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OBJECTIVE –
This is a case report and literature review of a patient with an infected aortic endograft with Histoplasma capsulatum with a distant history of disseminated gastrointestinal histoplasmosis.
METHODS –
A systematic review of all English language literature with information on endovascular histoplasmosis infections, endograft infections, native aortic aneurysms infections with histoplasmosis, disseminated histoplasmosis, and bypass graft infections with histoplasmosis was conducted.
RESULTS –
We present a case report of a 73 year-old male with a history of disseminated gastrointestinal histoplasmosis who presented six months after an endovascular aortic aneurysm repair with fevers, weight loss, abdominal pain and confusion. Computed Tomography (CT) imaging demonstrated a large aneurysm with thickened walls and adjacent rim-enhancing fluid collections.  He was initially diagnosed with an inflammatory periaortitis after an infectious workup was negative. The patient was discharged on oral steroids but returned a week later with worsening abdominal pain, nausea, and vomiting. Repeat CT imaging was unchanged. He underwent a staged revascularization procedure with an axillary bifemoral bypass and subsequent explantation of the aortic graft. Intraoperative cultures of the fluid, graft, mural thrombus and sac grew Histoplasma capsulatum.  Surgical pathology confirmed the presence of fungal organisms. He was treated with liposomal amphotericin and cefazolin with excellent tolerance. After completion of amphotericin, he was transitioned to oral itraconazole for a lifelong course.
CONCLUSIONS –
This is the first reported case of an aortic endograft infection with Histoplasma since the advent of endovascular aneurysm repair (EVAR). Histoplasmosis infections of aortic aneurysms and aortic grafts are a rare but known complication typically affecting patients from endemic areas who present with fevers and negative bacterial cultures. Evaluating serum serology markers for Histoplasma may be helpful in diagnosing the infection preoperatively. Treatment with intravenous amphotericin followed by oral itraconazole or ketoconazole along with appropriate surgical excision and revascularization are the recommended treatments of choice.