Image 40: This man spent a week in the Dominican Republic on the beach. He became ill 18 days after  return to Montreal, with a high fever (~39º, fatigue, profuse sweating, substernal chest tightness and, in the second week, a dry cough.  He was seen after 14 days of illness. His physical was normal except and his hematology was normal, but liver enzymes elevated [AST 305 U/L (N 10-37) ALT 397 U/L (N 10-40), normal alkaline phosphatase and bilirubin]. Malaria smear and blood cultures were negative. The images shown here on day 30 of his illness, when fever was down to ~38º. The diagnosis was:

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Image 41: Acute histoplasmosis. We were led astray by the the trip to the tropics. Everything that occurs subsequent to a trip to the tropics must be considered potentially of tropical origin. However 10 days after his return to Canada, 8 days before he bacame ill, he tore down an old farmhouse wall within which were large numbers of bat skeletons, feces and dead bat bodies. His histoplasma serology was positive (M band), his urine histoplasma antigen was positive and his trans-broncheal biopsy silver stain was positive for histoplasma like objects. He has had a slow response to itraconizole.

       October 19, 2005