{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T13:20:01Z","timestamp":1788441601354,"version":"build-2803163510"},"reference-count":19,"publisher":"BMJ","issue":"7","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2026,7,2]]},"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:p>Most histoplasmosis infections are asymptomatic or present as a self-limiting pulmonary illness; however, disseminated disease can occur in immunocompromised patients. Lower gastrointestinal (GI) bleeding (haematochezia) without other GI-related symptoms is an uncommon manifestation of disseminated histoplasmosis, posing a diagnostic challenge.<\/jats:p>\n                  <jats:p>\n                    We describe a renal transplant recipient in his 70s on chronic immunosuppressive therapy (tacrolimus and mycophenolate mofetil) who initially presented with progressive bilateral lower-extremity weakness and later developed haematochezia during hospitalisation. A colonoscopy was performed for worsening anaemia and haematochezia and revealed a localised ulcerated lesion. Histopathology demonstrated necrotising granulomatous inflammation with intracellular yeast forms on H&amp;E staining, with Grocott methenamine silver stain highlighting oval budding yeast consistent with\n                    <jats:italic>Histoplasma capsulatum<\/jats:italic>\n                    . Serum Histoplasma antigen was positive (5.2\u2009ng\/mL).\n                  <\/jats:p>\n                  <jats:p>MRI demonstrated multifocal enhancing lesions involving the brain and spinal cord. Cerebrospinal fluid analysis revealed lymphocytic pleocytosis (27\u2009cells\/\u00b5L, 90% lymphocytes), elevated protein (88.2\u2009mg\/dL) and low glucose (48\u2009mg\/dL; serum 101\u2009mg\/dL), concerning for fungal meningitis in the setting of disseminated histoplasmosis.<\/jats:p>\n                  <jats:p>He was treated with liposomal amphotericin B followed by itraconazole, with a reduction in his tacrolimus dosing from 3\u2009mg in the morning and 2\u2009mg in the evening to 1\u2009mg two times per day to reduce drug-drug interactions and risk of nephrotoxicity. At his 6-week follow-up, his neurologic deficits had significantly improved, and he was ambulating independently.<\/jats:p>","DOI":"10.1136\/bcr-2026-272828","type":"journal-article","created":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T12:05:45Z","timestamp":1784117145000},"page":"e272828","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Lower gastrointestinal bleeding (haematochezia) as the initial clue to disseminated histoplasmosis with central nervous system involvement in a renal transplant recipient"],"prefix":"10.1136","volume":"19","author":[{"given":"Peyton","family":"Frolek","sequence":"first","affiliation":[{"name":"Medical School, University of North Dakota School of Medicine & Health Sciences, Grand Forks, North Dakota, USA"},{"name":"Sanford Health North, Fargo, North Dakota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rita","family":"Ahmad","sequence":"additional","affiliation":[{"name":"Sanford Health North, Fargo, North Dakota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fadel","family":"Nammour","sequence":"additional","affiliation":[{"name":"Sanford Health North, Fargo, North Dakota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Recep","family":"Nigdelioglu","sequence":"additional","affiliation":[{"name":"Sanford Medical Center Fargo, Fargo, North Dakota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Avish","family":"Nagpal","sequence":"additional","affiliation":[{"name":"Sanford Medical Center Fargo, Fargo, North Dakota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,7,15]]},"reference":[{"key":"2026090306052506000_19.7.e272828.1","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1055\/s-0039-1698429","article-title":"Current Concepts in the Epidemiology, Diagnosis, and Management of Histoplasmosis Syndromes","volume":"41","author":"Azar","year":"2020","journal-title":"Semin Respir Crit Care Med"},{"key":"2026090306052506000_19.7.e272828.2","doi-asserted-by":"crossref","first-page":"536","DOI":"10.1056\/NEJMra2306821","article-title":"Coccidioidomycosis and Histoplasmosis in Immunocompetent Persons","volume":"390","author":"Galgiani","year":"2024","journal-title":"N Engl J Med"},{"key":"2026090306052506000_19.7.e272828.3","doi-asserted-by":"crossref","first-page":"i27","DOI":"10.1093\/cid\/ciaf256","article-title":"2025 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Histoplasmosis: Treatment of Asymptomatic Histoplasma Pulmonary Nodules (Histoplasmomas) and Mild or Moderate Acute Pulmonary Histoplasmosis in Adults, Children, and Pregnant People","volume":"81","author":"Arnold","year":"2026","journal-title":"Clin Infect Dis"},{"key":"2026090306052506000_19.7.e272828.4","doi-asserted-by":"crossref","unstructured":"Gajurel K , Dhakal R , Deresinski S . Histoplasmosis in transplant recipients. Clin Transplant 2017;31. doi:10.1111\/ctr.13087","DOI":"10.1111\/ctr.13087"},{"key":"2026090306052506000_19.7.e272828.5","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0009050","article-title":"Gastrointestinal disseminated histoplasmosis in HIV-infected patients: A descriptive and comparative study","volume":"15","author":"Nacher","year":"2021","journal-title":"PLoS Negl Trop Dis"},{"key":"2026090306052506000_19.7.e272828.6","doi-asserted-by":"crossref","DOI":"10.14309\/crj.2017.93","article-title":"Lower Gastrointestinal Bleeding Secondary to Intestinal Histoplasmosis in a Renal Transplant Patient","volume":"4","author":"Syed","year":"2017","journal-title":"ACG Case Rep J"},{"key":"2026090306052506000_19.7.e272828.7","doi-asserted-by":"crossref","first-page":"S2085","DOI":"10.14309\/01.ajg.0000962100.55829.ce","article-title":"S3115\u2003Disseminated Histoplasmosis: A Gastrointestinal Manifestation","volume":"118","author":"Omiwade","year":"2023","journal-title":"Am J Gastroenterol"},{"key":"2026090306052506000_19.7.e272828.8","unstructured":"Panel on Opportunistic Infections in Adults and Adolescents with HIV . Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association of the Infectious Diseases Society of America, 2025."},{"key":"2026090306052506000_19.7.e272828.9","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1038\/s41401-018-0070-2","article-title":"Biomarkers for individualized dosage adjustments in immunosuppressive therapy using calcineurin inhibitors after organ transplantation","volume":"40","author":"Fu","year":"2019","journal-title":"Acta Pharmacol Sin"},{"key":"2026090306052506000_19.7.e272828.10","doi-asserted-by":"crossref","DOI":"10.1111\/tid.14421","article-title":"Presentation and Outcomes of Histoplasmosis in Transplant Recipients: A Retrospective Single-Centre Cohort Study","volume":"27","author":"Rutjanawech","year":"2025","journal-title":"Transpl Infect Dis"},{"key":"2026090306052506000_19.7.e272828.11","first-page":"11924","article-title":"Gastrointestinal histoplasmosis: an updated review","volume":"20","author":"Antinori","year":"2014","journal-title":"World J Gastroenterol"},{"key":"2026090306052506000_19.7.e272828.12","doi-asserted-by":"publisher","DOI":"10.1016\/S1473-3099(21)00191-2"},{"key":"2026090306052506000_19.7.e272828.13","doi-asserted-by":"crossref","first-page":"644","DOI":"10.1016\/S2468-1253(18)30159-6","article-title":"Differential diagnosis of inflammatory bowel disease: imitations and complications","volume":"3","author":"Gecse","year":"2018","journal-title":"Lancet Gastroenterol Hepatol"},{"key":"2026090306052506000_19.7.e272828.14","doi-asserted-by":"crossref","unstructured":"C\u00e1ceres DH , Tob\u00f3n AM , Restrepo A , et al . 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