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Peddi P, Challa T, Meegada S, Annakula M, Mar E. A Case of Histoplasmosis with Central Nervous System Relapse after Itraconazole Therapy Needs Further Research. Cureus 2020; 12:e7064. [PMID: 32226666 PMCID: PMC7089622 DOI: 10.7759/cureus.7064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Central nervous system (CNS) histoplasmosis occurs in 5-20% of all cases and is most commonly seen in immunosuppressed patients who have acquired immunodeficiency syndrome (AIDS) or have received organ transplant. The prevalence of histoplasmosis in patients greater than 65 years old between the years of 1999-2008 in the state of Texas was about 2-3 cases per 100,000 patients year. Since 1990 with the discovery of Triazoles, itraconazole (ICZ) has become the standard initial and suppressive therapy in patients with mild-moderate histoplasmosis without CNS involvement. However, poor penetration of ICZ into the brain, in vitro fluconazole resistance and lack of controlled-trials pose challenge in the treatment of cerebral histoplasmosis.
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Affiliation(s)
- Prashanth Peddi
- Internal Medicine, The University of Texas Health Science Center/Christus Good Shepherd Medical Center, Longview, USA
| | - Tejo Challa
- Internal Medicine, The University of Texas Health Science Center/Christus Good Shepherd Medical Center, Longview, USA
| | - Sreenath Meegada
- Internal Medicine, The University of Texas Health Science Center/Christus Good Shepherd Medical Center, Longview, USA
| | - Madhavi Annakula
- Internal Medicine, The University of Texas Health Science Center/Christus Good Shepherd Medical Center, Longview, USA
| | - Evan Mar
- Internal Medicine, Methodist Richardson Medical Center, Richardson, USA
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Central Nervous System Infection with Histoplasma capsulatum. J Fungi (Basel) 2019; 5:jof5030070. [PMID: 31344869 PMCID: PMC6787664 DOI: 10.3390/jof5030070] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/10/2019] [Accepted: 07/19/2019] [Indexed: 12/19/2022] Open
Abstract
Histoplasmosis is an endemic fungal infection that may affect both immune compromised and non-immune compromised individuals. It is now recognized that the geographic range of this organism is larger than previously understood, placing more people at risk. Infection with Histoplasma capsulatum may occur after inhalation of conidia that are aerosolized from the filamentous form of the organism in the environment. Clinical syndromes typically associated with histoplasmosis include acute or chronic pneumonia, chronic cavitary pulmonary infection, or mediastinal fibrosis or lymphadenitis. Disseminated infection can also occur, in which multiple organ systems are affected. In up to 10% of cases, infection of the central nervous system (CNS) with histoplasmosis may occur with or without disseminated infection. In this review, we discuss challenges related to the diagnosis of CNS histoplasmosis and appropriate treatment strategies that can lead to successful outcomes.
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Kauffman CA. Treatment of the Midwestern Endemic Mycoses, Blastomycosis and Histoplasmosis. CURRENT FUNGAL INFECTION REPORTS 2017. [DOI: 10.1007/s12281-017-0281-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Makis W, Rakheja R, Probst S. Appearance of CNS histoplasmosis on 18F-FDG PET/CT with MRI correlation. BJR Case Rep 2016; 2:20150443. [PMID: 30459989 PMCID: PMC6243347 DOI: 10.1259/bjrcr.20150443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 03/02/2016] [Accepted: 03/08/2016] [Indexed: 11/12/2022] Open
Abstract
Disseminated histoplasmosis is an opportunistic infection encountered in immunocompromised patients such as those with human immunodeficiency virus infection/acquired immune deficiency syndrome. Involvement of the central nervous system (CNS) can occur in 5–20% of cases of disseminated histoplasmosis, and CNS histoplasmosis can be very difficult to diagnose via conventional imaging modalities such as CT or MRI. The role of 18F-fludeoxyglucose positron emission tomography/CT scan in the diagnosis of CNS histoplasmosis has not been established. A 66-year-old female presented with dizziness and unsteady gait and was diagnosed with human immunodeficiency virus infection and CNS histoplasmosis. In this report, we present the MRI and 18F-fludeoxyglucose positron emission tomography/CT image findings.
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Affiliation(s)
- William Makis
- Department of Diagnostic Imaging, Cross Cancer Institute, Edmonton, AB, Canada
| | - Rajan Rakheja
- Department of Nuclear Medicine, Jewish General Hospital, Montreal, QC, Canada
| | - Stephan Probst
- Department of Nuclear Medicine, Jewish General Hospital, Montreal, QC, Canada
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Nyalakonda H, Albuerne M, Suazo Hernandez LP, Sarria JC. Central Nervous System Histoplasmosis in Acquired Immunodeficiency Syndrome. Am J Med Sci 2016; 351:177-86. [PMID: 26897273 DOI: 10.1016/j.amjms.2015.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 10/22/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Involvement of the central nervous system (CNS) by Histoplasma capsulatum in AIDS is uncommon and not easily recognized. MATERIALS AND METHODS CNS histoplasmosis cases from our institution were identified by a retrospective chart review from 2004-2014. A thorough literature search was performed for additional cases and their characteristics were compared. Clinical findings, treatment and outcomes are discussed. RESULTS A total of 5 cases from our institution were identified. They had a clinical presentation that included classic signs of meningitis, often with evidence of disseminated involvement, and was typically severe with important neurological impairment. These cases were treated with antifungal agents, including a lipid amphotericin B formulation and azole drugs, but eventually 3 experienced nonresolution of their disease likely because of lack of adherence to therapy and died from their infection. The clinical presentation, treatment and outcome of these cases did not significantly differ from cases found in the review of the literature. CONCLUSIONS Clinicians practicing in endemic areas should be aware of this rare but serious form of histoplasmosis. The recognition of 5 cases of CNS histoplasmosis in AIDS patients from a single institution suggests that histoplasmosis should be included in the differential diagnosis of the CNS complications of AIDS.
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Affiliation(s)
- Harita Nyalakonda
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas.
| | - Marisol Albuerne
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | | | - Juan C Sarria
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
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Oikawa F, Carvalho D, Matsuda NM, Yamada AT. Histoplasmosis in the nasal septum without pulmonary involvement in a patient with acquired immunodeficiency syndrome: case report and literature review. SAO PAULO MED J 2010; 128:236-8. [PMID: 21120437 PMCID: PMC10938995 DOI: 10.1590/s1516-31802010000400012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 06/10/2010] [Accepted: 06/11/2010] [Indexed: 11/22/2022] Open
Abstract
CONTEXT Histoplasmosis is a fungal disease caused by inhaling spores of the fungus Histoplasma capsulatum. The spores can be found in soil contaminated with bird, bat or chicken feces. Histoplasmosis occurs worldwide and is one of the most common pulmonary and systemic mycoses. CASE REPORT We report here the case of a 37-year-old man with acquired immune deficiency syndrome and histoplasmosis in the nasal septum, without pulmonary involvement, that evolved rapidly to disseminated infection, multiple organ failure and death.
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Affiliation(s)
- Fernando Oikawa
- MD. Resident physician, Hospital Municipal de Campo Limpo "Dr. Fernando Mauro Pires da Rocha", São Paulo, SP, Brazil.
| | - Daniela Carvalho
- MD. Resident physician, Hospital Municipal de Campo Limpo "Dr. Fernando Mauro Pires da Rocha", São Paulo, SP, Brazil.
| | - Nilce Mitiko Matsuda
- MD, PhD. Research associate, Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.
| | - Alice Tatsuko Yamada
- MD, PhD. Cardiologist, Instituto do Coração (InCor), Hospital das Clínicas (HC), School of Medicine, Universidade de São Paulo (USP), São Paulo, and Hospital Municipal de Campo Limpo "Dr. Fernando Mauro Pires da Rocha", São Paulo, SP, Brazil.
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Aravalli RN, Hu S, Woods JP, Lokensgard JR. Histoplasma capsulatum yeast phase-specific protein Yps3p induces Toll-like receptor 2 signaling. J Neuroinflammation 2008; 5:30. [PMID: 18606009 PMCID: PMC2474602 DOI: 10.1186/1742-2094-5-30] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Accepted: 07/07/2008] [Indexed: 11/17/2022] Open
Abstract
Histoplasma capsulatum is a common cause of fungal infection in certain geographic areas, and although most infections are asymptomatic, it is capable of causing histoplasmosis, a disseminated, life-threatening disease, especially in immunocompromised individuals. A deeper understanding of this host-pathogen interaction is needed to develop novel therapeutic strategies to counter lethal infection. Although several lines of evidence suggest that this fungus is neurotropic in HIV patients, little is known about the immunobiology of Histoplasma infection in the central nervous system [CNS]. The goal of the present study was to understand the innate neuroimmune mechanisms that recognize H. capsulatum during the initial stages of infection. Using a 293T stable cell line expressing murine Toll-like receptor 2 [TLR2], we show here that TLR2 recognizes H. capsulatum cell wall protein Yps3p and induces the activation of NF-κB. In further experiments, we tested the ability of Yps3p to induce signaling from TLR2 in primary microglial cells, the resident brain macrophages of the CNS. Our data show that H. capsulatum Yps3p induced TLR2 signaling in wild-type microglia, but not in microglia isolated from TLR2 KO mice, confirming that Yps3p is a ligand for TLR2. Furthermore, Yps3p-induced TLR2 signaling was suppressed by vaccinia virus-encoded TLR inhibitors. This is the first demonstration of a fungal protein serving as a TLR ligand and mediating signaling in primary brain cells.
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Affiliation(s)
- Rajagopal N Aravalli
- Center for Infectious Diseases and Microbiology Translational Research, University of Minnesota Medical School, Minneapolis, Minnesota, USA.
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Wheat LJ, Freifeld AG, Kleiman MB, Baddley JW, McKinsey DS, Loyd JE, Kauffman CA. Clinical Practice Guidelines for the Management of Patients with Histoplasmosis: 2007 Update by the Infectious Diseases Society of America. Clin Infect Dis 2007; 45:807-25. [PMID: 17806045 DOI: 10.1086/521259] [Citation(s) in RCA: 791] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Accepted: 06/19/2007] [Indexed: 11/04/2022] Open
Abstract
AbstractEvidence-based guidelines for the management of patients with histoplasmosis were prepared by an Expert Panel of the Infectious Diseases Society of America. These updated guidelines replace the previous treatment guidelines published in 2000 (Clin Infect Dis 2000; 30:688–95). The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them. Since 2000, several new antifungal agents have become available, and clinical trials and case series have increased our understanding of the management of histoplasmosis. Advances in immunosuppressive treatment for inflammatory disorders have created new questions about the approach to prevention and treatment of histoplasmosis. New information, based on publications from the period 1999–2006, are incorporated into this guideline document. In addition, the panel added recommendations for management of histoplasmosis in children for those aspects that differ from aspects in adults.
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Affiliation(s)
- L Joseph Wheat
- MiraVista Diagnostics/MiraBella Technologies, Indianapolis, IN 46241, USA.
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Abstract
Infection with Histoplasma capsulatum occurs commonly in areas in the Midwestern United States and Central America, but symptomatic disease requiring medical care is manifest in very few patients. The extent of disease depends on the number of conidia inhaled and the function of the host's cellular immune system. Pulmonary infection is the primary manifestation of histoplasmosis, varying from mild pneumonitis to severe acute respiratory distress syndrome. In those with emphysema, a chronic progressive form of histoplasmosis can ensue. Dissemination of H. capsulatum within macrophages is common and becomes symptomatic primarily in patients with defects in cellular immunity. The spectrum of disseminated infection includes acute, severe, life-threatening sepsis and chronic, slowly progressive infection. Diagnostic accuracy has improved greatly with the use of an assay for Histoplasma antigen in the urine; serology remains useful for certain forms of histoplasmosis, and culture is the ultimate confirming diagnostic test. Classically, histoplasmosis has been treated with long courses of amphotericin B. Today, amphotericin B is rarely used except for severe infection and then only for a few weeks, followed by azole therapy. Itraconazole is the azole of choice following initial amphotericin B treatment and for primary treatment of mild to moderate histoplasmosis.
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Affiliation(s)
- Carol A Kauffman
- Infectious Diseases Division, Department of Internal Medicine, Ann Arbor Veterans Affairs Healthcare System, University of Michigan Medical School, Ann Arbor, MI, USA.
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Wheat LJ, Musial CE, Jenny-Avital E. Diagnosis and Management of Central Nervous System Histoplasmosis. Clin Infect Dis 2005; 40:844-52. [PMID: 15736018 DOI: 10.1086/427880] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Accepted: 10/22/2004] [Indexed: 11/03/2022] Open
Abstract
Two cases of Histoplasma meningitis are presented, illustrating the difficulty in diagnosis and treatment. The first case occurred in a patient with acquired immunodeficiency syndrome as a relapse of disseminated histoplasmosis and resolved after prolonged treatment and ongoing antiretroviral therapy. The second case occurred in a cardiac allograft recipient as meningitis and focal brain lesions that responded to liposomal amphotericin B, but the patient died shortly after therapy was completed. Unfortunately, there are no prospective studies addressing the diagnosis and management of patients with histoplasmosis of the central nervous system from which to provide evidence-based guidelines for care. In the absence of such data, an approach will be presented on the basis of our experience and opinions.
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Affiliation(s)
- L J Wheat
- MiraVista Diagnostics, Indianapolis, Indiana 46241, USA.
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Levi GC, Pozzi CM, Hirschheimer SMDS, Chahade WH, Gomes HR, Granato C. Histoplasmose do sistema nervoso central como única manifestação da doença em pacientes imunocompetentes: apresentação de dois casos. ARQUIVOS DE NEURO-PSIQUIATRIA 2003; 61:859-63. [PMID: 14595497 DOI: 10.1590/s0004-282x2003000500029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Apresentamos dois casos de histoplasmose em que o acometimento do sistema nervoso central foi a única manifestação clínica da doença. Revisão da literatura permitiu confirmar a raridade dessa forma de patologia, em particular em crianças, sendo o segundo caso aqui apresentado o de mais baixa idade na literatura nacional. São feitos comentários sobre a variedade das apresentações clínicas e os principais diagnósticos diferenciais da doença. São discutidos os resultados laboratoriais, tanto em relação às alterações liquóricas quanto aos resultados sorológicos. Finalmente, é analisada a terapêutica dessa forma de infecção fúngica tanto em relação aos medicamentos utilizáveis quanto à duração prolongada aconselhável para o tratamento específico.
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Affiliation(s)
- Guido C Levi
- Serviço de Moléstias Infecciosas, Hospital do Servidor Público Estadual 'Francisco Morato de Oliveira', São Paulo, SP, Brasil.
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Saccente M, McDonnell RW, Baddour LM, Mathis MJ, Bradsher RW. Cerebral histoplasmosis in the azole era: report of four cases and review. South Med J 2003; 96:410-6. [PMID: 12916564 DOI: 10.1097/01.smj.0000051734.53654.d0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report four cases of cerebral histoplasmosis and discuss features of six additional cases reported in the medical literature in the past 10 years, when azoles have been available for therapy. Most patients with this disease are immunocompromised or have a history that suggests heavy exposure to Histoplasma capsulatum. Fever and other clinical findings of systemic toxicity caused by disseminated histoplasmosis may be absent; 5 of 10 patients did not manifest these findings. Although the mainstay of treatment for central nervous system histoplasmosis remains amphotericin B, 9 of the 10 patients received itraconazole or fluconazole either as initial therapy or after a course of treatment with amphotericin B.
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Affiliation(s)
- Michael Saccente
- Division of Infectious Diseases, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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