Histoplasmosis in India. A critical review

A Twenty-First-Century Perspective of Disseminated Histoplasmosis in India: Literature Review and Retrospective Analysis of Published and Unpublished Cases at a Tertiary Care Hospital in North India

PURPOSE

Published literature lacks systematic studies on disseminated histoplasmosis in India, and previous reviews on its epidemiology in India were conducted two decades back. Thus, we review the Indian studies published in this century to understand the recent epidemiology of histoplasmosis in India and do a retrospective analysis of all cases diagnosed at our institute.

METHODS

A literature of review search was done in Pubmed/Medline and Scopus. Studies published during January 2001-December 2015 were considered along with retrospective analysis of cases presented to us. A distinction was made in the clinical presentation of immunocompetent and immunocompromised cases.

RESULTS

Ninety-five included studies described 204 cases, and 10 cases from our retrospective analysis were included. The mean age at presentation was 45.1 ± 15.4 years [range 3-83, median 45, interquartile range 37-55], and male-to-female ratio was 6:1. Most cases were reported from northern and northeastern states of India along the rivers Ganges, Yamuna and Brahmaputra and in people associated with agricultural activity. About 33% of cases were immunocompromised, out of which immunosuppression due to HIV was seen in 72% cases. The mean age of presentation was significantly lower in immunocompromised cases (37.9 vs. 49.2 years; p < 0.00001, Mann-Whitney test), and mortality was also higher (10 vs. 27.5%, p = 0.01, Fisher's exact test). Adrenal involvement was in significantly higher proportion of immunocompetent patients compared to immunocompromised population.

CONCLUSIONS

Disseminated histoplasmosis is being increasingly recognized in India. There is a need to undertake well-designed, analytical studies utilizing appropriate diagnostic modalities to understand the epidemiology of this neglected disease in proper perspective.

Disseminated Histoplasmosis with Skin Lesions and Osteomyelitis in a Patient from the Philippines

Histoplasmosis, caused by the dimorphic fungus Histoplasma capsulatum, is a disease of protean manifestations and of global distribution. Although increasingly reported in Asia, there are few reports from the Philippines. Here, we describe a case of microbiologically diagnosed histoplasmosis, probably acquired from the Philippines, in a returning traveler who presented with a right foot wound and papular rash. The final diagnosis was disseminated histoplasmosis with cutaneous and bone involvement, both unusual manifestations of the disease.

Histoplasmosis infections worldwide: thinking outside of the Ohio River valley

In the United States, histoplasmosis is generally thought to occur mainly in the Ohio and Mississippi River Valleys, and the classic map of histoplasmosis distribution reflecting this is second nature to many U.S. physicians. With the advent of the HIV pandemic reports of patients with progressive disseminated histoplasmosis and AIDS came from regions of known endemicity, as well as from regions not thought to be endemic for histoplasmosis throughout the world. In addition, our expanding armamentarium of immunosuppressive medications and biologics has increased the diagnosis of histoplasmosis worldwide. While our knowledge of areas in which histoplasmosis is endemic has improved, it is still incomplete. Our contention is that physicians should consider histoplasmosis with the right constellations of symptoms in any febrile patient with immune suppression, regardless of geographic location or travel history.

Oral histoplasmosis in India: a case report and an overview of cases reported during 1968-92

Oral histoplasmosis in a 30-year-old male with no history of travel outside India is described. An ulcerating lesion was located on the hard palate. A chest X-ray was normal. Based on physical examination, regional lymph nodes, liver and spleen were not involved. The diagnosis was established by demonstrating yeast-like budding cells in a biopsy of the lesion and by isolating Histoplasma capsulatum in pure culture. The identity of the isolate was confirmed by a chemiluminescent DNA-probe assay and the exoantigen test. A review of the Indian literature from 1968 to 1992 revealed the occurrence of 25 authentic cases of histoplasmosis in India. In 19 cases, lesions were confined to the oral cavity confirming prior observation that histoplasmosis in Indian patients tends to occur primarily in extrapulmonary sites, particularly the oral cavity.