histoplasmosis reported from the gangetic plains in india , is rare in renal transplantation , and more common in human immunodeficiency virus ( hiv ) infected individuals . as the presenting clinical features are usually prolonged fever , malaise , weight loss , cough , dyspnea and an abnormal chest roentgenogram with diffuse nodular patchy or miliary infiltrates , the condition may be misdiagnosed as tuberculosis and has been empirically treated as such without definitive investigations . here , we report a case of pulmonary histoplasmosis developing in a renal allograft recipient in a non - endemic area with no documented exposure . a 55-year - old lady , on dialysis since february 2011 , underwent a renal transplantation on 23 february 2012 with an allograft kidney from her daughter . she had been diagnosed with tuberculous lymphadenopathy in september 2011 and received isoniazid , rifampicin , pyrazinamide and ethambutol from september to december 2011 . there was 1 b and 1 dr mismatch and the lymphocyte cross match by complement dependent cytotoxicity was negative at 4% . immunosuppression consisted of intraoperative methylprednisolone , followed by tapering doses of oral prednisolone until 10 mg daily , tacrolimus 0.15 mg / kg / day adjusted according to trough levels and azathioprine 2 mg / kg / day . she was admitted on 18 july 2012 with daily evening fever up to 100f for 10 days , dry cough for 7 days and left sided pleuritic chest pain for 5 days . she had received oral amoxicillin clavulunate and paracetamol with temporary relief , but symptoms had worsened on the day of admission . examination revealed a temperature of 100.4f , pulse of 96/min and respiratory rate of 20/min . auscultation of the chest revealed decreased breath sounds at the left infraaxillary and infrascapular regions , without any bronchial breathing , rub or rales . a chest roentgenogram showed a homogeneous opacity without an air bronchogram in the left lower zone with obscured left costophrenic angle [ figure 1 ] . chest x - ray at presentation shows opacity in left hemithorax other investigations are shown in table 1 . she received empirical cefotaxime 2 g q 12 h , azithromycin 0.5 g daily and nebulization to induce sputum production . she continued to have chest pain and fever despite negative blood cultures and a complete absence of sputum . a left lateral roentgenogram confirmed the opacity and showed no evidence of pleural fluid . a high resolution computed tomography scan of the thorax on the 25 of july 2012 , revealed a heterogeneously enhancing necrotic mass lesion in the left lower lateral basal segment reaching up to the pleural surface , multiple discrete lower lobe nodules bilaterally , a discrete 1 cm nodular density in the inferior and paracardiac region of the right upper lobe and enlarged pre - tracheal , paratracheal , precarinal and subcarinal lymph nodes [ figure 2 ] . arrow shows inhomogeneous mass in left hemithorax , non - enhancing areas indicate necrosis a fine - needle aspiration and biopsy of the lesion was performed on 26 july 2012 , under computed tomographic guidance . the aspirate showed a necrotic background with few polymorphs , lymphocytes , eosinophils and budding yeast like fungal elements and was negative for acid fast bacilli , nocardia and pneumocystis jiroveci . the biopsy showed widespread areas of necrosis , infiltration with polymorhonuclear leukocytes and lymphocytes and histiocytic proliferation and fibrosis . the histiocytes contained multiple tiny , budding yeast like structures , which on periodic acid schiff ( pas ) , showed a distinct positively stained capsule [ figure 3 ] . the lesion was suggestive of histoplasmosis , which was confirmed on culture after 23 days of incubation . patient was treated with liposomal amphotericin b 200 mg daily , ( 4 mg / kg / day ) and discontinuation of azathioprine . after 20 days , her chest roentgenogram showed significant improvement and she was discharged on oral itraconazole 200 mg bid and her chest roentgenogram after 5 months of treatment [ figure 4 ] , showed complete resolution of the lesion . in october 2012 , she was found to have developed new onset diabetes after transplantation , which was controlled with oral hypoglycemic agents . gomoris silver stain showing typical budding yeasts ( arrow head ) against a necrotic background , 1000 chest x - ray showing resolution after 5 months of treatment it is rare in renal transplantation , usually does not appear to be related to the intensity of immunosuppression and can occur at any time , with the world 's largest series reporting an attack rate of 0.6/1000 patient years over a 10 year follow - up period . immunosuppressed patients may develop disseminated disease , which can progress to septic shock , disseminated intravascular coagulation , acute kidney injury and respiratory insufficiency and carries a mortality of up to 23% . the presenting clinical features , usually prolonged fever , malaise , weight loss , cough , dyspnea and an abnormal chest roentgenogram with diffuse nodular patchy or miliary infiltrates , resemble tuberculosis , which is endemic in india and hence it has been empirically treated as such without definitive investigations . falsely negative serological tests in immunosuppressed patients and negative antigen tests in patients without complete disseminated disease , make distinguishing the condition from other fungal infections , tuberculosis , sarcoidosis , lymphoma and malignancy difficult or impossible in the patient with pyrexia of unknown origin , without histopathological examination . the largest indian series of 24 cases reported diabetes and hiv infection to be the most common predisposing features with only one patient a renal allograft recipient . the most common presentation was subacute and ten patients had received empirical anti - tuberculous treatment for 2 - 3 months prior to diagnosis . additional case reports from india specifically in renal allograft recipients have reported cutaneous , pulmonary , concomitant colonic and genitourinary histoplasmosis presenting as a prostatic abscess and disseminated forms at different time periods . the organism is a dimorphic fungus , present as a mold in its natural reservoir , soil contaminated with bird droppings and converts to a budding yeast form in tissues during the invasive disease . acute pulmonary disease usually an asymptomatic disease can become severe and develop into acute respiratory distress syndrome in patients who have defective cell mediated immunity , while the untreated chronic form progresses to increasing pulmonary insufficiency and death . the presence of systemic signs such as fever ( seen in 93% of organ recipients ) , malaise , weight loss and evidence of bone marrow suppression indicate dissemination and is an indication for urgent treatment especially in solid organ recipients . in our patient , these signs developed while she had already been treated for tuberculosis for 10 months . the diagnosis rests upon histopathology of affected areas most often with demonstration of intracellular yeasts , the presence of budding and a distinct capsule seen best on the pas or gomori 's silver stain , all of which were seen in our patient . the value of direct demonstration of the organisms on smear or tissue was stressed in two studies both of which found the sensitivity to be 100% , in contrast to culture , which was positive in 20.8% and 16% respectively . as in our case , all studies reporting positive cultures noted a period of 3 - 4 weeks on special media to develop the mold form with the presence of microconidia . the absence of granuloma formation and presence of necrosis are associated with progressive disease and this prompted us to start treatment with liposomal amphotericin b , as per the american thoracic society recommendations before confirmation of the species histoplasma capsulatum on culture . most indian reports show similar patterns , as the serology maybe negative in immunosuppressed individuals and the mortality has been decreased from 80% to < 25% with antifungals . our patient made a complete recovery with clinical cure and radiological resolution and was maintained on oral itraconazole therapy . as stated by gopalakrishnan et al . , histoplasmosis may be underdiagnosed in india as it requires a high index of clinical suspicion and tissue diagnosis and growth on culture may be late .
histoplasmosis , seen rarely in kidney transplantracipients , can vary from an innocuous illness often misdiagnosed as tuberculosis to a severe disseminated disease with a high mortality . 
 we describe a case with non - specific signs in whom the diagnosis was made by histopathological examination of the lesion . 
 prompt introduction of specific treatment led to histoplasmosis , seen rarely in kidney transplantracipients , can vary from an innocuous illness often misdiagnosed as tuberculosis to a severe disseminated disease with a high mortality . 
 we describe a case with non - specific signs in whom the diagnosis was made by histopathological examination of the lesion . 
 prompt introduction of specific treatment led to the patient making an excellent recovery the patient making an excellent recovery .