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A 37-year-old woman from Illinois with a history of an idiopathic T-cell deficiency (CD4 cell count, 249 cells per cubic millimeter, and negative for infection with the human immunodeficiency virus), histoplasma pneumonia in childhood, and recurrent vulvovaginal candidiasis presented with nausea and odynophagia for three days. Physical examination was unremarkable except for the presence of oral candidiasis and mild tenderness in the left upper quadrant. As a part of the workup, she underwent computed tomography (CT) of the abdomen, which showed extensive, diffuse calcification of the spleen (Panel A, large arrow) with several calcified lymph nodes within the abdominal cavity (Panel A, small arrows). A chest CT also showed numerous calcified mediastinal lymph nodes (Panel B, arrows). The patient's acute symptoms were diagnosed as esophageal candidiasis. She was administered fluconazole, to which the infection responded. The calcifications visualized in the radiographic studies were diagnosed as due to a prior infection with Histoplasma capsulatum. The central United States is an area where histoplasmosis is endemic. Most cases of histoplasmosis are associated with enlargement of mediastinal lymph nodes, which can calcify and cause mediastinal obstructive syndromes. H. capsulatum infection is a common cause of diffuse splenic calcification; other considerations include brucellosis and tuberculosis.
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