A 24 year-old male came to the emergency room complaining of fever, headache, nausea, vomiting, blurred vision, photophobia, lethargy, altered mental status and stiff neck. His past medical history is significant for HIV positivity and asthma. Physical examination revealed an irritable and restless patient with fever, altered mental status, stiff neck, nystagmus, papilledema, and cranial nerve deficits. Laboratory tests revealed elevated WBC with lymphocyte predominance, HIV-1 viral load of 302,551 RNA copies/mL and a CD4+ counts <100 cells/mm3. CSF culture came positive for cryptococcus antigen. Patient was diagnosed with cryptococcal meningitis and was started on amphotericin B and fluconazole. He showed good response to the treatment. His symptoms improved rapidly. Realizing that his life-threatening cryptococcal infection was due to his AIDS , he wanted to get started on highly reactive antiretroviral therapy (HAART) . Upon his discharge from the hospital, he was started on HAART. Two weeks passed uneventfully. Then, one evening, he returned to the emergency room complaining of fever, lymphadenitis, myalgia, cough, and chest pain. Physical examination is remarkable for lymphadenopathy, mucocutaneous ulcers in the mouth, bilateral rales on chest auscultation and hepatosplenomegaly. Vital signs: Temp: 100.6F, Oxygen Sat = 94, BP 100/70; Pulse = 97/min; RR = 22/min Some of the laboratory results are as follows: CD4 count is 800 cells/mm3 HIV-1 viral load of 4800 RNA copies/mL CSF positive for cryptococcus antigen Urine assay is positive for histoplasmosis Chest X ray showed apical infiltrates and nodules When the patient was told about his test results, he said he never heard about histoplasmosis and never had a sickness from it. What is the most likely explanation for his emergency visit?
