Prospective study of histoplasmosis in patients infected with human immunodeficiency virus: incidence, risk factors, and pathophysiology

Pulmonary Histoplasmosis in People Living with Human Immunodeficiency Virus in French Guiana: Clinical Epidemiology, Medical Imaging and Prognostic

BACKGROUND

Histoplasmosis is mainly described as a disseminated disease in people living with HIV (PLHIV). Compared to historical descriptions in immunocompetent individuals, knowledge is lacking on the detailed clinical and radiological findings and outcomes of pulmonary histoplasmosis (PH). Overlooked or misdiagnosed with other AIDS-defining condition, prognostic of PLHIV may be at risk because of inappropriate care.

METHODS

A retrospective multicentric study was conducted in PLHIV from French Guiana between January 1988 and October 2019. Proven PH were documented through mycological direct examination, culture, or histology. Patients with concomitant respiratory infections were excluded.

RESULTS

Among 65 patients, sex ratio M:F was 2.4 with a median age of 39 years [IQR 25-75%: 34-44]. Median CD4 count was 24 cells/mm3 [11-71], with histoplasmosis as the AIDS-defining condition in 88% and concomitant AIDS-defining conditions in 29%. Clinical findings were fever (89%), cough (58%), dyspnea (35%), expectoration (14%), and hemoptysis (5%). Sixty-one X-rays and 24 CT-scans were performed. On X-rays, an interstitial lung disease was mainly found (77%). On CT-scans, a nodular pattern was predominant (83%): mostly miliary disease (63%), but also excavated nodules (35%). Consolidations were present in 46%, associated with miliary disease in 21%. Thoracic lymphadenopathies were found in 58%, mainly hilar and symmetric (33%). Despite antifungal treatment, case-fatality rate at one month was 22%.

CONCLUSION

When faced with an interstitial lung disease on X-rays or a miliary pattern on CT-scans in advanced PLHIV, physicians in endemic areas, apart from tuberculosis or pneumocystosis, should include histoplasmosis as part of their differential diagnoses.

Acrophialophora: A Comprehensive Review of Clinical Guidelines and Diagnosis

Acrophialophora is a saprotrophic genus of fungi found in both temperate and tropical regions. The genus is comprised of 16 species, with the subspecies A. fusispora and A. levis necessitating the most clinical concern. Acrophialophora is an opportunistic pathogen with a broad range of clinical manifestations; the fungus has been implicated in cases of fungal keratitis, lung infection, and brain abscess. Acrophialophora infection is particularly of concern for immunocompromised patients, who often present with a more severe disease course involving disseminated infection and may not exhibit typical symptoms. Early diagnosis and therapeutic intervention are critical to the successful clinical management of Acrophialophora infection. Guidelines for antifungal treatment have yet to be established, partially due to the lack of documented cases. Aggressive use of antifungal agents and long-term treatment is required, especially in immunocompromised patients and patients with systemic involvement, due to the potential for morbidity and mortality. In addition to outlining the rarity and epidemiology of the disease, this review provides an overview of the diagnosis and clinical management of Acrophialophora infection to facilitate an early diagnosis and appropriate interventions.

Pulmonary Infections in Intestinal Transplant Recipients With Preexisting Pulmonary Nodules

BACKGROUND

Pulmonary nodules in asymptomatic patients could represent latent pulmonary infections. Intestinal transplant (ITx) recipients with preexisting lung nodules might be at higher risk for pulmonary infections. However, data is scarce.

METHODS

This retrospective study included adult patients who underwent ITx from May 2016 to May 2020. Chest computed tomography scans performed within 12 months before ITx were obtained to evaluate for preexisting pulmonary nodules. Screening for endemic mycoses, Aspergillus, Cryptococcus, and latent tuberculosis infection performed within 12 months before ITx was obtained. We assessed for worsening pulmonary nodules, and fungal and mycobacterial infections during the first year post-transplant. Survival and graft loss at 1-year post-transplant was also assessed.

RESULTS

Forty-four patients underwent ITx. Thirty-one had preexisting lung nodules. No invasive fungi were recorded in the pretransplant period and one individual had latent tuberculosis infection. In the post-transplant period, one individual developed probable invasive aspergillosis and had worsening nodular opacities, whereas one had disseminated histoplasmosis with stable lung nodules in chest computed tomography. No mycobacterial infections were documented. The cohort survival was 84% at 12 months after transplant.

CONCLUSION

Preexisting pulmonary nodules were common in the cohort (71%), yet latent and active pulmonary infections were rare. Appearance of new or worsening pulmonary nodules does not appear to directly correlate with pulmonary infections in the post-transplant period. Routine chest computed tomography is not recommended in the pretransplant period, but follow-up is favored in patients with confirmed nodular opacities. Clinical monitoring is essential.

Pulmonary Histoplasmosis: A Clinical Update

Histoplasma capsulatum, the etiological agent for histoplasmosis, is a dimorphic fungus that grows as a mold in the environment and as a yeast in human tissues. The areas of highest endemicity lie within the Mississippi and Ohio River Valleys of North America and parts of Central and South America. The most common clinical presentations include pulmonary histoplasmosis, which can resemble community-acquired pneumonia, tuberculosis, sarcoidosis, or malignancy; however, certain patients can develop mediastinal involvement or progression to disseminated disease. Understanding the epidemiology, pathology, clinical presentation, and diagnostic testing performance is pivotal for a successful diagnosis. While most immunocompetent patients with mild acute or subacute pulmonary histoplasmosis should receive therapy, all immunocompromised patients and those with chronic pulmonary disease or progressive disseminated disease should also receive therapy. Liposomal amphotericin B is the agent of choice for severe or disseminated disease, and itraconazole is recommended in milder cases or as "step-down" therapy after initial improvement with amphotericin B. In this review, we discuss the current epidemiology, pathology, diagnosis, clinical presentations, and management of pulmonary histoplasmosis.

Disseminated Histoplasmosis in Central California Seen in an Immunocompromised Patient

Histoplasma capsulatum is a dimorphic fungus found in certain parts of North, Central, and South America. Transmission is primarily through airborne inoculation from inhaled fungal microconidia. Histoplasmosis is typically a self-limited mycosis; however, in patients with immunodeficiency, disseminated disease can occur and may lead to high disease burden. This report studies a case of disseminated histoplasmosis in a patient newly diagnosed with human immunodeficiency virus. His presentation on admission was consistent with infectious pulmonary granulomatous disease, and further imaging and laboratory results showed evidence of multi-organ involvement. It is likely his presentation in Central California was a reactivation infection after inoculation in Central America many years ago.

Key thermally dimorphic fungal pathogens: shaping host immunity

Exposure to fungal pathogens from the environment is inevitable and with the number of at-risk populations increasing, the prevalence of invasive fungal infection is on the rise. An interesting group of fungal organisms known as thermally dimorphic fungi predominantly infects immunocompromised individuals. These potential pathogens are intriguing in that they survive in the environment in one form, mycelial phase, but when entering the host, they are triggered by the change in temperature to switch to a new pathogenic form. Considering the growing prevalence of infection and the need for improved diagnostic and treatment approaches, studies identifying key components of fungal recognition and the innate immune response to these pathogens will significantly contribute to our understanding of disease progression. This review focuses on key endemic dimorphic fungal pathogens that significantly contribute to disease, including Histoplasma, Coccidioides and Talaromyces species. We briefly describe their prevalence, route of infection and clinical presentation. Importantly, we have reviewed the major fungal cell wall components of these dimorphic fungi, the host pattern recognition receptors responsible for recognition and important innate immune responses supporting adaptive immunity and fungal clearance or the failure thereof.

Paediatric Histoplasmosis 2000-2019: A Review of 83 Cases

Histoplasmosis is an endemic fungal infection that is confined to specific geographical regions. Histoplasma spp. are primary pathogens that cause disease in both immunocompetent and immunocompromised patients, ranging from a single-organ (mostly affecting the lungs) infection to life-threatening disseminated disease. Knowledge about the clinical epidemiology relies on data from adult populations; little is known about the patient and disease characteristics in the paediatric population. Therefore, a structured review of published cases of paediatric histoplasmosis between 2000 and 2019 was performed. A literature search of PubMed was conducted and the epidemiological and clinical data from 83 cases were analysed. The mean age at presentation was 9.5 ± 5.5 years, and 51% were girls. Two-thirds of the children were immunocompromised. The majority of children presented with disseminated disease. The most frequently observed clinical symptoms were respiratory symptoms, alongside non-specific systemic features, including fever, myalgia, fatigue and weight loss. The mortality rate was 11%. Histoplasmosis affects children of any age. Being immunocompromised is a risk factor for severe and disseminated disease. The lack of specific presenting features leads to underreporting and delay in diagnosis. To improve the recognition and outcome of histoplasmosis in childhood, increased awareness and surveillance systems are warranted.

Progressive disseminated histoplasmosis in children living with HIV: a case series study

Progressive disseminated histoplasmosis (PDH) is thought to be on the top of the list of AIDS-defining illnesses in South America. Reported experience in children is very scarce. The aim of this study was to describe the clinical characteristics, management, and outcomes of children living with HIV presenting with PDH in Ecuador. We did a retrospective study using collected data on medical records of children living with HIV attended in Francisco Icaza Bustamante Children's Hospital (Guayaquil) between 1997 and 2019. The inclusion criteria consisted of patients under 18 years of age at admission with documented HIV infection and laboratory-confirmed diagnosis of PDH. Twenty-four children living with HIV were attended due to laboratory-confirmed PDH. Median CD4 cell count was 39 cells/mm³ (p25-p75 21-155) between 1 and 5 years and 22 cells/mm³ (p25-p75 10-57) for those aged 6 years and over. Fever (96%) was the most common clinical manifestation, followed by hepatomegaly (75%), cough (67%), weight loss (63%), diarrhea (63%), and abdominal distension (58%). Most significant laboratory findings were hypoalbuminemia (90%), hypertransaminasemia (78%), and pancytopenia (46%). Intravenous treatment with amphotericin B deoxycholate was started in all but one case in which diagnosis was postmortem. All these 23 patients were discharged after being hospitalized for a median of 68 days (p25-p75 48-90). Two children showed relapse during follow-up, one of whom died during the hospitalization of this second episode of PDH.Conclusion: Clinical manifestations and laboratory findings of PDH in children living with HIV seem similar to those seen in adults, and low CD4 cell count appears to be the most important risk factor. What is Known: • Since 1987, progressive disseminated histoplasmosis has been considered an AIDS-defining illness and, although underdiagnosis is frequent, is thought to be on the top of the list of AIDS-defining illnesses in South America. • Reported experience in children is very scarce. What is New: • Clinical manifestations and laboratory findings of progressive disseminated histoplasmosis in children living with HIV seem similar to those seen in adults. • Low CD4 cell count to be the most important risk factor.

Treatment and Prevention of Histoplasmosis in Adults Living with HIV

Histoplasmosis causes life-threatening disseminated infection in adult patients living with untreated HIV. Although disease incidence has declined dramatically in countries with access to antiretroviral therapy, histoplasmosis remains prevalent in many resource-limited regions. A high index of suspicion for histoplasmosis should be maintained in the setting of a febrile multisystem illness in severely immunosuppressed patients, particularly in persons with hemophagocytic lymphohistiocytosis. Preferred treatment regimens for initial therapy include liposomal amphotericin B for severe disease, or itraconazole for mild to moderate disease. Subsequently, itraconazole maintenance therapy should be administered for at least one year and then discontinued if CD4 count increases to ≥150 cells/µL. Antiretroviral therapy, which improves outcome when administered together with an antifungal agent, should be instituted immediately, as the risk of triggering Immune Reconstitution Syndrome is low. The major risk factor for relapsed infection is nonadherence. Itraconazole prophylaxis reduces risk for histoplasmosis in patients with CD4 counts <100/µL but is not associated with survival benefit and is primarily reserved for use in outbreaks. Although most patients with histoplasmosis have not had recognized high-risk exposures, avoidance of contact with bird or bat guano or inhalation of aerosolized soil in endemic regions may reduce risk. Adherence to effective antiretroviral therapy is the most important strategy for reducing the incidence of life-threatening histoplasmosis.

Combining urine antigen and blood polymerase chain reaction for the diagnosis of disseminated histoplasmosis in hospitalized patients with advanced HIV disease

Disseminated histoplasmosis (DH) is endemic in Latin America and the Caribbean where diagnostic tools are restricted. We carried-out a 1-year prospective cohort study at a referral hospital in São Paulo, Brazil. Participants had > or =18 years old, were hospitalized due to any indication and had CD4+ < 200 cells/µl. A urine commercial monoclonal Histoplasma galactomannan enzyme-linked immunosorbent assay (IMMY, Norman, OK, USA) and 'in house' Histoplasma blood nested PCR were performed in all cases. Probable/proven DH cases were defined according to international guidelines. Conventional mycological methods were available in routine conditions to investigate suspected DH cases. Treatment of participants followed the institutional routine. One-hundred six participants were included. Median age (interquartile range [IQR]) was 39.5 years (30.0-47.3) and 80 individuals (75.5%) were males. Median (IQR) CD4 cell count was 26.5 (9.4-89.3) cells/mm3. DH was diagnosed in 8/106 patients (7.5%). Antigen assay and/or PCR were positive in 4.7% (5/106) of patients. The antigen assay and/or PCR identified 37.5% (3/8) of DH cases, which had not been diagnosed with conventional mycological methods, but had clinical manifestations compatible with HD. In conclusion, the use of Histoplasma urine antigen and Histoplasma blood PCR guided by CD4 status contributed to the diagnosis of DH in hospitalized individuals. These assays were complementary to conventional mycologic methods and are urgently needed in our setting.

LAY SUMMARY

In this prospective cohort study carried-out in a referral center in São Paulo, Brazil, we found a high frequency of AIDS-related disseminated histoplasmosis (8/106, 7.5%). We used urine antigen test and blood PCR assay to improve the diagnosis of this opportunistic disease.

Diagnostic accuracy of antigen detection in urine and molecular assays testing in different clinical samples for the diagnosis of progressive disseminated histoplasmosis in patients living with HIV/AIDS: A prospective multicenter study in Mexico

BACKGROUND

The progressive disseminated histoplasmosis (PDH) has been associated with severe disease and high risk of death among people living with HIV (PLWHIV). Therefore, the purpose of this multicenter, prospective, double-blinded study done in ten Mexican hospitals was to determine the diagnostic accuracy of detecting Histoplasma capsulatum antigen in urine using the IMMY ALPHA Histoplasma EIA kit (IAHE), clarus Histoplasma GM Enzyme Immunoassay (cHGEI IMMY) and MiraVista Histoplasma Urine Antigen LFA (MVHUALFA); as well as the Hcp100 and 1281-1283220SCAR nested PCRs in blood, bone-marrow, tissue biopsies and urine.

METHODOLOGY/PRINCIPAL FINDINGS

We included 415 PLWHIV older than 18 years of age with suspicion of PDH. Using as diagnostic standard recovery of H. capsulatum in blood, bone marrow or tissue cultures, or histopathological exam compatible, detected 108 patients (26%, [95%CI, 21.78-30.22]) with proven-PDH. We analyzed 391 urine samples by the IAHE, cHGEI IMMY and MVHUALFA; the sensitivity/specificity values obtained were 67.3% (95% CI, 57.4-76.2) / 96.2% (95% CI, 93.2-98.0) for IAHE, 91.3% (95% CI, 84.2-96.0) / 90.9% (95% CI, 87.0-94.0) for cHGEI IMMY and 90.4% (95% CI, 83.0-95.3) / 92.3% (95% CI, 88.6-95.1) for MVHUALFA. The Hcp100 nested PCR was performed on 393, 343, 75 and 297, blood, bone marrow, tissue and urine samples respectively; the sensitivity/specificity values obtained were 62.9% (95%CI, 53.3-72.5)/ 89.5% (95%CI, 86.0-93.0), 65.9% (95%CI, 56.0-75.8)/ 89.0% (95%CI, 85.2-92.9), 62.1% (95%CI, 44.4-79.7)/ 82.6% (95%CI, 71.7-93.6) and 34.9% (95%CI, 24.8-46.2)/ 67.3% (95%CI, 60.6-73.5) respectively; and 1281-1283220SCAR nested PCR was performed on 392, 344, 75 and 291, respectively; the sensitivity/specificity values obtained were 65.3% (95% CI, 55.9-74.7)/ 58.8% (95%CI, 53.2-64.5), 70.8% (95%CI, 61.3-80.2)/ 52.9% (95%CI, 46.8-59.1), 71.4% (95%CI, 54.7-88.2)/ 40.4% (95%CI, 26.4-54.5) and 18.1% (95%CI, 10.5-28.1)/ 90.4% (95%CI, 85.5-94.0), respectively.

CONCLUSIONS/SIGNIFICANCE

The cHGEI IMMY and MVHUALFA tests showed excellent performance for the diagnosis of PDH in PLWHIV. The integration of these tests in clinical laboratories will certainly impact on early diagnosis and treatment.

IL-22 Promotes IFN-γ-Mediated Immunity against Histoplasma capsulatum Infection

Histoplasma capsulatum is the agent of histoplasmosis, one of the most frequent mycoses in the world. The infection initiates with fungal spore inhalation, transformation into yeasts in the lungs and establishment of a granulomatous disease, which is characterized by a Th1 response. The production of Th1 signature cytokines, such as IFN-γ, is crucial for yeast clearance from the lungs, and to prevent dissemination. Recently, it was demonstrated that IL-17, a Th17 signature cytokine, is also important for fungal control, particularly in the absence of Th1 response. IL-22 is another cytokine with multiple functions on host response and disease progression. However, little is known about the role of IL-22 during histoplasmosis. In this study, we demonstrated that absence of IL-22 affected the clearance of yeasts from the lungs and increased the spreading to the spleen. In addition, IL-22 deficient mice (Il22-/-) succumbed to infection, which correlated with reductions in the numbers of CD4+ IFN-γ+ T cells, reduced IFN-γ levels, and diminished nitric oxide synthase type 2 (NOS2) expression in the lungs. Importantly, treatment with rIFN-γ mitigated the susceptibility of Il22-/- mice to H. capsulatum infection. These data indicate that IL-22 is crucial for IFN-γ/NO production and resistance to experimental histoplasmosis.

HIV-Associated Histoplasmosis: Current Perspectives

Histoplasmosis is an endemic mycosis caused by Histoplasma capsulatum. Infection develops by inhalation of microconidia from environmental sites inhabited by birds and bats. Disseminated disease is the usual presentation due to impaired cellular immunity. Common clinical manifestations include fever, fatigue, malaise, anorexia, weight loss, and respiratory symptoms. Histoplasma antigen detection is the most sensitive method for diagnosis. The sensitivity of the MVista^® Quantitative Histoplasma antigen enzyme immunoassay is 95-100% in urine, over 90% in serum and bronchoalveolar lavage (BAL) antigen and 78% in cerebral spinal fluid (CSF). A proven diagnosis can be established by culture or pathology with sensitivities between 70% and 80%. The sensitivity of antibody detection by immunodiffusion or complement fixation was between 60% and 70%. Diagnosis using molecular methods has not been adequately validated for implementation and FDA cleared assays are unavailable. Liposomal amphotericin B should be used for 1-2 weeks followed by itraconazole for at least one year until CD4 counts are above 150 cells/mm3, HIV viral load is below 400 copies/mL and Histoplasma urine antigen is negative. Serum itraconazole level should be monitored to avoid drug toxicity. Antigen should be measured periodically to establish that treatment is effective and to assist in identifying relapse. The incidence of immune reconstitution inflammatory syndrome is low but it must be considered in patients who are thought to be failing antifungal treatment as it does not respond to changing antifungal agents but rather to initiation of corticosteroid therapy. In this review, we discuss pathogenesis, clinical manifestations, diagnosis and treatment based on personal experience and relevant publications.

Histoplasmosis in HIV-Infected Patients: Epidemiological, Clinical and Necropsy Data from a Brazilian Teaching Hospital

Histoplasmosis occurs in 5-10% of HIV-infected patients in endemic areas and evolves to severe and disseminated infection with mortality rates over 50% in some regions. This report presents epidemiological, clinical and outcome data from HIV-infected patients with histoplasmosis confirmed by culture and/or at necropsy who were admitted to a Brazilian teaching hospital. Data from 65 patients were obtained from their respective medical and necropsy records. From 2005 to 2018, 36 HIV-infected patients were diagnosed with histoplasmosis confirmed by culture. At admission, most of these patients presented disseminated fungal infection, whereas 15 (41.7%) were simultaneously diagnosed with both HIV infection and histoplasmosis. Fever, weight loss, hepatosplenomegaly, respiratory and digestive symptoms were present in 86.2%, 50%, 44.4% and 41.7% of the patients, respectively. At admission, 24 patients had low CD4 T-cell count and high viral load values. Among the 30 patients who received antifungals, 16 (53.3%) were cured, 13 (43.3%) died, and one was lost to follow-up. Six patients died prior to therapy. From 1990 to 2018, 63 necropsies of patients with Histoplasma capsulatum infection were performed. Of these patients, 29 (46.0%) were HIV-infected individuals, including 21 (72.4%) who presented disseminated histoplasmosis and 21 (72.4%) who were diagnosed with histoplasmosis at necropsy. The epidemiological, clinical and outcome profiles presented herein are similar to those described elsewhere and reinforce the difficulties that are still present in limited-resource settings where advanced immunodeficiency, combined with severe fungal infection and late patient admissions, is related to poor outcomes.

An Italian Case of Disseminated Histoplasmosis Associated with HIV

Histoplasma capsulatum is a dimorphic fungus, endemic in the Americas, Africa (var. duboisii), India, and Southeast Asia. H. capsulatum infection is rarely diagnosed in Italy, while in Latin America, progressive disseminated histoplasmosis (PDH) is one of the most frequent AIDS-defining illnesses and causes of AIDS-related deaths. We report a case of PDH and new HIV infection diagnosis in a Cuban patient, who has been living in Italy for the past 10 years. Bone marrow aspirate and peripheral blood smear microscopy suggested H. capsulatum infection. The diagnosis was confirmed with the culture method identifying its thermal dimorphism. Liposomal amphotericin B was administered alone for 10 days and then for another 2 days, accompanied with voriconazole; the former was stopped for probable side effects (persistent fever and worsening thrombocytopenia), and voriconazole was continued to complete 4 weeks. PDH maintenance treatment consisted of itraconazole for one year. Antiretroviral therapy (ART) was started on the third week of antifungal treatment. At the 3-year follow-up, the patient is adherent on ART, the virus was suppressed, and she has an optimal immune recovery. This case highlights the need to suspect histoplasmosis in the differential diagnosis of opportunistic infections in immunocompromised persons, native to or who have traveled to endemic countries.

The occurrence of histoplasmosis in Brazil: A systematic review

BACKGROUND

Histoplasmosis is a systemic disease caused by the dimorphic fungus Histoplasma capsulatum. Diagnosis is often delayed, or it is misdiagnosed as tuberculosis. In Brazil, the infection is common and cases of histoplasmosis have been described in all regions of the country; however, the real problem is underestimated since notification of histoplasmosis is not mandatory.

METHODS

Human histoplasmosis cases diagnosed in Brazil and published up to December 2018 were identified through a search conducted in the PubMed/MEDLINE, SciELO, and Web of Science databases. Moreover, the isolation of H. capsulatum from animals or environmental sources in Brazil was also evaluated.

RESULTS

A total of 207 articles fulfilled the inclusion criteria and were evaluated, involving a total of 3530 patients with a diagnosis of histoplasmosis during the period studied. Of these patients, 78.3% were male, giving a male-to-female ratio of approximately 4:1. Histoplasmosis presented a higher frequency in individuals between the fourth and fifth decades of life. Disseminated disease was the most common form of histoplasmosis. Isolation of H. capsulatum on culture media and histopathology using staining methods were the diagnostic methods with the best efficiency. The best results in the identification of the H. capsulatum were achieved for samples from mononuclear phagocyte system components, skin and mucosa, and hematological samples. Regarding predisposing factors for histoplasmosis, HIV infection was the most common underlying condition. The overall mortality rate was 33.1%.

CONCLUSIONS

This study represents the first available systematic review demonstrating Brazilian cases of histoplasmosis in the literature and highlights that the disease is more widespread in the Brazilian territory than has previously been thought.

Histoplasmosis, An Underdiagnosed Disease Affecting People Living With HIV/AIDS in Brazil: Results of a Multicenter Prospective Cohort Study Using Both Classical Mycology Tests and Histoplasma Urine Antigen Detection

Background

Histoplasmosis is highly endemic in the American continent. This condition is associated with a high mortality, particularly in people living with HIV/AIDS (PLWHA). Diagnosis of histoplasmosis is usually late in South America, as Histoplasma antigen detection is rarely available. Here we determined the prevalence, risk factors, and outcome of histoplasmosis in PLWHA in Brazilian hospitals.

Methods

This was a prospective cohort study (2016-2018) involving 14 tertiary medical centers in Brazil. We included hospitalized PLWHA presenting with fever and additional clinical findings. Patients were investigated at each participant center with classical mycology methods. Also, Histoplasma antigen detection was performed in urine samples (IMMY). Probable/proven histoplasmosis was defined according to European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group/National Institute of Allergy and Infectious Diseases Mycoses Study Group criteria.

Results

From 616 eligible patients, 570 were included. Histoplasmosis was identified in 21.6% (123/570) of patients. Urine antigen testing increased the diagnostic yield in 53.8%, in comparison with standard mycology methods. Variables independently associated with histoplasmosis were CD4+ count <50 cells/mm³, use of an antiretroviral (protective effect), and sample collection in the Northeast region of Brazil. Dyspnea at presentation was independently associated with death. Histoplasmosis was more frequent than tuberculosis in patients with low CD4+ counts. Overall 30-day mortality was 22.1%, decreasing to 14.3% in patients with antigen-based diagnosis.

Conclusions

Histoplasmosis is a very frequent condition affecting PLWHA in Brazil, particularly when CD4+ counts are lower than 50 cells/mm³. Antigen detection may detect earlier disease, with a probable impact on outcomes. Access to this diagnostic tool is needed to improve clinical management of PLWHA in endemic countries.

Epidemiological aspects of travel-related systemic endemic mycoses: a GeoSentinel analysis, 1997-2017

Background

International travel has increased in the past few decades, placing more travellers at risk of acquiring systemic endemic mycoses. There are limited published data on systemic endemic mycoses among international travellers. We report epidemiological characteristics of non-migrant, international travellers who acquired systemic endemic mycoses during travel.

Methods

We analysed records of non-migrant international travellers with a confirmed diagnosis of histoplasmosis, coccidioidomycosis, paracoccidioidomycosis, blastomycosis or talaromycosis reported from 1997 through 2017 to GeoSentinel, a global surveillance network now consisting of 70 travel or tropical medicine centres in 31 countries.

Results

Sixty-nine records met the inclusion criteria. Histoplasmosis was most frequently reported; the 51 travellers with histoplasmosis had the lowest median age (30 years; range: 8-85) and shortest median duration of travel (12 days; range: 5-154). Coccidioidomycosis was reported in 14 travellers; travellers with coccidioidomycosis were older (median 62 years; range: 22-78) and had the longest median number of days between return from travel and presentation to a GeoSentinel site (55 days; range: 17-273). Almost all travellers with coccidioidomycosis were exposed in the USA. Other systemic endemic mycoses were less frequently reported, including blastomycosis (three travellers) and talaromycosis (one traveller).

Conclusions

Although relatively rare, systemic endemic mycoses should be considered as potential travel-related infections in non-migrant international travellers. Epidemiological exposures should be used to guide diagnostic evaluations and treatment.

Pathologic Features of Infectious Gastritis

This manuscript presents a review of infectious causes of gastritis aimed at the practicing anatomic pathologist. We shall highlight unique histologic findings and clinical attributes that will assist those analyzing endoscopically obtained mucosal biopsies of the stomach or resection specimens.

Histoplasma Peritonitis: An Extremely Rare Complication of Peritoneal Dialysis

Bacterial peritonitis is a common complication of peritoneal dialysis, but fungal peritonitis is unusual and is mostly due to Candida species. Peritonitis due to Histoplasma capsulatum is rare and we report one such case. A 63-year-old female presented with progressively worsening abdominal pain, fever, and altered mental status. She had end-stage renal disease and had been on peritoneal dialysis for 4 years. She had abdominal tenderness without rebound or guarding. Laboratory studies and CT of abdomen were significant for leukocytosis and peritoneal membrane thickening, respectively. Peritoneal dialysis fluid study was consistent with peritonitis and culture of the fluid grew Histoplasma capsulatum. Treatment recommendations include removal of catheter and initiation of antifungal therapy. With the availability of newer antifungals, medical management without removal of PD catheter is possible, but at the same time if there is no response to treatment within a week, PD catheter should be removed promptly.

Histoplasmosis in Africa: An emerging or a neglected disease?

Histoplasmosis in Africa has markedly increased since the advent of the HIV/AIDS epidemic but is under-recognised. Pulmonary histoplasmosis may be misdiagnosed as tuberculosis (TB). In the last six decades (1952-2017), 470 cases of histoplasmosis have been reported. HIV-infected patients accounted for 38% (178) of the cases. West Africa had the highest number of recorded cases with 179; the majority (162 cases) were caused by Histoplasma capsulatum var. dubuosii (Hcd). From the Southern African region, 150 cases have been reported, and the majority (119) were caused by H. capsulatum var. capsulatum (Hcc). There have been 12 histoplasmin skin test surveys with rates of 0% to 35% positivity. Most cases of Hcd presented as localised lesions in immunocompetent persons; however, it was disseminated in AIDS patients. Rapid diagnosis of histoplasmosis in Africa is only currently possible using microscopy; antigen testing and PCR are not available in most of Africa. Treatment requires amphotericin B and itraconazole, both of which are not licensed or available in several parts of Africa.

A 30-year delayed presentation of disseminated histoplasmosis in a heart transplant recipient: diagnostic challenges in a non-endemic area

A 70-year-old man with history of heart transplant performed in 1986, presented with altered mental status. CT scan of brain showed ring-enhancing lesions, raising suspicion for metastatic malignancy. Work-up revealed bilateral adrenal masses, biopsy showed granulomatous changes consistent with histoplasmosis. The possibility of histoplasmosis was less likely as the patient had no prior history of symptomatic disease and had lived in the endemic area 30 years prior to presentation. Brain biopsy confirmed central nervous system involvement. Amphotericin B was initiated for disseminated disease but his hospital course was complicated by renal failure and new liver hypodensities on follow-up imaging. Acute progressive disseminated histoplasmosis can manifest after decades of initial exposure and should always be in differential diagnosis even in non-endemic areas for prompt diagnosis and better clinical outcome.

Opportunistic Invasive Mycoses in AIDS: Cryptococcosis, Histoplasmosis, Coccidiodomycosis, and Talaromycosis

PURPOSE OF REVIEW

The goal of this review is to provide an update on the epidemiology, diagnosis, and treatment of opportunistic fungal infections in patients with human immunodeficiency virus (HIV) infection including Cryptococcus spp., Histoplasma spp., Coccidioides spp., and Talaromyces marneffei, formerly Penicillium marneffei.

RECENT FINDINGS

In many settings, despite increasing roll out of antiretroviral therapy (ART), opportunistic invasive mycoses produce a substantial burden of disease. The prevalence of specific fungal pathogens depends on their endemicity. Viral suppression achieved by greater access to ART and increased the availability of point-of-care testing with rapid diagnostic tests (RDTs) aid to curtail the associated fungi morbidity. RDTs allow earlier screening to preemptively initiate treatment of opportunistic fungal pathogens. Identifying asymptomatic cryptococcal infection before starting ART is crucial in reducing the risk of the immune reconstitution inflammatory syndrome (IRIS). There is an urgent need to decrease the burden of opportunistic invasive fungal infections in individuals with HIV/AIDS through different interventions: (a) continue to expand the deployment of ART to the most affected populations to achieve viral suppression; (b) ensure early diagnosis of fungal pathogen with point-of-care testing;

Approach to Fungal Infections in Human Immunodeficiency Virus-Infected Individuals: Pneumocystis and Beyond

Many fungi cause pulmonary disease in patients with human immunodeficiency virus (HIV) infection. Pathogens include Pneumocystis jirovecii, Cryptococcus neoformans, Aspergillus spp, Histoplasma capsulatum, Coccidioides spp, Blastomyces dermatitidis, Paracoccidioides brasiliensis, Talaromyces marneffei, and Emmonsia spp. Because symptoms are frequently nonspecific, a high index of suspicion for fungal infection is required for diagnosis. Clinical manifestations of fungal infection in HIV-infected patients frequently depend on the degree of immunosuppression and the CD4⁺ helper T cell count. Establishing definitive diagnosis is important because treatments differ. Primary and secondary prophylaxes depend on CD4⁺ helper T cell counts, geographic location, and local prevalence of disease.

Histoplasmosis with Deep CNS Involvement: Case Presentation with Discussion and Literature Review

Central nervous system (CNS) histoplasmosis is rare and difficult to diagnose because it is often overlooked or mistaken for other pathologies due to its nonspecific symptoms. A 32-year-old Hispanic man with advanced acquired immunodeficiency virus presented with altered mental status and reported confusion for the past 3 months. He had a Glasgow Coma Scale of 12, repetitive nonfluent speech, and a disconjugate gaze with a right gaze preference. Lung computed tomography (CT) findings indicated a pulmonary histoplasmosis infection. Magnetic resonance imaging of the brain revealed a ring-enhancing lesion in the left caudate nucleus. A CT-guided left retroperitoneal node biopsy was performed and indicated a benign inflammatory process with organisms compatible with fungal yeast. Treatment with amphotericin B followed by itraconazole was initiated in spite of negative cerebrospinal fluid (CSF) cultures and proved effective in mitigating associated CNS lesions and resolving neurologic deficits. The patient was discharged 3 weeks later in stable condition. Six weeks later, his left basal ganglia mass decreased. Early recognition of symptoms and proper steps is key in improving outcomes of CNS histoplasmosis. Aggressive medical management is possible in the treatment of intracranial deep mass lesions, and disseminated histoplasmosis with CNS involvement can be appropriately diagnosed and treated, despite negative CSF and serology studies.

Lymphnodal Co-infection of Cryptococcus and Histoplasma in a HIV-Infected Patient and Review of Published Reports

Human infection with Histoplasma capsulatum and Cryptococcus runs the gamut from asymptomatic illness to disseminated disease. Though both are the most prevalent systemic mycoses in HIV-infected patients, simultaneous infection by both the pathogens rarely occurs. We document the first case from Asian subcontinent with concurrent infection with disseminated cryptococcosis and histoplasmosis infections in a HIV-infected Indian patient diagnosed by morphological examination of fine-needle aspiration cytology samples obtained from the enlarged lymph nodes on light microscopy and were later confirmed by culture studies. A prompt, accurate and timely diagnosis of the disseminated form of dual mycosis (or either of the mycosis as well) is of utmost importance which has obvious impact on early initiation of treatment. Fine-needle aspiration cytology is a rapid, cost-effective and reliable method to identify infection with Cryptococcus and Histoplasma and is comparable with the essential culture studies.

Chronic infections of the small intestine

PURPOSE OF REVIEW

Chronic infections of the small intestine cause significant morbidity and mortality globally. This review focuses on the recent advances in the field of our understanding of selected intestinal infections.

RECENT FINDINGS

Primary and secondary immunodeficiency increase the susceptibility to many chronic intestinal infections. Endoscopy and intestinal biopsies are central to establishing a diagnosis of these conditions. Tuberculosis (TB) remains a major global health challenge. Emerging therapeutic agents to counteract multidrug-resistant strains have shown clinical efficacy, but concerns regarding mortality remain. PCR-based diagnostic TB tests have the potential to reduce diagnostic delays, but remain to be validated for intestinal infections. Adjunctive diagnostic imaging modalities can differentiate infections from Crohn's disease with increasing accuracy. Whipple's disease remains rare, but there have been substantial advances in our understanding of the causative organism Tropheryma whipplei. Extended treatment with broad-spectrum antibiotics is effective in most cases. The narrow therapeutic window and limited armamentarium for treating invasive filamentous fungal infections contribute to their significant morbidity and high rates of mortality.

SUMMARY

The speed and accuracy of diagnosing chronic intestinal infections have improved with recent imaging and laboratory methodologies. Significant research opportunities remain for clinicians and scientists to improve the diagnostic accuracy and clinical outcomes of chronic intestinal infections.

Histoplasmosis in Patients With Cell-Mediated Immunodeficiency: Human Immunodeficiency Virus Infection, Organ Transplantation, and Tumor Necrosis Factor-α Inhibition

Background. Histoplasmosis causes severe disease in patients with defects of cell-mediated immunity. It is not known whether outcomes vary related to the type of immunodeficiency or class of antifungal treatment.

Methods. We reviewed cases of active histoplasmosis that occurred at Vanderbilt University Medical Center from July 1999 to June 2012 in patients with human immunodeficiency virus (HIV) infection, a history of transplantation, or tumor necrosis factor (TNF)-α inhibitor use. These groups were compared for differences in clinical presentation and outcomes. In addition, outcomes were related to the initial choice of treatment.

Results. Ninety cases were identified (56 HIV, 23 transplant, 11 TNF-α inhibitor). Tumor necrosis factor-α patients had milder disease, shorter courses of therapy, and fewer relapses than HIV patients. Histoplasma antigenuria was highly prevalent in all groups (HIV 88%, transplant 95%, TNF-α 91%). Organ transplant recipients received amphotericin B formulation as initial therapy less often than other groups (22% vs 57% HIV vs 55% TNF-α; P = .006). Treatment failures only occurred in patients with severe disease. The failure rate was similar whether patients received initial amphotericin or triazole therapy. Ninety-day histoplasmosis-related mortality was 9% for all groups and did not vary significantly with choice of initial treatment.

Conclusions. Histoplasmosis caused milder disease in patients receiving TNF-α inhibitors than patients with HIV or solid organ transplantation. Treatment failures and mortality only occurred in patients with severe disease and did not vary based on type of immunosuppression or choice of initial therapy.

Histoplasmosis in HIV-Infected Patients: A Review of New Developments and Remaining Gaps

Histoplasma capsulatum is responsible for histoplasmosis, a fungal disease with worldwide distribution that can affect both immunocompromised and imunocompetent individuals. During the highly active antiretroviral therapy (HAART) era, morbidity and mortality due to histoplasmosis remained a public heatlh problem in low-income and high-income countries. The true burden of HIV-associated histoplasmosis is either not fully known or neglected since it is not a notifiable disease. Progress has been made in DNA patterns of strains and understanding of pathogenesis, and hopefully these will help identify new therapeutic targets. Unfortunately, histoplasmosis is still widely mistaken for multidrug-resistant tuberculosis, leading to numerous avoidable deaths, even if they are easily distinguishable. The new diagnostic tools and therapeutics developments have still not been made available in most endemic regions. Still, recent developments are promising because of their good clinical characteristics and also because they will be commercially available and affordable. This review of published data and gaps may help define and guide future research.

Risk factors for disseminated histoplasmosis in a cohort of HIV-infected patients in French Guiana

Disseminated histoplasmosis is the first AIDS-defining infection in French Guiana. A retrospective cohort study studied predictive factors of disseminated histoplasmosis in HIV-infected patients between 1996 and 2008. Cox proportional hazards models were used. The variables studied were age, sex, last CD4/CD8 count, CD4 nadir, herpes or pneumocystosis, cotrimoxazole and fluconazole use, antiretroviral treatment and the notion of recent initiation of HAART. A total of 1404 patients were followed for 6833 person-years. The variables independently associated with increased incidence of disseminated histoplasmosis were CD4 count<50 per mm3, CD4 count between 50 and 200 per mm3, a CD4 nadir <50 per mm3, CD8 count in the lowest quartile, herpes infection, and recent antiretroviral treatment initiation (less than 6 months). The variables associated with decreased incidence of histoplasmosis were antiretroviral treatment for more than 6 months, fluconazole treatment, and pneumocystosis. There were 13.5% of deaths at 1 month, 17.5% at 3 months, and 22.5% at 6 months after the date of diagnosis of histoplasmosis. The most important predictive factors for death within 6 months of diagnosis were CD4 counts and antiretroviral treatment. The present study did not study environmental/occupational factors but provides predictive factors for disseminated histoplasmosis and its outcome in HIV patients in an Amazonian environment during the HAART era.

Disseminated histoplasmosis is the first AIDS-related disease in French Guiana, and probably in the Amazonian area. In order to determine the factors that are associated with histoplasmosis, a retrospective looked at a cohort of HIV-infected patients between 1996 and 2008. Multiple models were used to study the relation of age, sex, last CD4/CD8 count, CD4 nadir, herpes or pneumocystosis, cotrimoxazole and fluconazole use, antiretroviral treatment and the notion of recent initiation of antiretroviral treatment with the occurrence of disseminated histoplasmosis. A total of 1404 patients were followed for 6833 person-years. The variables independently associated with the incidence of disseminated histoplasmosis were low CD4 counts, the lowest CD4 counts were most at risk; Patients with the lowest CD8 counts were also at increased risk; Antiretroviral treatment was generally associated with lower histoplasmosis incidence, but for the first 6 months following antiretroviral treatment initiation there was a transient period of increased risk of diagnosing histoplasmosis; Herpes was also associated with more histoplasmosis; Pneumocystosis and Fluconazole treatment were negatively associated with histoplasmosis. Of 156 patients with histoplasmosis, there were 13.5% of deaths at 1 month, 17.5% at 3 months, and 22.5% at 6 months after the date of diagnosis of histoplasmosis. The most important predictive factors for death within 6 months of diagnosis were low CD4 counts and no antiretroviral treatment. The present study did not study environmental/occupational factors but provides predictive factors for disseminated histoplasmosis and its outcome in HIV patients in an Amazonian environment during the HAART era. These results are useful to guide clinicians working in an area where this diagnosis is often overlooked.

Endemic fungal infections in inflammatory bowel disease associated with anti-TNF antibody therapy

Patients with inflammatory bowel disease are susceptible to complications from pharmacologic treatment of their disease. Tumor necrosis factor (TNF)-α inhibitors are being used increasingly in the treatment of inflammatory bowel disease and can be associated with adverse events, including common infections, and rarely the development of serious life-threatening opportunistic infections. TNF-α inhibitors have the ability to prevent an effective patient granulomatous response, and this may be associated with an increased risk of developing mycobacterial and certain fungal infections, including histoplasmosis, blastomycosis, and coccidioidomycosis, endemic in several parts of the United States. The concern for invasive fungal infection was realized during clinical trials and further demonstrated after the marketing of TNF-α inhibitors. Because of this awareness, the Food and Drug Administration developed an adverse event-reporting system to capture cases of infections associated with the use of TNF-α inhibitors. These opportunistic fungi have a great degree of regional variability, and it has been very difficult to quantify the incidence of infection in patients treated with TNF-α inhibitors. Currently, there are no formal guidelines regarding the use of TNF-α inhibitors and these fungal infections. Considering that gastroenterologists have embraced the use TNF-α inhibitors as a valuable armamentarium in the treatment of inflammatory bowel disease, they must be aware of therapy-related infectious complications, including appropriate diagnostic, therapeutic, and preventive strategies. In this article, we explore the association of these fungal entities in relation to the TNF-α inhibitor therapy by considering information provided in the gastroenterology, infectious diseases, rheumatology, and transplant literature. Finally, we provide some recommendations on diagnosis and treatment.

Co-infection of disseminated histoplasmosis and tuberculosis in an AIDS patient

Histoplasmosis is a fungal disease caused by the dimorphic fungus Histoplasma capsulatum, recognized as an AIDS-defining illness since the Center for Disease Control's revision criteria in 1985. This infection is reported to be present in 5-20% of AIDS patients, and in 95% of the cases it is manifested in its disseminated form. Serum antibodies and/or antigen research can make diagnosis, but the demonstration of the agent by culture or histopathological examination remains the gold standard methods. Co-infections in patients with AIDS are well known; however, reports on disseminated tuberculosis and histoplasmosis are scarce. The authors report the case of a female patient who presented a short-course history of weight loss, fever, and mild respiratory symptoms, with hepatosplenomegaly and lymphadenopathy. Laboratory workup called attention to anemia, altered liver, canalicular enzymes, liver function tests, high titer of lactate dehydrogenase (LDH), and pulmonary nodules on thoracic computed tomography. Incidental finding of yeast forms within the leukocytes during a routine blood cell count highlighted the diagnosis of histoplasmosis. The patient started receiving amphotericin B but succumbed soon after. The authors emphasize the possibility of this co-infection, the diagnosis of severe infection through the finding of yeast forms within peripheral leukocytes, and for the high titer of LDH in aiding the differential diagnosis.

Temporal trends, clinical characteristics, and outcomes of histoplasmosis in a tertiary care center in Kentucky, 2000 to 2009

The impact of highly active antiretroviral therapy (HAART) on the epidemiology of AIDS-associated histoplasmosis in the past decade is poorly defined. Among 100 patients with histoplasmosis in an endemic region between 2000 and 2009, 42 patients were immunocompetent, 32 were infected with HIV, and 26 were non-HIV-immunocompromised patients. The percentage with HIV decreased 67% in 2000-2001 to 18% in 2008-2009 (P = .004), while the proportion of non-HIV immunocompromised patients increased, 8% to 41% (P = .14). Histoplasma antigen was the most sensitive test (73%), whereas potassium hydroxide examination of clinical specimens was the least sensitive test (33%) in all 3 groups. Bronchoalveloar fluid culture (74%) had the highest yield among the cultures. The relapse rate was higher in HIV-infected patients compared to the other 2 groups (P = .04). The epidemiology of histoplasmosis in our endemic area has changed during the era of HAART. Organ transplantation and increasing use of immunosuppressive agents for chronic inflammatory conditions in non-HIV patients now account for most of the cases of histoplasmosis.

AN, Facanha MC, Leitao TDMJS. HISTOPLASMIN SURVEY IN HIV-POSITIVE PATIENTS: RESULTS FROM AN ENDEMIC AREA IN NORTHEASTERN BRAZIL

SUMMARY Background. Disseminated histoplasmosis is common in AIDS patients with advanced immunosuppression in Ceará, Northeastern Brazil. The goal of this study was to determine the prevalence of Histoplasma infection in patients with HIV/AIDS living in Fortaleza, the capital of Ceará. Methods. Intradermal tests with histoplasmin (mycelial phase) were performed in 161 HIV patients with CD4 ≥ 350 cells/mm 3 . Evidence of recent illness was evaluated with immunodiffusion (ID) tests in 76 of these individuals. Results. A total of 11.8% of patients reacted to histoplasmin and 2.63% had ID test positive to Histoplasma. The presence of mango trees (Mangifera indica) in the patient neighborhood (OR = 2.870; 95% CI = 1.081-7.617; p = 0.040) and past activity involving soil (OR = 2.834; 95% CI = 1.045-7.687; p = 0.045) or visits to a farm (OR = 3.869; 95% CI = 1.189-12.591; p = 0.033) were significantly associated with Histoplasma infection. Conclusions. Patients with HIV living in Fortaleza have an expressive prevalence of infection with Histoplasma.

Chronic primary central nervous system histoplasmosis in a healthy child with intermittent neurological manifestations

Meningitis is an unusual clinical manifestation of Histoplasma capsulatum infection in nonimmunosuppressed children. We report a previously healthy 6-year-old boy with primary, chronic histoplasma meningitis and magnetic resonance imaging findings consistent with demyelinating disease presenting with brief, intermittent neurological manifestations for 7 months before diagnosis.

[Pulmonary fungal infection in patients with AIDS]

Fungal infections are the most common opportunistic infections (OI) occurring during the course of HIV infection, though their incidence has decreased dramatically with the introduction of highly active antiretroviral therapy (cART). Most cases occur in untreated patients, noncompliant patients or patients whose multiple antiretroviral regimens have failed and they are a good marker of the severity of cellular immunodepression. Pneumocystis jiroveci pneumonia is the second most frequent OI in France and cryptococcosis remains a major problem in the Southern Hemisphere. With the increase in travel, imported endemic fungal infection can occur and may mimic other infections, notably tuberculosis. Fungal infections often have a pulmonary presentation but an exhaustive search for dissemination should be made in patients infected with HIV, at least those at an advanced stage of immune deficiency. Introduction of cART in combination with anti-fungal treatment depends on the risk of AIDS progression and on the risk of cumulative toxicity and the immune reconstitution inflammatory syndrome (IRIS) if introduced too early. Fungal infections in HIV infected patients remain a problem in the cART era. IRIS can complicate the management and requires an optimised treatment regime.

Tuberculosis and histoplasmosis co-infection in AIDS patients

Abstract. Coinfection with tuberculosis in some countries occurs in 8-15% of human immunodeficiency virus (HIV) -infected patients who have histoplasmosis. This coinfection interferes with prompt diagnosis, and treatment is difficult because of drug interactions. We retrospectively reviewed the cases of 14 HIV-infected patients who had concomitant tuberculosis and histoplasmosis. The most frequent clinical manifestations were weight loss (85.7%), asthenia (78.5%), and fever (64.2%). The diagnosis of histoplasmosis was made primarily by histopathology (71.4%), and the diagnosis of tuberculosis was made by means of direct microscopic examination (71.4%). Death occurred in two patients, and relapse of both infections occurred in one patient. Moxifloxacin was substituted for rifampicin in six patients, with good outcomes noted for both infections. The clinical presentation does not readily identify acquired immunodeficiency syndrome (AIDS) patients who have tuberculosis and histoplasmosis. The use of a fluoroquinolone as an alternative agent in place of rifampicin for tuberculosis allows effective therapy with itraconazole for histoplasmosis.

Oral histoplasmosis masquerading as oral cancer in HIV-infected patient: A case report

Histoplasmosis is an endemic mycoses caused by Histoplasma capsulatum with endemicity around midwestern United States and central America. The endemicity of histoplasmosis in India is not clearly known. Histoplasmosis, especially oral histoplasmosis, is now increasingly being reported from India. We report here a culture-confirmed and sequence confirmed, oral histoplasmosis in a HIV seropositive individual who was referred to our regional cancer centre with a suspicion of oral cancer.

Histoplasma mechanisms of pathogenesis--one portfolio doesn't fit all

Histoplasma capsulatum is the leading cause of endemic mycosis in the world. Analyses of clinical isolates from different endemic regions show important diversity within the species. Recent molecular studies of two isolates, the Chemotype I NAm2 strain G217B and the Chemotype II Panamanian strain G186A, reveal significant genetic, structural, and molecular differences between these representative Histoplasma strains. Some of these variations have functional consequences, representing distinct molecular mechanisms that facilitate Histoplasma pathogenesis. The realization of Histoplasma strain diversity highlights the importance of characterizing Histoplasma virulence factors in the context of specific clinical strain isolates.

Management of fungal lung disease in the immunocompromised

Pulmonary mycoses are among the most feared infections encountered in immunocompromised patients. The problem is amplified by the increasing numbers of chronically immunocompromised patients that have substantially increased both the prevalence and clinical severity of infections caused by fungi. Moreover, fungal infections in this patient population pose challenges in diagnosis and management. Fortunately, recent advances in diagnostics and antifungal therapy, and their direct application to specific diseases, provide important new approaches to this complex and often seriously ill patient population. In this article we review the commonly occurring pulmonary fungal infections in the immunocompromised population with a particular focus on their management.

HIV-associated histoplasmosis in French Guiana: recent infection or reactivation?

In order to determine whether HIV-associated disseminated histoplasmosis was a recent infection or a reactivation, time series of first episodes of disseminated histoplasmosis were analyzed. Climatic variables were associated with histoplasmosis incidence. This suggested an important proportion of cases were due to recent exposure, and therefore primary prophylaxis may be warranted in French Guiana.

[Clinical and evolutionary characteristics of 134 patients with disseminated histoplasmosis associated with AIDS in the State of Ceará]

INTRODUCTION

Since the beginning of the HIV epidemic in Ceará, disseminated histoplasmosis (DH) has often been detected among AIDS patients.

METHODS

In order to investigate the clinical and laboratory characteristics, evolution and survival of cases of DH/AIDS coinfection, the medical records on 134 cases of DH admitted to a reference hospital in Ceará between 1999 and 2005 were analyzed.

RESULTS

Patients with DH presented higher frequency of daily fever, coughing, weight loss, enlarged liver and spleen and acute kidney failure. The diagnosis was made using investigation and/or cultures. At admission, the following were risk factors for death among DH patients: vomiting, dyspnea, respiratory failure, acute kidney failure, hemoglobin < or = 8g/l, urea > or = 40mg/dl and creatinine > or = 1.5 mg/dl.

CONCLUSIONS

Patients with DH characteristically presented higher fever, previous hospitalization due to respiratory infection and more clinical complications. Significant anemia and elevated urea were independent risk factors for death among DH patients.