PERSISTENT OVERT DISSEMINATED INTRAVASCULAR COAGULATION ASSOCIATED WITH OPPORTUNISTIC CO-INFECTION BY DISSEMINATED HISTOPLASMOSIS AND CYTOMEGALOVIRUS DISEASE IN NEWLY DIAGNOSED HUMAN IMMUNODEFICIENCY VIRUS INFECTION: A RARE CASE REPORT
- 1Hospital Eduardo de Menezes, Fundação Hospitalar do Estado de Minas Gerais (Fhemig), Belo Horizonte, Brazil
- 2Departamento de Imagens Médicas, Hematologia e Oncologia, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP), Ribeirão Preto, Brazil
Abstract
Introduction: Disseminated intravascular coagulation (DIC) is an acquired hemostatic disorder characterized by systemic coagulation activation, consumption of platelets and coagulation factors, and hemorrhagic or thrombotic manifestations. In advanced human immunodeficiency virus (HIV) infection, opportunistic infections may promote endothelial injury and sustained coagulation activation. Case report: A 54-year-old woman was admitted in September 2025 with gastroenteritis, dysphagia, hyporexia, constitutional decline, and disseminated cutaneous lesions. HIV infection was diagnosed during hospitalization, and antiretroviral therapy with dolutegravir, lamivudine, and tenofovir was started on October 1, 2025. HIV RNA declined from 6,080 copies/mL on October 9 to 59 copies/mL on November 17. During admission, she developed progressive pancytopenia and severe consumptive coagulopathy, with unmeasurable INR, prolonged activated partial thromboplastin time, hypofibrinogenemia, elevated D-dimer, severe thrombocytopenia, and anemia, fulfilling International Society on Thrombosis and Haemostasis criteria for overt DIC. Hematemesis and recurrent melena required support with red blood cells, platelets, and cryoprecipitate. Despite supportive stabilization, DIC parameters remained persistently abnormal until pathogen-directed therapy was established, suggesting ongoing infection-driven hemostatic activation. Pulmonary embolism was also documented, reflecting concomitant thrombotic expression. Cutaneous lesions, initially interpreted as HIV-associated prurigo, increased in number and extent. A skin biopsy performed on November 19, 2025, showed yeast-like structures suggestive of Histoplasma spp. on direct examination, and fungal culture isolated Histoplasma capsulatum. Bacterial culture, acid-fast bacilli testing, and leishmaniasis evaluation were negative. Concomitant cytomegalovirus (CMV) disease was documented by oral cavity biopsy, showing ulcerated mucosa with mixed inflammatory infiltrate and CMV immunohistochemistry positivity in isolated cells. Ophthalmologic evaluation identified a small granular area of right-eye retinitis. Histoplasmosis treatment consisted of lipid-complex amphotericin B 5 mg/kg/day from November 20 to December 26, 2025, followed by itraconazole 200 mg twice daily. CMV disease was treated with ganciclovir from December 4 to December 29, 2025. She also received antibiotics for nosocomial pneumonia and therapeutic-dose sulfamethoxazole-trimethoprim from December 9, 2025, to January 5, 2026, for suspected or treated pneumocystosis, followed by prophylaxis. Following targeted treatment of disseminated histoplasmosis and CMV disease, coagulation parameters progressively improved, with eventual resolution of DIC criteria by late January 2026. She was discharged and maintained clinical recovery at outpatient follow-up on February 13, 2026. Discussion and conclusion: This case highlights persistent overt DIC with hemorrhagic and thrombotic manifestations in newly diagnosed HIV infection, temporally associated with disseminated histoplasmosis and CMV disease. The persistence of consumptive coagulopathy until pathogen-directed therapy, followed by progressive reversal after antifungal and anti-CMV treatment, supports the role of opportunistic infection as the main driver of sustained hemostatic activation.
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BibTeX
@article{santos2026persistent,
title = {{PERSISTENT OVERT DISSEMINATED INTRAVASCULAR COAGULATION ASSOCIATED WITH OPPORTUNISTIC CO-INFECTION BY DISSEMINATED HISTOPLASMOSIS AND CYTOMEGALOVIRUS DISEASE IN NEWLY DIAGNOSED HUMAN IMMUNODEFICIENCY VIRUS INFECTION: A RARE CASE REPORT}},
author = {Diego Alcântara SANTOS and Ana Carolina De Almeida MILAGRES and Lucas De Barros ANASTÁCIO},
journal = {Hematology, Transfusion and Cell Therapy},
year = {2026},
month = oct,
doi = {10.1016/j.htct.2026.108036},
url = {https://doi.org/10.1016/j.htct.2026.108036},
note = {CC BY},
}
RIS
TY - JOUR
TI - PERSISTENT OVERT DISSEMINATED INTRAVASCULAR COAGULATION ASSOCIATED WITH OPPORTUNISTIC CO-INFECTION BY DISSEMINATED HISTOPLASMOSIS AND CYTOMEGALOVIRUS DISEASE IN NEWLY DIAGNOSED HUMAN IMMUNODEFICIENCY VIRUS INFECTION: A RARE CASE REPORT
AU - Diego Alcântara SANTOS
AU - Ana Carolina De Almeida MILAGRES
AU - Lucas De Barros ANASTÁCIO
PY - 2026
DA - 2026/10/23
JO - Hematology, Transfusion and Cell Therapy
DO - 10.1016/j.htct.2026.108036
UR - https://doi.org/10.1016/j.htct.2026.108036
AB - Introduction: Disseminated intravascular coagulation (DIC) is an acquired hemostatic disorder characterized by systemic coagulation activation, consumption of platelets and coagulation factors, and hemorrhagic or thrombotic manifestations. In advanced human immunodeficiency virus (HIV) infection, opportunistic infections may promote endothelial injury and sustained coagulation activation. Case report: A 54-year-old woman was admitted in September 2025 with gastroenteritis, dysphagia, hyporexia, constitutional decline, and disseminated cutaneous lesions. HIV infection was diagnosed during hospitalization, and antiretroviral therapy with dolutegravir, lamivudine, and tenofovir was started on October 1, 2025. HIV RNA declined from 6,080 copies/mL on October 9 to 59 copies/mL on November 17. During admission, she developed progressive pancytopenia and severe consumptive coagulopathy, with unmeasurable INR, prolonged activated partial thromboplastin time, hypofibrinogenemia, elevated D-dimer, severe thrombocytopenia, and anemia, fulfilling International Society on Thrombosis and Haemostasis criteria for overt DIC. Hematemesis and recurrent melena required support with red blood cells, platelets, and cryoprecipitate. Despite supportive stabilization, DIC parameters remained persistently abnormal until pathogen-directed therapy was established, suggesting ongoing infection-driven hemostatic activation. Pulmonary embolism was also documented, reflecting concomitant thrombotic expression. Cutaneous lesions, initially interpreted as HIV-associated prurigo, increased in number and extent. A skin biopsy performed on November 19, 2025, showed yeast-like structures suggestive of Histoplasma spp. on direct examination, and fungal culture isolated Histoplasma capsulatum. Bacterial culture, acid-fast bacilli testing, and leishmaniasis evaluation were negative. Concomitant cytomegalovirus (CMV) disease was documented by oral cavity biopsy, showing ulcerated mucosa with mixed inflammatory infiltrate and CMV immunohistochemistry positivity in isolated cells. Ophthalmologic evaluation identified a small granular area of right-eye retinitis. Histoplasmosis treatment consisted of lipid-complex amphotericin B 5 mg/kg/day from November 20 to December 26, 2025, followed by itraconazole 200 mg twice daily. CMV disease was treated with ganciclovir from December 4 to December 29, 2025. She also received antibiotics for nosocomial pneumonia and therapeutic-dose sulfamethoxazole-trimethoprim from December 9, 2025, to January 5, 2026, for suspected or treated pneumocystosis, followed by prophylaxis. Following targeted treatment of disseminated histoplasmosis and CMV disease, coagulation parameters progressively improved, with eventual resolution of DIC criteria by late January 2026. She was discharged and maintained clinical recovery at outpatient follow-up on February 13, 2026. Discussion and conclusion: This case highlights persistent overt DIC with hemorrhagic and thrombotic manifestations in newly diagnosed HIV infection, temporally associated with disseminated histoplasmosis and CMV disease. The persistence of consumptive coagulopathy until pathogen-directed therapy, followed by progressive reversal after antifungal and anti-CMV treatment, supports the role of opportunistic infection as the main driver of sustained hemostatic activation.
SN - 2531-1379
SN - 2531-1387
ER -