Contributed by Zaibo Li MD and Sara Monaghan MD
The patient is a 19-year-old male with a two-week history of febrile illness, respiratory failure, and septic shock. His illness started with low grade fever, intermittent headache, and nausea. Gradually, his symptoms progressed into high fever, prominent weakness, shortness of breath, and respiratory failure.
Past medial history: No significance.
Social history: He lives at a home in a farm area with history of exposure to the dog, cat, and rodent.
Physical examination showed a few areas of ecchymosis, jaundice and hepatosplenomegaly.
3. A Grocott stain of a bronchoalveolar lavage showed numerous budding yeast forms; culture of bronchoalveolar lavage is positive for confirmatory DNA probe for Histoplasma capsulatum.
4. Other laboratory testing results: elevated serum ferritin, normal fasting triglycerides and normal fibrinogen.
5. Peripheral blood smears (Figure 1-3). Figure 1: peripheral blood smear; figure 2: toxic granulation; figure 3: Dohle bodies.
6. Bone marrow aspirate smears (Figure 4-5). Figure 4: hemophagocytosis; figure 5: hemophagocytosis.
7. Bone marrow biopsy (Figure 6). Figure 6: normal cellular bone marrow.
8. Bone marrow Grocott stain (Figure 7). Figure 7: numerous budding yeast forms.
9. Flow Cytometry: heterogeneous cellular populations, including granulocytes, lymphocytes and monocytes. No significant abnormality.
10. Cytogenetics: 46,XY. Apparently normal male bone marrow chromosome analysis. No clonal numerical or structural abnormalities were observed.