Chronic Sore Throat and a Tonsillar Mass

Posted by • October 17th, 2014

In the latest Case Record of the Massachusetts General Hospital, a 78-year-old woman with rheumatoid arthritis was admitted to the Massachusetts Eye and Ear Infirmary because of a chronic sore throat, odynophagia, and a tonsillar mass. A diagnostic procedure was performed.

Histoplasma capsulatum is commonly found in soil in certain regions of the United States and South America, and 50 to 80% of people living in regions where the fungus is endemic have evidence of prior exposure.

Clinical Pearls

What is the differential diagnosis of acute vesicular pharyngitis?

Acute vesicular pharyngitis may be caused by coxsackievirus (and occasionally other enteroviruses), herpes simplex virus (HSV), and varicella-zoster virus (VZV). Coxsackievirus causes a bilateral pharyngitis that primarily affects young children and resolves in a few days. Primary HSV-associated stomatitis may be severe in immunocompromised patients and is bilateral. Recurrent HSV may produce atypical lesions in immunocompromised patients and may involve the pharynx and larynx; the lesions are usually bilateral. Patients with rheumatoid arthritis are at increased risk for herpes zoster, and patients with a zoster rash affecting the second or third divisions of cranial nerve V may have an accompanying ipsilateral pharyngitis or laryngitis, although this is rare. VZV pharyngitis or laryngitis may also develop without a concurrent facial zoster rash, but in these cases, one or more cranial neuropathies are almost always present.

Who is at greatest risk for histoplasmosis and disseminated histoplasmosis?

In the United States, histoplasmosis infections occur mainly in the regions of the Mississippi River Valley and Ohio River Valley, although a study of the geographic distribution of infection among older adults showed that 12% of cases occur in areas where the fungus is not endemic, including New England. Histoplasmosis is initially asymptomatic or produces a mild acute respiratory illness that resolves. Disseminated disease develops in 0.05% of patients, most of whom are immunocompromised. Dissemination occurs either soon after the primary infection or reinfection or after reactivation of previously unrecognized latent disease.

Morning Report Questions

Q: How does anti-tumor necrosis factor-alpha (TNF-alpha) therapy alter the risk of histoplasmosis?

A: Anti-TNF-alpha therapy increases the risk of histoplasmosis, and histoplasmosis is the most common invasive fungal infection in patients receiving these medications. In patients who are receiving TNF-alpha inhibitors, histoplasmosis is three times more common than tuberculosis, according to one report, and is associated with a mortality of 20%, with deaths often due to a delay in diagnosis and treatment. The risk of disease is higher among patients who are receiving infliximab than among those who are receiving etanercept.

Q: What are the features of oropharyngeal histoplasmosis?

A: Disseminated histoplasmosis may involve the throat, with the most common sites of involvement being the buccal mucosa, tongue, and palate; the larynx may also be involved. The lesions are often painful, ulcerated, and indurated, with heaped-up borders, and may mimic cancer. Oral and laryngeal lesions may be present simultaneously. Oropharyngeal or laryngeal lesions may be the only signs of disseminated disease, and fever occurs in only one third of patients with such disease.

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