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Old 10-18-2011
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Question A 5-year old East African with productive cough and hepatomegaly

A 15-year old East African immune-competent boy with a history of smear-positive tuberculosis and a two-year history of rock cutting presented to the hospital with chronic productive cough, fever, massive unilateral consolidation, and hepatomegaly. At the time of presentation to our hospital, this patient was empirically treated for recurrent tuberculosis without success, but he died on the seventh day after admission. The autopsy revealed a huge granulomatous lesion with caseation in the lung, but no acid-fast bacilli were detected on several Ziehl-Neelsen stains. However, periodic acid-Schiff staining was positive. Autopsy specimen from the liver stained with Gomori's Methenamine Silver is shown below:
What is the most likely casue of this condition?
A) Mycobacterium avium
B) Cryptococcus neoformans
C) Histoplasma capsulaturn
D) Aspergillus fumigates
E) Sporothrix schenckii
F) Blastomyces dermatitidis
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Old 10-18-2011
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I think the answer is C) Histoplasma capsulaturn

(1) Not Mycobacterium avium-because it is not a fungus therefore does not stain with Gomori's Methenamine Silver. Plus mycobacterial infection occurs in the later stages of AIDS not in immunocompetent px.

(2) Not C. neoformans, as it causes a lung fungal infection in immunocompromised or AIDS patient.

(3) Yes it is Histoplasmosis because it may affect immunocompetent people if they are very young or very old . Although Histoplsmosis mostly causes fibrotic granuloma rather than caseating one, I think in this case the caseating granuloma was just an inheritence from previous TB infections (even though the TB bug has been cleared).

(4) not Aspergillus because they are rather slim strips in GMS rather than the short-and-fat grainy clumps in your picture. (see the photo I attached showing the difference)

(5) Not Sporothrix schenckii, because it causes Sporotrichosis which is a subcutaneous infection, causing pyoderma gangrenosum. It does not normally cause lung problem.

(6) Not Blastomyces because it mostly causes skin condition (called blostomycosis). It may multiple in the lung, only if the px is immunocompromised. Otherwise it will just causes skin lesions in immunocompetent people .

*** By the way have a look at the attached histologic photos of GMS stains. The photo in the question is appearantly looking like Histoplasma capsulaturn
Attached Thumbnails
A 5-year old East African with productive cough and hepatomegaly-histo.jpg  

Last edited by HaipengWang; 10-18-2011 at 10:14 PM.
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