Disseminated Histoplasmosis Associated with the Treatment of Rheumatoid Arthritis with Anticytokine Therapy

Background: Tumor necrosis factor (TNF)–α antagonists increase risk for opportunistic infection.

Objective: To describe a case of disseminated histoplasmosis associated with treatment with adalimumab.

Case Report: A 41-year-old white man with rheumatoid arthritis, treated with adalimumab for 9 months, presented for evaluation of 3 weeks of worsening malaise and intermittent fevers. He did not report any joint pain, myalgias, or rash. He subsequently developed progressive dyspnea without cough or chest pain.

On physical examination, his temperature was 39.4 °C, and he had tachycardia and tachypnea. His oxygen saturation was 94% on 3 L of oxygen by nasal cannula. He had scleral icterus but no lymphadenopathy. His lungs were clear to auscultation. He had no cardiac murmurs. His abdomen was distended, with marked, tender hepatosplenomegaly. Joint …