Infliximab-induced disseminated histoplasmosis in a patient with Crohn's disease

Background A 56-year-old female with a 30-year history of ileocolic Crohn's disease presented with a 1-month history of bloody diarrhea and decreased caliber of stools; physical examination revealed a broad indurated anal fissure. The patient had been receiving antimetabolite therapy with 6-mercaptopurine and maintenance therapy with infliximab for over a year. Investigations Physical examination; proctoscopy; perianal and anal canal biopsy; chest CT; blood and stool analysis, measurement of serum histoplasmosis antibodies and urine histoplasmosis antigen levels; fungal culture and Gomori's methenamine silver staining of resected tissue specimens. Diagnosis Disseminated histoplasmosis. Management Proctocolectomy and end ileostomy followed by treatment with liposomal amphotericin and then oral itraconazole. A palmar space abscess required multiple debridements, and a muscle flap to cover the defect.