We present a case report of transverse myelitis as a presentation of disseminated histoplasmosis in an immunocompromised patient.

Our patient is 46-year-old male with past medical history of insulin dependent type 1 diabetes presenting with 5 days of progressive left leg weakness and numbness along with urinary retention and unintentional weight loss. A few months prior to presentation, he had been hiking around creeks and rocks in Arkansas and following that, had been having back pain that progressed few weeks prior to presentation. Neurological exam demonstrated left leg weakness, hyperreflexia, sensory level above belly button along with spastic gait. He underwent MRI of the brain and spine which demonstrated numerous enhancing brain lesions and enhancing intramedullary spinal cord lesion at T4 level. For initial concern for malignancy, CT chest, abdomen and pelvis were done which demonstrated bilateral adrenal masses, innumerable tiny pulmonary nodules in bilateral upper lobes, and splenomegaly. CSF showed only elevated protein 104, otherwise unremarkable. His total T-cell count was 487. Patient underwent radiation therapy for suspected malignancy due to progressive weakness initially but later on discontinued. He underwent adrenal mass biopsy which showed yeast forms along with urine test positive for histoplasma antigen. He was diagnosed and subsequently treated for disseminated histoplasmosis with amphotericin B infusions and eventually had resolution of his weakness.

Disseminated histoplasmosis can involve CNS in 10-20% of cases and higher in immunocompromised patients. Clinical presentations include isolated chronic meningitis, cerebral vasculitis with stroke syndrome, focal brain lesions, encephalitis, and localized spinal cord involvement. Such diffuse CNS involvement with disseminated histoplasmosis has rarely been reported and rarer are reports of intramedullary spinal cord histoplasmosis. Diagnosis can be challenging as differentials such as metastatic cancer, abscess, etc. are more prevalent and hence CNS histoplasmosis needs a higher clinical suspicion.