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A 37-year-old male with h istory of HIV with poor compl iance with HAART presents for evalua tion of 1 month of fever. fatigue. and weigh t loss. Review of systems does not point to a specific source of infectious process. Physical exami nation reveals spleno-megaly. Laboratory workup shows hemoglobin of 9.2 g/dl. leu kocyte count of Lj,700/f1L, and platelet count of 1 3Lj ,QQO/f1L. The most recent CDL.j cell count is 1 3 5/fll. Peripheral blood is shown below.
Bone marrow aspi rate is obtai ned and is shown below in addition to a si lver-stained sec tion of the bone marrow aspira te.
What is the most likely diagnosis?
- Disseminated tuberculosis
- Disseminated histoplasmosis
- Disseminated mycobacterium avium complex infection
- AIDS-related lymphoma
- Hemophagocytosis
Medicine
B. Peripheral blood smear and bone marrow demonstrate multiple intracellular crescent-ring organisms that stain positively with Gomori methamine silver ( GMS) stain. This is a classical presentation of disseminated histoplasmosis associated with HIV infection. Blood and bone marrow cultures yielded Histoplasma capsulatum. Fever and weight loss are the most common manifestation of histoplasmosis and HIV infection. Anemia, neutropenia, or thrombocytopenia reflecting bone marrow involvement may be present. Between 5% and 10% of patients present with an acute illness with hypotension, disseminated intravascular coagulation, and shock. Careful inspection of the pe- ripheral blood smear may be helpful in the evaluation of HIV patients with fever and anemia.
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