Gretchen Rios Grant, MD1, Lidynell Burgos, MD1, Paloma Velasco, MD1, Vanessa Sepulveda, MD1, Jonathan Ruiz, MD1, Gabriel Galindez, MD1, Victor J. Carlo-Chevere, MD2, Reinaldo Hernandez, MD1, Steven Velez, MD1 1University District Hospital, San Juan, Puerto Rico; 2AdventHealth Orlando, Orlando, FL Introduction: Patients with inflammatory bowel disease (IBD) receiving anti-TNF alpha inhibitors are at increased risk for opportunistic infections. Histoplasmosis, though uncommon, may present with nonspecific pulmonary symptoms and radiographic findings that mimic other etiologies such as hypersensitivity pneumonitis and sarcoidosis. This case highlights the diagnostic challenge of differentiating atypical infections from inflammatory or immune-mediated conditions in an immunosuppressed patient with Crohn’s disease.
Case Description/
Methods: A 32-year-old male with penetrating ileocolonic and perianal Crohn’s disease, maintained on infliximab, presented with a two-month history of progressive nonproductive cough, fevers, and chills. He is a nonsmoker and denied sick contacts, recent travel, weight loss, or hemoptysis. He worked in agriculture, primarily hydroponics.On examination, he was febrile, tachycardic, and diaphoretic. Laboratory studies revealed elevated inflammatory markers (CRP, ESR), positive (1→3)-β-D-glucan, and elevated serum IgE. Chest X-ray showed bilateral patchy infiltrates, and CT chest revealed diffuse ground-glass opacities without lymphadenopathy or tree-in-bud opacities. The differential diagnosis included subacute hypersensitivity pneumonitis, sarcoidosis and atypical fungal infections.Abdominopelvic CT revealed splenomegaly. Bronchoalveolar lavage (BAL) showed chronic inflammation but no malignant cells or organisms. Lung biopsy revealed non-caseating granulomas. BAL fungal cultures later grew Histoplasma capsulatum, and urine Histoplasma antigen was positive. The patient declined amphotericin B and was treated with oral itraconazole. Infliximab was discontinued. Over one year of follow-up, he had complete resolution of symptoms, normalization of imaging, and negative Histoplasma antigen. His Crohn’s disease remained stable off biologic therapy, and he is currently under re-evaluation for biologic reinitiation. Discussion: This case emphasizes the importance of considering opportunistic infections like histoplasmosis in patients with IBD on biologic therapy who present with atypical pulmonary findings. Non-caseating granulomas can be misleading and are not pathognomonic for sarcoidosis or hypersensitivity pneumonitis. Occupational exposure history and comprehensive infectious workup are essential to avoid misdiagnosis. Discontinuation of immunosuppressive therapy and timely antifungal treatment led to full clinical recovery in this case.
Disclosures: Gretchen Rios Grant indicated no relevant financial relationships. Lidynell Burgos indicated no relevant financial relationships. Paloma Velasco indicated no relevant financial relationships. Vanessa Sepulveda indicated no relevant financial relationships. Jonathan Ruiz indicated no relevant financial relationships. Gabriel Galindez indicated no relevant financial relationships. Victor Carlo-Chevere indicated no relevant financial relationships. Reinaldo Hernandez indicated no relevant financial relationships. Steven Velez indicated no relevant financial relationships.
Gretchen Rios Grant, MD1, Lidynell Burgos, MD1, Paloma Velasco, MD1, Vanessa Sepulveda, MD1, Jonathan Ruiz, MD1, Gabriel Galindez, MD1, Victor J. Carlo-Chevere, MD2, Reinaldo Hernandez, MD1, Steven Velez, MD1. P5517 - Non-Caseating Granulomas and a Hidden Fungus: Disseminated Histoplasmosis in a Crohn’s Patient on Anti-TNF Therapy, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
