate again today.
Residuals have been between 10ml-100 ml.

The calculated needs for E.C. were as follows:

Estimated Nutrition Needs: Using ABW= 49.5 kg (2/1/18)
1485-1980 kcal/d Based on: 30-40 kcal/kg (promote wt gain)
79-89 g pro/d Based on: 1.6-1.8 g/kg (repletion, promote wt gain)
1238-1485 ml fluid/d Based 25-30 ml/kg (hydration)
on:
E.C. was initially prescribed multiple nutritional supplements to improve po intake and to
prevent weight loss as able, but would eventually not be able to tolerate most real foods, and
would quickly become dependent on EN and TPN to meet a majority of her energy needs. Some
nutritional supplement recommendations are as follows:

- Gelatein Plus (cherry) BID @ 1000 and 1400

- Carnation Breakfast essentials mixed in 2% milk TID @ 1000, 1400, and HS

 Siemieniak 10

- Culturelle one capsule BID - Recommend OTC medication: daily probiotic to help replenish
healthy GI flora with hx of chronic diarrhea
- Theragran daily & Vitamin D3 if depleted - Recommend vitamin and mineral supplement
therapy given suspected micronutrient deficiencies

First use of TPN on 2/2/18: Dietary consult received to initiate TPN. Patient was found to have
possible small bowel obstruction vs. Ileus on Abdominal X-Ray. Patient is currently NPO and
NG was placed for suction.

 Clinimix E 5/15 @ 65 ml/hr -- Start at 20 ml/hr x 6 hours. If tolerated, increase by 15 ml/hr

every 6 hours until goal rate is reached.
 440 ml L20 every Monday, Wednesday, Friday
Provides: ~1485 kcal (~30 kcal/kg); 78 g protein (~1.6 g/kg); 1560 ml fluid (~31 ml/kg)
Dex Load= 3.3 mg/kg/min
Lipid Load= 0.08 g/kg/hr

Estimated Nutrition Needs: wt=49.1kg (3/9/18)

1473-1964 kcal/d Based on: 30-40 kcal/kg, prevent wt loss
73-88 g pro/d Based on: 1.5-1.8g/kg, repletion
1227-1473 ml fluid/d Based 25-30ml/kcal, hydration
on:

E.C. energy needs differ substantially once being transferred to CCU during 4/15/18 admission
and meeting vent/CCU parameters.

Estimated Nutrition Needs: No changes. 43.9kg (4/23/18)

880-1100 kcal/d Based on: 20-25/kg actual weight, vent/CCU parameters,
BMI 18
66-88 g pro/d Based on: 1.5-2/kg, repletion, vent parameters, ,muscle
wasting
965-1320 or per MD ml fluid/d Based 1ml/kcal Vs 25-30/kg hydration
on:

E.C. does not completely adhere to a vegetarian diet or lifestyle, but little research is
available to show any clear evidence that a plant-based lifestyle is beneficial in the treatment of
Disseminated Histoplasmosis. Below are some suggested supplements and herbal remedies that
may play a role in reducing symptoms related to the fungal infection Histoplasma.
 Siemieniak 11

Although no supplements cure histoplasmosis, a few studies suggest that some

supplements may help reduce symptoms.8 Following these nutritional tips may help reduce
symptoms:

 Eat bitter and spicy foods, such as those containing turmeric (curries), cayenne peppers,
green chilies, olives, figs, garlic, and ginger.
 Drink warm teas which contain spices, such as cardamom, clove, and cinnamon.9
 Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes) and
vegetables (such as squash and bell peppers).9
 Drink 6 to 8 glasses of filtered water daily.

The following supplements may help reduce symptoms, although more scientific research needs
to be performed to know for sure:

 Vitamin C, 500 to 1,000 mg, 1 to 3 times daily. Vitamin C is an antioxidant and may help
strengthen the immune system.9
 Grapefruit seed extract (Citrus paradisi), 100 mg capsule or 5 to 10 drops (in favorite
beverage) three times daily when needed.9 Grapefruit seed may have antibacterial,
antifungal, and antiviral properties. It may also help strengthen the immune system.
 Probiotic supplement (containing Lactobacillus acidophilus), 5 to 10 billion CFUs
(colony forming units) a day, when needed for maintenance of gastrointestinal and
immune health.9 You should refrigerate your probiotic supplements for best results.
 Coenzyme Q10, 100 to 200 mg at bedtime, for antioxidant and immune system support.9
Coenzyme Q 10 may interact with blood thinners, such as warfarin (Coumadin),
clopidogrel (Plavix), or aspirin and make them less effective.

Herbs can strengthen and tone the body's systems. Use herbs as dried extracts (capsules,
powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts).10 Unless otherwise
indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 to 10
minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day. Use
tinctures alone or in combination as noted.
 Siemieniak 12

These herbs have not been studied specifically for histoplasmosis, but they seem to stop the
growth of some fungi:

 Cat's claw (Uncaria tomentosa) standardized extract, 20 mg, 3 times per day, to reduce
inflammation and stop the growth of fungus.10 Cat’s claw may boost the immune system,
so people with autoimmune diseases (such as rheumatoid arthritis or psoriasis) may want
to avoid it.
 Garlic (Allium sativum), standardized extract, 400 mg, 2 to 3 times per day, to kill fungus
and boost the immune system.10 Garlic may increase the risk of bleeding.
 Cranberry (Vaccinium macrocarpon), 300 to 1,800 mg, 2 times per day, to fight fungus.10
Cranberry contains salicylic acid, the same ingredient in aspirin.
 Reishi mushroom (Ganoderma lucidum), 150 to 300 mg, 2 to 3 times per day, to reduce
inflammation and strengthen the immune system.10 One may also take a tincture of this
mushroom extract, 30 to 60 drops, 2 to 3 times a day. Reishi may interact with blood
pressure medications and blood-thinning medications.10
 Olive leaf (Olea europaea) standardized extract, 250 to 500 mg, 1 to 3 times per day, for
antifungal activity and immunity.10 One may also prepare teas from the leaf of this herb.
Olive leaf can lower both blood pressure and blood sugar.10

Prognosis

Many people do not have serious complications, but rarely they may include:

 Fibrous tissue in the lining of the chest wall cavity, which may squeeze the esophagus,
heart, or lungs, so they cannot work properly.8
 Meningitis
 Scar tissue in the lungs
 Blindness -- if infection spreads to the eyes

Most cases of histoplasmosis are mild, and symptoms go away in 10 days without
treatment. Sometimes symptoms may last for several weeks. In the most severe cases,
particularly when the infection spreads throughout the body, a person may need to take
antifungal medications for a long time.8 If left untreated, severe cases can cause death. People in
 Siemieniak 13

areas where the fungus is common may get a second infection, even after treatment. But the
second one is usually milder than the first.

It remains unclear of whether or not E.C. will manage to make a healthy recovery or not.
She has been vented, sedated, and bed-ridden for ~11 days now, and continues to have high
gastric residuals. Patient unable to tolerate any form of po nutrition, including water, and will
vomit. Patient may be dependent on TPN for the rest of her life, or unless medically warranted.
Per medical disciplinary team, E.C. planned to have trach placement sometime this week.

Conclusion

Throughout this case study, I became more familiar with Disseminated Histoplasmosis. I
investigated treatment options, typical diagnostic tests, and prescribed medications for said
condition. Furthermore, I gained an understanding of the relationship between Histoplasma and
its relation to other organ systems. Granted this is not a minor case of Histoplasmosis, with many
factors coming into play such as gastrointestinal issues as well as severe malnutrition,
nonetheless, provided me with a greater understanding of the disease, and how to be more
prepared for future patients who deal with the same condition. It was difficult at times speaking
with the family of E.C. as they were extremely caring, and spent many countless hours at the
bedside waiting for better news to arrive that has yet to come. I'm glad I was able to capture
some of their turmoil, and present a topic that many are not entirely familiar with, as it is quite an
unusual condition in this area of the country. I would have liked to retrieve more nutrition history
from E.C. herself prior to being mechanically ventilated and under more severe medical
supervision. Overall this was a rewarding experience, and I hope I can share my knowledge of
Histoplasmosis with interns of my own one day, or with my co-workers.
 Siemieniak 14

References

1. Azar MM, Hage CA. Clinical Perspectives in the Diagnosis and Management of
Histoplasmosis. Clinics in Chest Medicine. 2017;38(3):403-415.
doi:10.1016/j.ccm.2017.04.004.

2. Zhu L-L, Wang J, Wang Z-J, Wang Y-P, Yang J-L. Intestinal histoplasmosis in
immunocompetent adults. World Journal of Gastroenterology. 2016;22(15):4027.
doi:10.3748/wjg.v22.i15.4027.

3. Doleschal B, Rödhammer T, Tsybrovskyy O, Aichberger KJ, Lang F. Disseminated

Histoplasmosis: A Challenging Differential Diagnostic Consideration for Suspected
Malignant Lesions in the Digestive Tract. Case Reports in Gastroenterology.
2016;10(3):653-660. doi:10.1159/000452203.

4. Wheat LJ, Freifeld AG, Kleiman MB, et al. Clinical Practice Guidelines for the Management
of Patients with Histoplasmosis: 2014 Update by the Infectious Diseases Society of
America. Clinical Infectious Diseases. 2014;45(7):807-825. doi:10.1086/521259.

5. Azar MM, Hage CA. Laboratory Diagnostics for Histoplasmosis. Journal of Clinical
Microbiology. 2017;55(6):1612-1620. doi:10.1128/jcm.02430-16.

6. Carod-Artal FJ. Fungal Infections of the Central Nervous System. CNS Infections. 2017:129-
156. doi:10.1007/978-3-319-70296-4_7.

7. Shaikh MS, Memon AM. Disseminated histoplasmosis in an immuno-competent young male:

Role of bone marrow examination in rapid diagnosis. Diagnostic Cytopathology.
2017;46(3):273-276. doi:10.1002/dc.23834.

8. Lum J, Abidi MZ, Mccollister B, Henao-Martínez AF. Miliary Histoplasmosis in a Patient

with Rheumatoid Arthritis. Case Reports in Medicine. 2018;2018:1-6.
doi:10.1155/2018/2723489.

9. Liu X, Ma Z, Zhang J, Yang L. Antifungal Compounds against Candida Infections from

Traditional Chinese Medicine. BioMed Research International. 2017;2017:1-12.
doi:10.1155/2017/4614183.
 Siemieniak 15

10. Goncagul G, Ayaz E. Antimicrobial Effect of Garlic (Allium sativum). Recent Patents on
Anti-Infective Drug Discovery. 2013;5(1):91-93. doi:10.2174/157489110790112536.

Appendices

Comprehensive Metabolic Panel results as follows:

Lab values on admit Lab values drawn Reference ranges

1/31/18 2/19/18
Glucose Random 65 (L) 82 74 - 109 mg/dL
Blood Urea Nitrogen 18 20 6 - 20 mg/dL
Creatinine 0.4 (L) 0.7 0.5 - 1.0 mg/dL
BUN/Creatinine Ratio 45 (H) 29* 7 - 25
EGFR >60 >60 >60 mL/min
Sodium 131 (L) 133* 136 - 145 mmol/L
Potassium 4.2 3.5 3.5 - 5.1 mmol/L
Chloride 96 (L) 97* 98 - 107 mmol/L
CO2 25 24 22 - 29 mmol/L
Anion Gap 10 12 5 - 14 mmol/L
Total Calcium 8.5 (L) 9.1 8.6 - 10.0 mg/dL
Total Protein 6.7 6.7 6.4 - 8.3 g/dL
Albumin 2.3 (L) 2.4* 3.5 - 5.2 g/dL
Globulin 4.4 (H) 4.3* 2.3 - 3.9 g/dL
Albumin/Globulin 0.5 (L) 0.6* 1.2 - 2.2
Ratio
AST 21 16 <33 U/L
ALT 12 17 <34 U/L
Alkaline Phosphatase 257 (H) 295* 35 - 104 U/L
Total Bilirubin 0.4 0.4 <1.3 mg/dL
Magnesium 2.0 1.8 1.7 - 2.4 mg/dL
Lipase 6 (L) --- 13 - 60 U/L

Medication list as follows:

Medication Purpose Drug/Food Interaction Side Effects

Itraconazole It can treat fungal Food increases the  diarrhea, constipation,
(SPORANOX) infections. absorption of bloating, mild nausea,
itraconazole capsules but
 joint pain, muscle pain
decreases the absorption or weakness
of itraconazole oral
solution.
pantoprazole Proton-Pump inhibitor, There are no known weight changes;
(PROTONIX works by decreasing the interactions with nausea, vomiting, mild
amount of acid your pantoprazole and food diarrhea;
 Siemieniak 16

stomach makes or beverages. gas, stomach pain;

dizziness, drowsiness
TRI-LINYAH Besides preventing aromatase inhibitors, Nausea, vomiting, head
pregnancy, birth control ospemifene, tamoxifen, ache, bloating, breast te
pills may make your tizanidine, tranexamic nderness
periods more regular acid
ondansetron HCl (PF) prevent nausea and low amount of Headache,
(ZOFRAN) vomiting magnesium, fever, lightheadedness,
calcium, dizziness, drowsiness,
potassium in the blood tiredness, constipation

HYDROmorphone It can treat moderate to Do not use alcohol or Agitation

(DILAUDID) severe pain. medications that contain bloody, black, or tarry
alcohol while you are stools
receiving treatment with blurred vision,
HYDROmorphone. changes in behavior,
chest pain or discomfort

amphotericin B It can treat fungal cancer medications, fever,

liposome infections. antifungal medication shaking,
(AMBISOME) chills,
flushing (warmth,
redness, or tingly
feeling),
loss of appetite,
dizziness,

HYDROcodone- It can treat pain. Alcohol may potentiate lightheadedness,

acetaminophen the central nervous dizziness, sedation,
(NORCO) system (CNS) nausea and vomiting.
depressant effects
Gabapentin It can treat seizures and Alcohol can increase the ataxia, dizziness,
(NEURONTIN) pain nervous system side drowsiness, fatigue,
effects of gabapentin fever, nystagmus
such as dizziness,
drowsiness, and
difficulty concentrating
Morphine (MS help relieve severe alcohol, marijuana, Nausea, vomiting, const
CONTIN) ongoing pain drugs ipation, sweating, lighth
for sleep or anxiety eadedness, dizziness
Levophed It can treat low blood blood pressure Allergic reaction,
pressure and heart medications, MAO Blackish-color of your
failure. inhibitors, or toes,
antidepressants Chest pain,
Pain, itching, swelling,
burning

Intropin Blood pressure support Diuretics, blood pressure Headache, anxiety.

meds, depressants Nausea or vomiting.
Tingling feeling,
 Siemieniak 17

goosebumps

Reglan Gut motility stimulator Alcohol can increase the Lightheadedness, dizzin
nervous system side ess, or fainting
effects of Problems
metoclopramide such as with balance or walking
dizziness, drowsiness,
and difficulty
concentrating
Miralax Provide effective relief herbal Mild cramps, bloating,
from occasional remedies, vitamins, and diarrhea, or gas.
constipation nutritional supplements.
Diprivan Anesthetic Alcohol can increase the Confusion, weakness,
nervous system side or numbness, Fever,
effects of propofol chills, cough, sore
throat, body aches
Lower back or side pain
Muscle pain, tightness,

Humulin/Novolin treat diabetes by Alcohol may affect  Low blood sugar.

lowering your blood blood glucose levels in  Allergic reaction.
sugar levels patients with diabetes.
 Reaction at the
Both hypoglycemia and
injection site.
hyperglycemia may
occur.  Thickened skin at the
injection site.
 Itching.
 Rash.

Solu-cortef Steroid to treat Dietary sodium mood swings, trouble

inflammation. restriction and potassium sleeping, unusual
supplementation thoughts, feelings, or
behavior
Dry mouth, increased
thirst, muscle
cramps, nausea or vomi
ting,

Lasix Diuretic may reduce  nausea or vomiting.

the potassium level in  diarrhea.
your blood
 constipation.
 stomach cramping.
 feeling like you or the
room is spinning
(vertigo)
 dizziness.
 Siemieniak 18

E.C. Family history as follows:

Cancer Mother
Heart disease Father
Cancer Maternal Uncle
Cancer Paternal Aunt
High cholesterol Paternal Uncle
Cancer Maternal Grandfather
Heart disease Paternal Grandmother
High cholesterol Paternal Grandmother
Heart disease Paternal Grandfather
High cholesterol Paternal Grandfather