History and admission findings: A 29-years-old Brazilian woman was admitted to hospital because of progressive dyspnoea, shivering and fever. She reported a noticeable swelling at the right mandible and an ulcerative tumor at the side of the nose.
Investigations: Laboratory tests showed normocytic, normochromic anemia with an elevation of the inflammatory parameters. Radiology showed an enlargement of the upper mediastinum. Computed tomography revealed extensive, confluent lymphoma. There were groups of cervical lymph nodes, especially in the area of the right jaw. Bronchoscopy showed extensive space-occupying lesions with severe inflammation of the trachea.
Diagnosis: Bronchial biopsy revealed necrotizing, granulomatous inflammation with dense infiltration of lymphatic cells. Small and spheroidal pathogens were seen within giant cells. Grocott-silver stain was positive, indicating histoplasmosis. Histological work-up of the ulcerating tumor at the side of the nose also showed Histoplasma capsulatum.
Treatment and course: 8 weeks after starting specific treatment with oral itraconazole the inflammatory parameters had fallen to normal and computed tomography showed regression of the mediastinal bulge.
Conclusion: Large mediastinal and cervical lymphatic masses with space-occupying bronchial lesions suggest should, in the differential diagnosis, consider not only malignant tumor but also infections. If the patient had been abroad (in this case in Brazil), pathogens like Histoplasma capsulatum, which is not present in Europe, have to be considered. In this immunocompetent patient the severe progression and dissemination of the disease, involving mediastinum, throat and skin, is most unusual.