PMC9940204_01
Magnetic resonance imaging (MRI) of the brain demonstrating bifrontal hemorrhagic contusions (red arrows, larger on the left), scattered subarachnoid hemorrhages without demonstrable mass effect or midline shift (blue arrows), and few scattered tiny hypointense areas on gradient echo.
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The patient was found to be in status epilepticus refractory to anti-epileptic drugs secondary to traumatic brain injury (TBI) from multiple ground-level falls, and magnetic resonance imaging (MRI) of the brain demonstrated bifrontal hemorrhagic contusions (larger on the left), scattered subarachnoid hemorrhages without demonstrable mass effect or midline shift, and few scattered tiny hypointense areas on gradient echo (Figure 1).
Chest x-ray taken on admission showing left basilar atelectasis (red arrow), left hemi diaphragm elevation (blue arrow), and a right upper lobe irregular calcification (yellow arrow).
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Initial chest x-ray revealed left basilar atelectasis, left hemidiaphragm elevation, and a right upper lobe irregular calcification (Figure 2).
Computed tomography (CT) without contrast of the abdomen and pelvis revealed hepatomegaly with a craniocaudal length of 21 cm (red arrow), splenomegaly with a length of 18.2 cm (blue arrow), bilateral adrenal masses measuring 4 cm each (yellow arrow), and enlarged pericaval lymph nodes with a length of 2.3 cm x 1.7 cm x 4 cm.
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Given this along with recent weight loss, the team performed cancer workup that included a computed tomography (CT) without contrast of the abdomen and pelvis, which revealed hepatomegaly with a craniocaudal length of 21 cm, splenomegaly with a length of 18.2 cm, bilateral adrenal masses measuring 4 cm each, and enlarged pericaval lymph nodes with a length of 2.3 cm x 1.7 cm x 4 cm (Figures 3 and 4).
Computed tomography (CT) without contrast of the abdomen and pelvis revealed hepatomegaly with a craniocaudal length of 21 cm (red arrow), splenomegaly with a length of 18.2 cm (blue arrow), bilateral adrenal masses measuring 4 cm each, and enlarged pericaval lymph nodes with a length of 2.3 cm x 1.7 cm x 4 cm.
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Given this along with recent weight loss, the team performed cancer workup that included a computed tomography (CT) without contrast of the abdomen and pelvis, which revealed hepatomegaly with a craniocaudal length of 21 cm, splenomegaly with a length of 18.2 cm, bilateral adrenal masses measuring 4 cm each, and enlarged pericaval lymph nodes with a length of 2.3 cm x 1.7 cm x 4 cm (Figures 3 and 4).
PMC9940204_02
Left adrenal biopsy stained with: (A) histoplasmosis on hematoxylin and eosin. Hematoxylin and eosin demonstrated small, round, shadowlike microorganisms (yellow arrow). (B) Histoplasmosis stained with Grocott's methenamine silver. Grocott's methenamine silver stained the microorganisms black (red arrow).
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Subsequently, a left adrenal biopsy was performed and stained with hematoxylin and eosin, demonstrating small, round, shadowlike microorganisms that turned dark black when stained with GMS:consistent with HP (Figure 5).