CTICasesAcute Pulmonary Histoplasmosis Presenting as Consolidation
Imaging findings
A woman in her 50s with psoriatic arthritis on a TNF-alpha inhibitor (adalimumab) presented with cough and fever and had left lower lobe consolidation with a positive spine sign, background emphysema from smoking, a thin sliver of effusion, and reactive draining lymph nodes. The consolidation failed to respond to antibiotics; workup showed granulomatous inflammation and cultures grew histoplasma. Serial imaging over months shows gradual retraction with air bronchograms, dilated distorted airways, and residual bronchitis on the most recent CT.
Key takeaways
Histoplasmosis presenting as lobar consolidation is a rare manifestation, as it far more often appears as a nodule, a cluster of nodules, or lymphadenopathy. Impaired T-cell immunity from a TNF-alpha inhibitor likely predisposed this patient, either to new infection or reactivation. A community-acquired-appearing consolidation that fails to respond to standard antibiotics should prompt further workup for granulomatous and fungal infection, and treated histoplasmosis may leave residual bronchial scarring.
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