TUBERCULOSIS-LIKE PRESENTATION IN AN INDIGENOUS PERSON LIVING WITH HIV/AIDS: ALERT FOR HISTOPLASMOSIS MIMICKING PULMONARY TUBERCULOSIS

Differentiating tuberculosis from pulmonary systemic mycoses represents a major diagnostic challenge in endemic regions, especially in people living with HIV/AIDS with advanced immunosuppression. A young adult Indigenous patient, with a history of disrupted community ties and currently living in homelessness, presented with afternoon fever, night sweats, significant weight loss, persistent cough, and consumptive symptoms. Imaging studies showed nonspecific pulmonary infiltrates, without typical findings of tuberculosis. Serology confirmed HIV infection, with high viral load and CD4 T-lymphocyte count below 200 cells/mm³, characterizing severe immunosuppression. A rapid urinary lipoarabinomannan test for mycobacteria (TB-LAM) was positive, leading to initiation of antituberculosis treatment with rifampicin, isoniazid, and pyrazinamide. However, the patient showed no significant clinical improvement, prompting the need for alternative etiological investigation. Tests were performed for nontuberculous mycobacteria, Rhodococcus equi , Nocardia spp., and invasive mycoses, with the urinary antigen test for Histoplasma capsulatum initially negative. During hospitalization, the patient continued active use of crack, cocaine, alcohol, and tobacco, factors that increase the risk of coinfections and hinder treatment adherence. The refractory clinical course culminated in discharge against medical advice before diagnostic completion, and subsequent test results confirmed disseminated pulmonary histoplasmosis as the cause of the tuberculosis-like syndrome. This case reinforces the importance of comprehensive investigation in people living with HIV/AIDS presenting with consumptive and respiratory manifestations, particularly among socially vulnerable individuals, as early diagnosis and treatment of systemic mycoses can significantly reduce morbidity and mortality in endemic areas. Caution is warranted when interpreting isolated positive TB-LAM results, considering possible false positives or coinfections, especially in the absence of clinical response to initial antituberculosis therapy, in accordance with Brazilian Ministry of Health Clinical Protocols and Therapeutic Guidelines for HIV infection (2022) and tuberculosis (2019).