A liver biopsy specimen disclosed granulomatous hepatitis, without evidence for AFB or fungal disease. However, symptoms and liver function test abnormalities resolved entirely within 3 weeks of receiving empiric isoniazid, rifampin, and ethambutol. Treatment with these drugs was discontinued 3 months PTA on return of abdominal pain, nausea, vomiting, weight loss, malaise, and night sweats. An extensive gastrointestinal evaluation was unre-vealing and the patient was admitted to the hospital for progression of symptoms.
At the time of hospital admission, the patient also complained of dyspnea, and was found to have a new large right pleural effusion with right lower lobe consolidation and atelectasis, in addition to a smaller left pleural effusion. A diagnostic right thoracentesis yielded serosanguineous fluid compatible with an exudate (total protein, 4,000 mg/dL; lactate dehydrogenase [LDH], 441 lU/mL [serum, 451 IU/mL]; glucose, 84 mg/dL [serum glucose not available]; RBC, 3,575/mm; WBC, 170/mm [20% polymorphonuclear leukocytes, 60% lymphocytes, 20% mesothelial cells]); special stains and cultures for routine bacterial, AFB, and fungal pathogens were negative. A pleural biopsy specimen demonstrated abundant invasive fungal elements involving the pleura, with morphologic features consistent with Histoplasma capsula-tum, prompting initiation of intravenous amphotericin В therapy. other
On the seventh hospital day, the patient developed hypotension, melena, hematemesis, and abdominal pain. The patient was successfully resuscitated with intravenous crystalloid, 4 U of packed RBCs, and 6 U of fresh frozen plasma, but he required intubation for progressive respiratory compromise. A chest radiograph demonstrated increased interstitial markings bilaterally, enlarged cardiac silhouette, and bilateral pleural effusions, findings that were interpreted as representing congestive heart failure.