# Disseminated Histoplasmosis in a Patient With HIV Infection Untreated for 23 Years

## TL;DR

A woman with untreated HIV for 23 years developed severe histoplasmosis, highlighting the risks of delayed care and the importance of early HIV diagnosis.

## Contribution

This case emphasizes the consequences of prolonged untreated HIV and the role of stigma in delaying care.

## Key findings

- Prolonged untreated HIV led to severe immunosuppression and disseminated histoplasmosis.
- Clinical and immunologic improvement followed antiretroviral therapy and antifungal treatment.
- Stigma and barriers to care contributed to delayed diagnosis and severe disease.

## Abstract

Histoplasmosis is a potentially life-threatening opportunistic fungal infection in patients with advanced human immunodeficiency virus (HIV), particularly in endemic regions such as the Ohio and Mississippi River valleys. Despite advances in antiretroviral therapy, delayed diagnosis, lack of linkage to care, and treatment nonadherence continue to contribute to severe opportunistic infections in individuals with untreated HIV.

We present the case of a 43-year-old woman with a 23-year-long history of untreated HIV infection who presented with fever, weight loss, diarrhea, and malaise. Laboratory evaluation revealed a viral load of 327,000 copies/mL and severe immunosuppression with a Cluster of Differentiation (CD4) count of 8 cells/µL, hyponatremia, and elevated liver transaminases. Computed tomography imaging demonstrated extensive mesenteric and retroperitoneal lymphadenopathy. Biopsy of a retroperitoneal lymph node revealed granulomas containing fungal organisms consistent with disseminated histoplasmosis. The patient was initially treated with empiric broad-spectrum antibiotics and intravenous amphotericin B, followed by long-term itraconazole therapy and initiation of antiretroviral treatment, resulting in clinical and immunologic improvement.

This case highlights the direct relationship between prolonged untreated HIV infection, advanced immunosuppression, and disseminated histoplasmosis, while underscoring the impact of stigma and barriers to care on delayed diagnosis and disease severity. Early HIV diagnosis, timely linkage to care, and sustained patient engagement remain essential to preventing severe opportunistic infections.