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Pipitò L, Medaglia AA, Trizzino M, Mancuso A, Catania B, Mancuso S, Calà C, Florena AM, Cascio A. Hemophagocytic lymphohistiocytosis secondary to histoplasmosis: A case report in a patient with AIDS and recent SARS-CoV-2 infection and minireview. Heliyon 2023; 9:e18537. [PMID: 37533984 PMCID: PMC10392081 DOI: 10.1016/j.heliyon.2023.e18537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/04/2023] Open
Abstract
Here, we describe the case of a naïve HIV late presenter female African patient with progressive disseminated histoplasmosis and a severe life-threatening clinical picture in a non-endemic area. She had not visited Africa in the past decade. She developed a reactive hemophagocytic lymphohistiocytosis and an acute psychiatric disorder. Histoplasmosis was diagnosed after two bone marrow biopsies. Therapy with liposomal amphotericin B resulted in rapid and progressive improvements in blood examinations and clinical conditions, including the disappearance of psychiatric disorders. The characteristics of our case were compared with those of all other cases of hemophagocytic syndrome secondary to histoplasmosis in HIV-positive patients reported in PubMed. In conclusion, clinicians outside endemic areas should evaluate histoplasmosis as a cause of severe clinical picture, especially in a patient with a travel history to an endemic area, even after many years, considering the possible reactivation of latent infection.
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Affiliation(s)
- Luca Pipitò
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G D'Alessandro,” University of Palermo, Palermo, Italy
- Infectious and Tropical Disease Unit and Sicilian Regional Reference Center for the Fight Against AIDS, AOU Policlinico “P. Giaccone”, 90127 Palermo, Italy
- Palermo Fast-Track City, Casa dei Diritti, Via Libertà 45, 90143 Palermo, Italy
| | - Alice Annalisa Medaglia
- Infectious and Tropical Disease Unit and Sicilian Regional Reference Center for the Fight Against AIDS, AOU Policlinico “P. Giaccone”, 90127 Palermo, Italy
- Palermo Fast-Track City, Casa dei Diritti, Via Libertà 45, 90143 Palermo, Italy
| | - Marcello Trizzino
- Infectious and Tropical Disease Unit and Sicilian Regional Reference Center for the Fight Against AIDS, AOU Policlinico “P. Giaccone”, 90127 Palermo, Italy
- Palermo Fast-Track City, Casa dei Diritti, Via Libertà 45, 90143 Palermo, Italy
| | - Alessandro Mancuso
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G D'Alessandro,” University of Palermo, Palermo, Italy
- Infectious and Tropical Disease Unit and Sicilian Regional Reference Center for the Fight Against AIDS, AOU Policlinico “P. Giaccone”, 90127 Palermo, Italy
- Palermo Fast-Track City, Casa dei Diritti, Via Libertà 45, 90143 Palermo, Italy
| | - Bianca Catania
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G D'Alessandro,” University of Palermo, Palermo, Italy
- Infectious and Tropical Disease Unit and Sicilian Regional Reference Center for the Fight Against AIDS, AOU Policlinico “P. Giaccone”, 90127 Palermo, Italy
- Palermo Fast-Track City, Casa dei Diritti, Via Libertà 45, 90143 Palermo, Italy
| | - Salvatrice Mancuso
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G D'Alessandro,” University of Palermo, Palermo, Italy
| | - Cinzia Calà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G D'Alessandro,” University of Palermo, Palermo, Italy
- Microbiology and Virology Unit- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G D'Alessandro,” University of Palermo, Palermo, Italy
| | - Ada Maria Florena
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G D'Alessandro,” University of Palermo, Palermo, Italy
- Unit of Pathology, Universital Hospital Paolo Giaccone, Palermo (PA), viale del vespro 147, Palermo, Italy
| | - Antonio Cascio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G D'Alessandro,” University of Palermo, Palermo, Italy
- Infectious and Tropical Disease Unit and Sicilian Regional Reference Center for the Fight Against AIDS, AOU Policlinico “P. Giaccone”, 90127 Palermo, Italy
- Palermo Fast-Track City, Casa dei Diritti, Via Libertà 45, 90143 Palermo, Italy
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Gupta H, Yadav KL P, Totaganti M, Kant R, Monica Devi Y. A Rare Case of Disseminated Histoplasmosis With Hemophagocytic Syndrome in a Patient With Diabetes Mellitus: A Case Report. Cureus 2023; 15:e36333. [PMID: 37077607 PMCID: PMC10108889 DOI: 10.7759/cureus.36333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2023] [Indexed: 03/20/2023] Open
Abstract
We report a case of Histoplasma-associated hemophagocytic syndrome in a diabetes mellitus patient. The patient presented with a fever, cough, and an ulcer on the tongue. The biopsy confirmed the diagnosis of histoplasmosis from the tongue ulcer. Other investigations revealed normal clusters of differentiation 4 (CD4) count and increased hemoglobin A1c (HbA1c) and lactate dehydrogenase (LDH) levels. The patient was diagnosed with hemophagocytic syndrome secondary to Histoplasma after fulfilling the hemophagocytic lymphohistiocytosis (HLH)-2004 criteria required for diagnosis, including fever (with peak temperatures of >38.5° C), splenomegaly, cytopenia affecting two cell lineages in peripheral blood, hypertriglyceridemia (fasting triglycerides >265 mg/dL), and hemophagocytosis in the bone marrow biopsy. The patient was started on injection amphotericin B with remarkable improvement.
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Fretz A, Penner JC, Bainbridge ED, Babik JM. A silver lining. J Hosp Med 2023; 18:82-86. [PMID: 36178229 DOI: 10.1002/jhm.12966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 07/12/2022] [Accepted: 09/06/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Anna Fretz
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - John C Penner
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Emma D Bainbridge
- Division of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer M Babik
- Division of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA
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Freire M, Carvalho V, Spener R, da Silva CR, da Silva Neto JR, Carlos Ferreira L, Nogueira PA. Hemophagocytic Syndrome in a Patient with HIV and Histoplasmosis: A not so Rare Correlation. Clin Med Insights Pathol 2022; 15:2632010X221118059. [PMID: 36051652 PMCID: PMC9425888 DOI: 10.1177/2632010x221118059] [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] [Received: 10/29/2021] [Accepted: 07/15/2022] [Indexed: 11/18/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a disorder that occurs due to unsuitable monocyte activation in a variety of infections. In human immunodeficiency virus (HIV) infections, patients with advanced immunossupression associated with opportunistic infections are at increased risk of developing HLH. We describe a clinical case of a 33-year-old male student diagnosed with HIV who was hospitalized for investigation of asthenia and dyspnea, accompanied by adynamia, decreased motor force in the left leg, dysphagia, and dysfluency. His general condition was regular, he was pale, feverish, and had normal cardiac and pulmonary auscultation. Physical examination revealed ulcerated lesions in the perianal region and hepatosplenomegaly without palpable lymph node enlargement. Laboratory parameters showed pancytopenia, a slight increase in liver function accompanied by high lactate dehydrogenase, and hiperferritinemia. The initial diagnosis was disseminated histoplasmosis, thus amphotericin B deoxycholate was empirically prescribed while waiting on myeloculture and blood cultures for fungi and mycobacteria. Other clinical procedures were blood transfusion, resumption of antiretroviral therapy (ART) and secondary prophylaxis. Myeloculture blood cultures of fungi and mycobacteria were negative. Patient evolved well in relation to the initial complaints and showed partial clinical and laboratory improvement. However, 23 days after hospitalization, he developed a febrile episode accompanied by chills and a convulsive crisis. The patient was transferred to the intensive unit care and developed septic shock and respiratory failure. He died 25 days after the onset of the condition. After the postmortem examination, histopathology revealed countless rounded fungal structures compatible with Histoplasma sp., which were observed in the peripancreatic lymph node, liver, and spleen, in addition to hemophagocytosis in the splenic parenchyma. We thus conclude that when the patient met criteria for HLH, such as fever, hepatosplenomegaly, hiperferritinemia, and pancytopenia, the evolution was fast due to the aggressive and rapidly fatal nature of HLH, despite anti-fungal and corticoid treatment. Therefore, this case report reinforces the need to consider hemophagocytic syndrome in patients with HIV and disseminated histoplasmosis, especially where histoplasmosis is highly endemic, in order for the treatment be started early when there is high clinical suspicion.
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Affiliation(s)
- Monique Freire
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil.,Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
| | - Viviane Carvalho
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | - Renata Spener
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | - Christiane Rodrigues da Silva
- Programa de Pós-graduação em Biologia da Realação Patogeno Hospedeiro, Instituto Leônidas e Maria Deane, Manaus, Brazil
| | | | - Luiz Carlos Ferreira
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil.,Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
| | - Paulo Afonso Nogueira
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil.,Programa de Pós-graduação em Biologia da Realação Patogeno Hospedeiro, Instituto Leônidas e Maria Deane, Manaus, Brazil
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Nguyen D, Nacher M, Epelboin L, Melzani A, Demar M, Blanchet D, Blaizot R, Drak Alsibai K, Abboud P, Djossou F, Couppié P, Adenis A. Hemophagocytic Lymphohistiocytosis During HIV Infection in Cayenne Hospital 2012-2015: First Think Histoplasmosis. Front Cell Infect Microbiol 2020; 10:574584. [PMID: 33072627 PMCID: PMC7542182 DOI: 10.3389/fcimb.2020.574584] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/19/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction: Haemophagocytic Lymphohistiocytosis (HLH), during HIV infection is a rare complication with a poor prognosis. There are few data on HLH within the Amazon region. The objective was to describe epidemiological, clinical and therapeutic features of HIV-related HLH in French Guiana. Methods: A retrospective analysis of adult HIV patients at Cayenne hospital with HLH between 2012 and 2015. A diagnosis of HLH was given if the patient presented at least 3 of 8 criteria of the HLH-2004 classification. Results: Fourteen cases of HLH were tallied during the study period. The mean age was 46 years with a sex ratio of 1.8. The most frequent etiology of HLH was an associated infection (12/14). Confirmed disseminated histoplasmosis, was found in 10 of 14 cases, and it was suspected in 2 other cases. The CD4 count was below 200/mm3 in 13/14 cases. An HIV viral load >100,000 copies/ml was observed in 13/14 cases. An early treatment with liposomal amphotericin B was initiated in 12/14 cases. The outcome was favorable in 12/14 of all cases and in 10/12 cases involving histoplasmosis. Case fatality was 2/14 among all cases (14.3%) et 1/10 among confirmed disseminated histoplasmosis with HLH (10%). During the study period 1 in 5 cases of known HIV-associated disseminated histoplasmosis in French Guiana was HLH. Conclusion: Histoplasmosis was the most frequent etiology associated with HLH in HIV-infected patients in French Guiana. The prognosis of HLH remains severe. However, a probabilistic empirical first line treatment with liposomal amphotericin B seemed to have a favorable impact on patient survival.
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Affiliation(s)
- Duc Nguyen
- Centre d'Investigation Clinique Antilles Guyane, INSERM 1424, Centre Hospitalier de Cayenne, Cayenne, French Guiana
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Mathieu Nacher
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
- COREVIH Guyane, Centre Hospitalier de Cayenne, Cayenne, French Guiana
- DFR Santé, Université de Guyane, Cayenne, French Guiana
| | - Loic Epelboin
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Alessia Melzani
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Magalie Demar
- DFR Santé, Université de Guyane, Cayenne, French Guiana
- UMR TBIP, Université de Guyane, Cayenne, French Guiana
- Laboratory, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Denis Blanchet
- UMR TBIP, Université de Guyane, Cayenne, French Guiana
- Laboratory, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Romain Blaizot
- Service de Dermatologie-Vénéréologie, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Kinan Drak Alsibai
- Service d'Anatomopathologie, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Philippe Abboud
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Félix Djossou
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
- UMR TBIP, Université de Guyane, Cayenne, French Guiana
| | - Pierre Couppié
- DFR Santé, Université de Guyane, Cayenne, French Guiana
- Service de Dermatologie-Vénéréologie, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Antoine Adenis
- Centre d'Investigation Clinique Antilles Guyane, INSERM 1424, Centre Hospitalier de Cayenne, Cayenne, French Guiana
- COREVIH Guyane, Centre Hospitalier de Cayenne, Cayenne, French Guiana
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Histoplasmosis-Associated Hemophagocytic Lymphohistiocytosis: A Review of the Literature. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2019; 2019:7107326. [PMID: 31662810 PMCID: PMC6791197 DOI: 10.1155/2019/7107326] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/30/2019] [Indexed: 12/27/2022]
Abstract
Background Histoplasmosis is an endemic fungal disease with diverse clinical presentations. Histoplasmosis-associated hemophagocytic lymphohistiocytosis (HLH) is a rare disorder with limited data regarding treatment and outcome. We described the clinical features, treatment, and outcomes of five patients in our institution with histoplasmosis-associated HLH. This review also summarizes the current literature about presentation, treatment, and outcome of this infection-related HLH entity. Methods We searched the electronic medical records for patients with histoplasmosis-associated HLH at our institution from 1/1/2006 to 9/30/2017. Diagnosis of HLH was confirmed by chart review using the HLH-04 criteria. We also searched the current literature for case reports and case series. Results Five cases of histoplasmosis-associated HLH were included from our institution. All five patients were diagnosed after 2010. The literature review yielded 60 additional cases of histoplasmosis-associated HLH. The most common underlying condition was HIV in 61% of cases. The majority of histoplasmosis patients (81%) were treated with amphotericin B formulations. Documented specific treatments for HLH were as follows: nine patients received steroids only, six patients received intravenous immunoglobulin (IVIG) only, three patients received dexamethasone and etoposide, two patients received etoposide, dexamethasone, and cyclosporine, two patients received steroids and IVIG, and one patient received Anakinra and IVIG. The inpatient case fatality rate was 31% with most of the deaths occurring within two weeks of hospital admission. Conclusions Histoplasmosis-associated HLH among adults is an uncommon but serious complication with high associated mortality. Early antifungal therapy with a lipid formulation amphotericin B is critical. The initiation of immunosuppressive therapy with regimens like HLH-04 in this disease entity should be individualized.
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Disturbances in NK Cells in Various Types of Hemophagocytic Lymphohistiocytosis in a Population of Polish Children. J Pediatr Hematol Oncol 2019; 41:e277-e283. [PMID: 31107368 DOI: 10.1097/mph.0000000000001514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease associated with immune system hyperactivation and the appearance of serious systemic disturbances. The purpose of this study was an assessment of natural killer (NK) cell disturbances in a group of children with clinical signs of HLH. A total of 43 children with HLH and 17 healthy children were enrolled in the study. NK phenotyping, intracellular perforin staining, and cytotoxicity tests were performed by using the flow cytometry method. HLH patients were divided into 6 HLH types: 9% infection-related HLH; 7% malignancy-related HLH; 21% macrophage activating syndrome; 12% familial hemophagocytic lymphohistiocytosis; 2% X-linked lymphoproliferative syndrome; and 49% as HLH of unknown background. A positive correlation was observed between cytotoxicity and NK cells in children with HLH (P=0.01). In all HLH groups, the percentage of NK cells was significantly lower than in the control population. The spontaneous cytotoxicity was significantly lower in HLH patients. The results presented in this study indicate the importance of impaired function and the number of NK cells in the pathogenesis of HLH. Nonetheless, the background of disturbances seems to be different in various cases.
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Lebowitz D, Celi L, Tshikung ON, Starobinski M, Chappuis F, Serratrice J. Fever of un-Swiss origin. Presse Med 2019; 48:740-744. [PMID: 31130333 DOI: 10.1016/j.lpm.2019.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/20/2019] [Accepted: 05/07/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Dan Lebowitz
- Geneva university hospitals, division of general internal medicine, 1205 Geneva, Switzerland.
| | - Letizia Celi
- Geneva university hospitals, division of general internal medicine, 1205 Geneva, Switzerland
| | | | - Michel Starobinski
- Geneva university hospitals, division of hematology, 1205 Geneva, Switzerland
| | - François Chappuis
- Geneva university hospitals, division of tropical and humanitarian medicine, 1205 Geneva, Switzerland
| | - Jacques Serratrice
- Geneva university hospitals, division of general internal medicine, 1205 Geneva, Switzerland
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Ragab G, Atkinson TP, Stoll ML. Macrophage Activation Syndrome. THE MICROBIOME IN RHEUMATIC DISEASES AND INFECTION 2018. [PMCID: PMC7123081 DOI: 10.1007/978-3-319-79026-8_14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH), or termed macrophage activation syndrome (MAS) when associated with rheumatic disorders, is a frequently fatal complication of infections, rheumatic disorders, and hematopoietic malignancies. Clinically, HLH/MAS is a life-threatening condition that is usually diagnosed among febrile hospitalized patients (children and adults) who commonly present with unremitting fever and a shock-like multiorgan dysfunction scenario. Laboratory studies reveal pancytopenia, elevated liver enzymes, elevated markers of inflammation (ESR, CRP), hyperferritinemia, and features of coagulopathy. In about 60% of cases, excess hemophagocytosis (macrophages/histiocytes engulfing other hematopoietic cell types) is noted on biopsy specimens from the bone marrow, liver, lymph nodes, and other organs. HLH/MAS has been hypothesized to occur when a threshold level of inflammation has been achieved, and genetic and environmental risk factors are believed to contribute to the hyperinflammatory state. A broad variety of infections, from viruses to fungi to bacteria, have been identified as triggers of HLH/MAS, either in isolation or in addition to an underlying inflammatory disease state. Certain infections, particularly by members of the herpesvirus family, are the most notorious triggers of HLH/MAS. Treatment for infection-triggered MAS requires therapy for both the underlying infection and dampening of the hyperactive immune response.
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Affiliation(s)
- Gaafar Ragab
- Faculty of Medicine, Cairo University, Cairo, Egypt
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Loganantharaj N, Oliver B, Smith T, Jetly R, Engel L, Sanne S. Hemophagocytic lymphohistiocytosis in an HIV-positive patient with concomitant disseminated histoplasmosis. Int J STD AIDS 2018; 29:925-928. [PMID: 29433397 DOI: 10.1177/0956462417753008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A 46-year-old Dominican man, known to have HIV, presented with constitutional symptoms of two week's duration. The patient was found to have cytopenias, significantly elevated ferritin level and lymphadenopathy. Biopsies and laboratory studies met the criteria for hemophagocytic lymphohistiocytosis (HLH). A concomitant diagnosis of histoplasmosis was confirmed as the trigger for HLH and treatment resulted in clinical improvement and resolution of symptoms.
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Affiliation(s)
- Nisha Loganantharaj
- 1 Department of Medicine, LSU Health Science Center at New Orleans, New Orleans, LA, USA
| | - Brianna Oliver
- 1 Department of Medicine, LSU Health Science Center at New Orleans, New Orleans, LA, USA
| | - Taylor Smith
- 1 Department of Medicine, LSU Health Science Center at New Orleans, New Orleans, LA, USA
| | - Rachna Jetly
- 2 Department of Pathology, LSU Health Science Center at New Orleans, New Orleans, LA, USA
| | - Lee Engel
- 3 Department of Medicine, Section of Hospital Medicine, LSU Health Sciences Center at New Orleans, New Orleans, LA, USA
| | - Shane Sanne
- 3 Department of Medicine, Section of Hospital Medicine, LSU Health Sciences Center at New Orleans, New Orleans, LA, USA
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Simon CT, Murga-Zamalloa CA, Bachman MA, Petty LA, Choi SM. Unexpected disseminated histoplasmosis detected by bone marrow biopsy in a solid organ transplant patient. Clin Case Rep 2018; 6:49-51. [PMID: 29375836 PMCID: PMC5771918 DOI: 10.1002/ccr3.1282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 10/21/2017] [Accepted: 10/23/2017] [Indexed: 11/08/2022] Open
Abstract
Disseminated histoplasmosis and hemophagocytic lymphohistiocytosis show overlapping features, which require careful contextual interpretation. Histopathologic evaluation can potentially rapidly identify cases of possible histoplasmosis. A high index of clinical suspicion, particularly in endemic areas and in a setting of immunosuppression, is critical to appropriate diagnosis and treatment.
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Affiliation(s)
- Caroline T Simon
- Department of Pathology University of Michigan Ann Arbor Michigan USA
| | | | - Michael A Bachman
- Department of Pathology University of Michigan Ann Arbor Michigan USA
| | - Lindsay A Petty
- Department of Internal Medicine University of Michigan Ann Arbor Michigan USA
| | - Sarah M Choi
- Department of Pathology University of Michigan Ann Arbor Michigan USA
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Schulze AB, Heptner B, Kessler T, Baumgarten B, Stoica V, Mohr M, Wiewrodt R, Warneke VS, Hartmann W, Wüllenweber J, Schülke C, Schäfers M, Wilmes D, Becker K, Schmidt LH, Groll AH, Berdel WE. Progressive histoplasmosis with hemophagocytic lymphohistiocytosis and epithelioid cell granulomatosis: A case report and review of the literature. Eur J Haematol 2017; 99:91-100. [DOI: 10.1111/ejh.12886] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2017] [Indexed: 01/08/2023]
Affiliation(s)
| | - Britta Heptner
- Department of Medicine A; University Hospital Muenster; Muenster Germany
| | - Torsten Kessler
- Department of Medicine A; University Hospital Muenster; Muenster Germany
| | - Birgit Baumgarten
- Department of Medicine A; University Hospital Muenster; Muenster Germany
| | - Viorelia Stoica
- Department of Medicine B; University Hospital Muenster; Muenster Germany
| | - Michael Mohr
- Department of Medicine A; University Hospital Muenster; Muenster Germany
| | - Rainer Wiewrodt
- Department of Medicine A; University Hospital Muenster; Muenster Germany
| | | | - Wolfgang Hartmann
- Gerhard Domagk Institute of Pathology; University Hospital Muenster; Muenster Germany
| | - Jörg Wüllenweber
- Institute of Medical Microbiology; University Hospital Muenster; Muenster Germany
| | - Christoph Schülke
- Department of Clinical Radiology; University Hospital Muenster; Muenster Germany
| | - Michael Schäfers
- Department of Nuclear Medicine; University Hospital Muenster; Muenster Germany
| | - Dunja Wilmes
- National Reference Center for Cryptococcosis, Scedosporiosis, and Endemic Mycoses; Robert Koch Institute; Berlin Germany
| | - Karsten Becker
- Institute of Medical Microbiology; University Hospital Muenster; Muenster Germany
| | | | - Andreas H. Groll
- Infectious Disease Research Program; Department of Pediatric Hematology/Oncology; Center for Bone Marrow Transplantation; University Hospital Muenster; Muenster Germany
| | - Wolfgang E. Berdel
- Department of Medicine A; University Hospital Muenster; Muenster Germany
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13
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Wormsbecker AJ, Sweet DD, Mann SL, Wang SY, Pudek MR, Chen LYC. Conditions associated with extreme hyperferritinaemia (>3000 μg/L) in adults. Intern Med J 2016; 45:828-33. [PMID: 25851400 DOI: 10.1111/imj.12768] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 03/24/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND The clinical significance of extreme hyperferritinaemia has come under scrutiny with the increasing recognition of haemophagocytic lymphohistiocytosis (HLH) in adults. Most studies of hyperferritinaemia have focused on serum ferritin greater than 1000 μg/L, often in ambulatory patients. The conditions associated with more extreme hyperferritinaemia are poorly understood. AIMS To examine conditions associated with extreme hyperferritinaemia greater than 3000 μg/L in acutely ill adults at a quaternary care hospital. METHODS Patients with serum ferritin greater than 3000 μg/L at Vancouver General Hospital between 1 August 2011 and 1 August 2012 were identified. Those over 18 years of age and with clinical data available were included in the study. RESULTS Eighty-three subjects were identified. Twenty-one cases (25%) were due to transfusional iron overload, 16 (19%) due to liver disease and 15 (18%) due to mixed factors. Haemophagocytic lymphohistiocytosis (HLH) was diagnosed in six of 83 patients (7%) with ferritin greater than 3000 μg/L, but six of eight patients (75%) with ferritin greater than 20 000 μg/L. CONCLUSIONS Extreme hyperferritinaemia greater than 3000 μg/L is uncommon in adult patients. The highest serum ferritin values are seen in HLH, but the differential diagnosis for serum ferritin greater than 3000 μg/L remains broad with iron overload and liver disease being the most common causes.
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Affiliation(s)
- A J Wormsbecker
- Department of Medicine, University of British Columba, Vancouver, Canada
| | - D D Sweet
- Department of Medicine, University of British Columba, Vancouver, Canada.,Department of Emergency Medicine, University of British Columba, Vancouver, Canada
| | - S L Mann
- Department of Medicine, University of British Columba, Vancouver, Canada
| | - S Y Wang
- Department of Medicine, University of British Columba, Vancouver, Canada
| | - M R Pudek
- Department of Pathology and Laboratory Medicine, University of British Columba, Vancouver, Canada
| | - L Y C Chen
- Department of Medicine, University of British Columba, Vancouver, Canada
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Castelli AA, Rosenthal DG, Bender Ignacio R, Chu HY. Hemophagocytic Lymphohistiocytosis Secondary to Human Immunodeficiency Virus-Associated Histoplasmosis. Open Forum Infect Dis 2015; 2:ofv140. [PMID: 26566535 PMCID: PMC4630451 DOI: 10.1093/ofid/ofv140] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/16/2015] [Indexed: 12/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) in immunocompromised hosts is a fulminant syndrome of immune activation with high rates of mortality that may be triggered by infections or immunodeficiency. Rapid diagnosis and treatment of the underlying disorder is necessary to prevent progression to multiorgan failure and death. We report a case of HLH in a patient with human immunodeficiency virus, disseminated histoplasmosis, Mycobacterium avium complex, and Escherichia coli bacteremia. We discuss management of acutely ill patients with HLH and treatment of the underlying infection versus initiation of HLH-specific chemotherapy.
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Affiliation(s)
| | | | - Rachel Bender Ignacio
- Division of Allergy and Infectious Diseases, Department of Medicine , University of Washington ; Global Oncology, Vaccine and Infectious Disease Division , Fred Hutchinson Cancer Research Center , Seattle, Washington
| | - Helen Y Chu
- Division of Allergy and Infectious Diseases, Department of Medicine , University of Washington
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Disseminated Histoplasmosis and Secondary Hemophagocytic Syndrome in a Non-HIV Patient. Case Rep Crit Care 2015; 2015:295735. [PMID: 26347828 PMCID: PMC4546971 DOI: 10.1155/2015/295735] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/17/2015] [Accepted: 07/26/2015] [Indexed: 12/30/2022] Open
Abstract
Histoplasma duboisii, a variant of Histoplasma capsulatum that causes “African histoplasmosis,” can be resistant to itraconazole, requiring intravenous amphotericin B treatment. Rarely, these patients do not respond to intravenous antifungal therapy, and in such cases, patients may progress to develop secondary hemophagocytic lymphohistiocytosis (HLH). We present a case of a 34-year-old male patient with sickle cell disease who presented with a 5-month history of an enlarging painless axillary mass, persistent low grade fevers, night sweats, weight loss, and anorexia. An excisional biopsy of the right axillary lymph node revealed yeast and granulomas consistent with histoplasma infection. He was started on oral itraconazole. After 4 weeks of therapy, laboratory evaluation revealed worsening anemia, thrombocytopenia, and transaminitis. Due to failure of oral therapy, he was admitted for intravenous amphotericin B treatment. During his hospital course anemia, thrombocytopenia, and transaminitis all worsened. A bone marrow biopsy was done that was consistent with HLH. His clinical status continued to deteriorate, developing multiorgan failure and disseminated intravascular coagulation. He unfortunately had a cardiorespiratory arrest after eight days of admission and passed away.
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Disseminated Histoplasmosis in Immunocompetent Individuals- not a so Rare Entity, in India. Mediterr J Hematol Infect Dis 2015; 7:e2015028. [PMID: 25960856 PMCID: PMC4418405 DOI: 10.4084/mjhid.2015.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Accepted: 03/03/2015] [Indexed: 11/23/2022] Open
Abstract
Introduction Histoplasmosis is a rare fungal disease caused by dimorphic fungi Histoplasma capsulatum. The causative fungus persists in soil, infects through inhalation and manifests in three main types-acute primary, chronic cavitary and progressive disseminated histoplasmosis. Disseminated Histoplasmosis (DH) is defined as a clinical condition where the fungus is present in more than one location. Among the forms of histoplasmosis, DH is the rarest and mostly found in an immuno-compromised individual. Here we are presenting our experiences of the series of cases of DH in immuno-competent individuals who have been diagnosed in our institute in last 5 years. Materials and methods This is a single centre retrospective observational study, conducted in Institute of Haematology and Transfusion Medicine, which is a referral centre for Eastern India, from May 2009 to April 2014. Only cases with DH in otherwise healthy immuno-competent individuals were included in the study. The histoplasmosis was confirmed either by presence of Histoplasma in biopsy specimen from an extrapulmonary organ or by positive growth in fungal culture Result Total seven patients met the inclusion criteria. Five out of 7 patients were male. The mean age was 35 years. Five of the 7 patients presented with fever for a long duration. Six patients complained of significant weight loss before diagnosis. On examination, one patient had skin nodules, five patients had hepato-splenomegaly, and two patients had lymphadenopathy. The laboratory investigations revealed anaemia in six out of 7 patients, and pancytopenia in 3 patients. Two patients had features of the hemophagocytic syndrome in the bone marrow. All patients were treated with conventional amphotericin B deoxycholate and azole antifungal. One patient with adrenal involvement died in hospital. The patient with skin nodule had recurrent relapses. The other patients had resolution of symptoms and were clinically cured. Conclusion DH is not an uncommon aetiology of fever of prolonged duration even in immuno-competent individual and should be kept as a differential diagnosis. Targeted investigation through early bone marrow biopsy and fungal culture may help in the diagnosis of DH. Imaging study to exclude adrenal involvement prevents case fatality. Cytopenia may be due to a secondary hemophagocytic syndrome, which improves with anti-fungal therapy. Treatment with either amphotericin B or itraconazole gives excellent outcome though therapy may have to be given for a prolonged period in case of relapses.
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Townsend JL, Shanbhag S, Hancock J, Bowman K, Nijhawan AE. Histoplasmosis-Induced Hemophagocytic Syndrome: A Case Series and Review of the Literature. Open Forum Infect Dis 2015; 2:ofv055. [PMID: 26380347 PMCID: PMC4567100 DOI: 10.1093/ofid/ofv055] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 04/14/2015] [Indexed: 12/31/2022] Open
Abstract
Background. Histoplasmosis-associated hemophagocytic lymphohistiocytosis (HLH) is a relatively rare disorder for which data are limited regarding optimal treatment and clinical outcomes in adults. We describe the clinical features, treatment, and outcomes of patients with histoplasmosis-associated HLH at our institution. Methods. We performed a retrospective chart review of all inpatients at Parkland Hospital diagnosed with HLH associated with Histoplasma capsulatum from 2003 to 2013. Results. Eleven cases of histoplasmosis-associated HLH over this time period were identified. Nine of eleven cases were males (82%). Nine of these patients had human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), 1 was a renal transplant patient on immunosuppressants, and the other had no documented immunocompromise. The most common HLH criteria were splenomegaly (n = 10), fever (n = 10), and ferritin >500 ng/dL (n = 9). Urine Histoplasma antigen was positive in every patient tested (n = 9 of 9), and most antibodies for Histoplasma were positive if checked (n = 4 of 5). A majority of patients received liposomal amphotericin B (n = 9) with an average treatment duration of 11 days, and 5 patients also received prednisone, intravenous immunoglobulin (IVIG), or both. Overall, 5 patients died within 30 days (45.5%), and 7 patients died within 90 days (63.6%). Of the 5 patients that received immunosuppression, 4 died (80%), whereas in the group not given additional immunosuppression (n = 5), 2 died (40%). Conclusions. Histoplasmosis-associated HLH among adults is a lethal disease of highly immunocompromised patients, especially patients with HIV/AIDS. Clinical features such as splenomegaly, elevated ferritin, and cytopenias should prompt evaluation for HLH in this population. Further data are needed to define the role of immunosuppression, IVIG, and highly active antiretroviral therapy in treating this condition.
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Subedee A, Van Sickels N. Hemophagocytic Syndrome in the Setting of AIDS and Disseminated Histoplasmosis: Case Report and a Review of Literature. J Int Assoc Provid AIDS Care 2015; 14:391-7. [PMID: 25670709 DOI: 10.1177/2325957415570740] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is traditionally regarded as a rapidly progressive and often fatal illness. In patients with AIDS, HLH usually occurs secondary to opportunistic infections. Although popular guidelines exist for the diagnosis and management of HLH in general, no formal study has evaluated their applicability among adult patients who develop HLH in the setting of AIDS and opportunistic infections. The study reports on a case of HLH in a patient with AIDS and disseminated histoplasmosis. Eighteen other previously reported cases of HLH in the setting of AIDS and histoplasmosis were reviewed. Majority of the cases occurred in patients with a CD4 count of less than 70 cells/mm(3). Overall mortality was 44%. Not getting antifungal treatment and having Histoplasma in blood were the 2 main risk factors for death. Among the patients who had a timely diagnosis of histoplasmosis and were initiated on antifungal therapy, the survival rates were significantly better, especially in the post-2000 ad period.
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Affiliation(s)
- Anup Subedee
- Baton Rouge General Medical Center, Internal Medicine Residency Program, Baton Rouge, LA, USA
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Putot A, Perrin S, Jolivet A, Vantilcke V. HIV-associated disseminated histoplasmosis in western French Guiana, 2002-2012. Mycoses 2015; 58:160-6. [DOI: 10.1111/myc.12293] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 11/30/2014] [Accepted: 12/16/2014] [Indexed: 11/28/2022]
Affiliation(s)
- A. Putot
- Department of Medicine; Centre Hospitalier de l'Ouest Guyanais; Saint Laurent du Maroni French Guiana
| | - S. Perrin
- Department of Medicine; Centre Hospitalier de l'Ouest Guyanais; Saint Laurent du Maroni French Guiana
| | - A. Jolivet
- Department of Public Health; Centre Hospitalier de l'Ouest Guyanais; Saint Laurent du Maroni French Guiana
| | - V. Vantilcke
- Department of Medicine; Centre Hospitalier de l'Ouest Guyanais; Saint Laurent du Maroni French Guiana
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Babiker ZOE, Wingfield T, Galloway J, Snowden N, Ustianowski A. Extreme elevation of ferritin and creatine kinase in primary infection with HIV-1. Int J STD AIDS 2014; 26:68-71. [DOI: 10.1177/0956462414531936] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The diagnosis of primary HIV-1 infection can be challenging, especially in the absence of reported risks or when presenting features are unusual and uncommon. We report an atypical case of primary HIV-1 infection with HIV-1 subtype C in a 61-year old Caucasian man who presented with extreme hyperferritinaemia without iron overload and marked elevation of serum creatine kinase without rhabdomyolysis. In view of his symptomatic seroconversion and low baseline CD4+ T-lymphocyte count, the patient was treated promptly with combination antiretroviral therapy. Subsequently, he made good clinical improvement on treatment and no opportunistic infections were diagnosed at presentation or as part of a later immune reconstitution syndrome. This novel case highlights the importance of clinical suspicion of HIV and suggests that primary HIV-1 infection should be considered in patients presenting with severe hyperferritinaemia or markedly elevated creatine kinase levels. Further studies are required to explain the causative biological mechanisms underlying this rare presentation.
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Affiliation(s)
| | - Tom Wingfield
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Manchester, UK
- Section of Infection and Immunity, Wellcome Centre for Tropical Medicine, Imperial College, London, UK
| | - James Galloway
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Manchester, UK
| | - Neil Snowden
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Manchester, UK
| | - Andrew Ustianowski
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Manchester, UK
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Abstract
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.
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Rosado FGN, Kim AS. Hemophagocytic lymphohistiocytosis: an update on diagnosis and pathogenesis. Am J Clin Pathol 2013; 139:713-27. [PMID: 23690113 DOI: 10.1309/ajcp4zdkj4icouat] [Citation(s) in RCA: 219] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a frequently fatal and likely underdiagnosed disease involving a final common pathway of hypercytokinemia, which can result in end-organ damage and death. Although an early diagnosis is crucial to decrease mortality, the definitive diagnosis is often challenging because of the lack of specificity of currently accepted diagnostic criteria and the absence of confirmatory gold standards. Because of the wide range of laboratory assays involved in the diagnosis of HLH, practicing pathologists from a broad spectrum of clinical specialties need to be aware of the disease so that they may appropriately flag results and convey them to their clinical counterparts. Our article summarizes these new advances in the diagnosis of HLH and includes a review of clinical findings, updated understanding of the pathogenesis, and promising new testing methods.
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Debate around infection-dependent hemophagocytic syndrome in paediatrics. BMC Infect Dis 2013; 13:15. [PMID: 23324497 PMCID: PMC3549728 DOI: 10.1186/1471-2334-13-15] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 01/11/2013] [Indexed: 02/08/2023] Open
Abstract
Background Hemophagocytic syndrome (HPS) is clinically defined as a combination of fever, liver dysfunction, coagulation abnormalities, pancytopenia, progressive macrophage proliferation throughout the reticuloendothelial system, and cytokine over-production, and may be primary or secondary to infectious, auto-immune, and tumoral diseases. The most consistent association is with viral infections but, as it is still debated whether any micro-organisms are involved in its pathogenesis, we critically appraised the literature concerning HPS and its relationship with infections. Discussion Infection-dependent HPS has been widely observed, but there are no data concerning its incidence in children. A better understanding of the pathophysiology of HPS may clarify the interactions between the immune system and the variously implicated potential infectious agents. Epstein-Barr virus (EBV) infection has been prominently associated with HPS, with clonal proliferation and the hyperactivation of EBV-infected T cells. However, a number of other viral, bacterial, fungal, and parasitic infections have been reported in association with HPS. In the case of low-risk HPS, corticosteroids and/or intravenous immunoglobulin or cyclosporine A may be sufficient to control the biological process, but etoposide is recommended as a means of reversing infection-dependent lymphohistiocytic dysregulation in high-risk cases. Summary HPS is a potential complication of various infections. A polymerase chain reaction search for infectious agents including EBV, cytomegalovirus and Leishmania is recommended in clinical settings characterised by non-remitting fever, organomegaly, cytopenia and hyperferritinemia.
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Hyperferritinemia in pulmonary tuberculosis. Indian J Clin Biochem 2012; 28:309-10. [PMID: 24426230 DOI: 10.1007/s12291-012-0289-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 12/02/2012] [Indexed: 10/27/2022]
Abstract
High ferritin levels have been found to be associated with non infectious as well as infectious causes including tuberculosis. This is one case report of 41 year old male who presented with cough with expectoration. The patient had Multi drug resistant tuberculosis (MDRTB) and type 2 diabetes mellitus. The laboratory findings showed Iron 280 μg/dl, Total iron binding capacity (TIBC) 61 μg/dl, and ferritin 92,945 ng/ml which indicates that iron is an essential nutrient for the survival of the pathogen Mycobacterium tuberculosis.
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Causes of hyperferritinaemia classified by HIV status in a tertiary-care setting in South Africa. Epidemiol Infect 2012; 141:207-11. [DOI: 10.1017/s0950268812000398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
SUMMARYThis study included all patients, with known HIV-1 status, admitted to hospital over a 5-year period with serum ferritin values exceeding 1500 μg/l. Markedly elevated serum ferritin levels are associated with a host of causes which poses a diagnostic dilemma, as the aetiology is often highly dependent on local epidemiology. We evaluated patients' records retrospectively to determine underlying causes of possible hyperferritinaemia. Aetiologies associated with hyperferritinaemia varied significantly depending on HIV-1 status. In patients infected with the HIV-1 virus, infectious causes predominated with Mycobacterium tuberculosis accounting for more than 50% of the patient population with an odds ratio of 17·98 (95% confidence interval 8·31–38·88) in HIV-positive compared to HIV-negative patients. Of the HIV-1-negative patients, hereditary haemochromatosis accounted for less than 2% of patients and chronic renal failure was the most common diagnosis. The finding of hyperferritinaemia should prompt determination of HIV-1 status, as this impacts significantly on aetiological epidemiology. In HIV-1-positive patients, aggressive investigation for mycobacterial infection should be undertaken in cases of combined hyperferritinaemia and positive HIV-1 serology.
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Visser A, van de Vyver A. Severe Hyperferritinemia in Mycobacteria tuberculosis Infection. Clin Infect Dis 2010; 52:273-4. [DOI: 10.1093/cid/ciq126] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ribeiro LC, Hahn RC, Favalessa OC, Tadano T, Fontes CJF. Micoses sistêmicas: fatores associados ao óbito em pacientes com infecção pelo vírus da imunodeficiência humana, Cuiabá, Estado de Mato Grosso, 2005-2008. Rev Soc Bras Med Trop 2009; 42:698-705. [DOI: 10.1590/s0037-86822009000600017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Accepted: 11/27/2009] [Indexed: 12/28/2022] Open
Abstract
A prevalência de micose sistêmica entre 1.300 pacientes portadores de HIV/Aids de Cuiabá, Mato Grosso foi de 4,6%, no período de 2005-2008. As espécies de fungos isoladas foram o Cryptococcus neoformans (50%), Cryptococcus gattii (1,6%), Cryptococcus spp (6,6%), Histoplasma capsulatum (38,3%) e Paracoccidioides brasiliensis (3,3%). Óbito foi registrado em 32 (53,3%) pacientes, sendo a criptococose a principal causa. A contagem de linfócitos T CD4+ foi baixa e semelhante entre os pacientes que sobreviveram ou faleceram por micose sistêmica. O etilismo (OR:8,2; IC95%: 1,4-62,1; p=0,005) e o nível médio de desidrogenase lática [758 (182) U/L vs 416 (268) U/L; p<0,001] foram as características independentemente associadas ao óbito dos pacientes do estudo. Os resultados mostram alta letalidade por micoses sistêmicas em pacientes portadores de HIV/Aids de Cuiabá e sugerem que características clínico-laboratoriais tais como o etilismo e a elevação precoce da desidrogenase lática podem ser fatores relacionados ao pior prognóstico nessas condições.
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Affiliation(s)
| | - Rosane Christine Hahn
- Universidade Federal do Mato Grosso; Associação Mato-Grossense Para Estudo das Endemias Tropicais; Universidade de Cuiabá
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Abstract
PURPOSE OF REVIEW Haemophagocytic syndrome (HPS) is a relatively rare complication of HIV infection but one that can take a particularly aggressive and potentially fatal course. The condition may be underrecognized due to the nonspecific nature of the clinical features. This review summarizes the pathogenesis, clinical and diagnostic features, common associations and current options in the management of HPS in the context of HIV infection, with the aim of increasing diagnostic awareness and facilitating early intervention. RECENT FINDINGS Our understanding of HPS is being increasingly informed by research into the molecular basis of the familial forms of the condition. The list of associated infections and neoplasms continues to lengthen, although the occurrence of HPS is increasingly recognized in the context of HIV infection alone, occasionally as its initial presentation in acute seroconversion. Diagnostic guidelines have recently been refined and attempts to adapt these to particular patient groups are ongoing. Management of HIV-associated HPS is adapted to the clinical context and may involve treatment of an underlying disorder or immunosuppressive therapy to reduce the activation of macrophages and T cells. SUMMARY The spectrum of HIV-related lymphoproliferative disorders continues to expand. Our understanding of their molecular and cellular basis and the role of infectious organisms in their development increasingly shapes and advances our clinical management of these complex conditions.
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Affiliation(s)
- Tomas Doyle
- Department of Infectious Diseases, UK bDepartment of Haematology, Royal Free Hospital, London, UK
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Secondary hemophagocytic lymphohistiocytosis and severe sepsis/ systemic inflammatory response syndrome/multiorgan dysfunction syndrome/macrophage activation syndrome share common intermediate phenotypes on a spectrum of inflammation. Pediatr Crit Care Med 2009; 10:387-92. [PMID: 19325510 DOI: 10.1097/pcc.0b013e3181a1ae08] [Citation(s) in RCA: 192] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In an effort to attain earlier diagnoses in children with hemophagocytic lymphohistiocytosis (HLH), the International Histiocyte Society has now broadened their diagnostic criteria to no longer differentiate primary (HLH) and secondary hemophagocytic lymphohistiocytosis (SHLH). Five of the following eight diagnostic criteria needed to be met: 1) fever, 2) cytopenia of two lines, 3) hypertriglyceridemia and/or hypofibrinogenemia, 4) hyperferritinemia (>500 microg/L), 5) hemophagocytosis, 6) elevated soluble interleukin-2 receptor (CD25), 7) decreased natural killer-cell activity, and 8) splenomegaly can also commonly be found in patients with sepsis, systemic inflammatory response syndrome (SIRS), multiorgan dysfunction syndrome (MODS), and macrophage activation syndrome (MAS). Nevertheless, the therapeutic options for these are radically different. Chemotherapy and bone marrow transplant have been used for treatment of HLH/SHLH, whereas antibiotics and supportive treatment are used in severe sepsis/SIRS and MODS. MAS is treated with limited immune suppression. Outcomes are also different, SHLH has a mortality rate around 50%, whereas pediatric septic shock and MODS have a mortality of 10.3% and 18%, respectively, and severe sepsis in previously healthy children has a mortality rate of 2%. MAS has a mortality rate between 8% and 22%. Because SHLH and severe sepsis/SIRS/MODS/MAS share clinical and laboratory inflammatory phenotypes, we recommend extreme caution when considering applying HLH therapies to children with sepsis/SIRS/MODS/MAS. HLH therapies are clearly warranted for children with HLH; however, a quantitative functional estimate of cytotoxic lymphocyte function may be a more precise approach to define the overlap of these conditions, better identify these processes, and develop novel therapeutic protocols that may lead to improved treatments and outcomes.
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De Lavaissière M, Manceron V, Bourée P, Garçon L, Bisaro F, Delfraissy JF, Lambotte O, Goujard C. Reconstitution inflammatory syndrome related to histoplasmosis, with a hemophagocytic syndrome in HIV infection. J Infect 2008; 58:245-7. [PMID: 19095307 DOI: 10.1016/j.jinf.2008.11.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Revised: 11/03/2008] [Accepted: 11/15/2008] [Indexed: 01/09/2023]
Abstract
Immune reconstitution after initiation of antiretroviral therapy may unmask a latent infection. We report a case of disseminated Histoplasma capsulatum capsulatum infection associated with a hemophagocytic syndrome in an HIV-infected patient, three weeks after initiation of antiretroviral therapy. The immune reconstitution inflammatory syndrome might be a risk factor for hemophagocytosis.
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Affiliation(s)
- Marc De Lavaissière
- Service de Médecine Interne, Hôpital Bicêtre, AP-HP, Le Kremlin Bicêtre, France
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Gil-Brusola A, Pemán J, Santos M, Salavert M, Lacruz J, Gobernado M. Disseminated histoplasmosis with hemophagocytic syndrome in a patient with AIDS: description of one case and review of the Spanish literature. Rev Iberoam Micol 2008; 24:312-6. [PMID: 18095767 DOI: 10.1016/s1130-1406(07)70063-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
We report a case of disseminated histoplasmosis in a 33-year old Ecuadorian patient with AIDS and a CD4 lymphocyte count of 39 cells/microl. He presented with prolonged fever and cough, was diagnosed with hemophagocytic syndrome and multiple organ failure and died 18 days after admission. Histoplasma capsulatum was isolated post-mortem from bone marrow biopsy and blood culture. In a literature review we found 22 published cases of disseminated histoplasmosis in patients with AIDS in Spain since 1988. All but two were men under 50 years old. Nineteen had been born or had lived in endemic areas. The diagnosis of histoplasmosis was established by culture of bone marrow biopsy in 10 cases. Itraconazole was introduced as a second drug after amphotericin B in ten of the thirteen patients who survived.
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Affiliation(s)
- Ana Gil-Brusola
- Servicio de Microbiología, Hospital Universitario La Fe, Valencia, Spain.
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Rouphael NG, Talati NJ, Vaughan C, Cunningham K, Moreira R, Gould C. Infections associated with haemophagocytic syndrome. THE LANCET. INFECTIOUS DISEASES 2008; 7:814-22. [PMID: 18045564 PMCID: PMC7185531 DOI: 10.1016/s1473-3099(07)70290-6] [Citation(s) in RCA: 394] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Haemophagocytic syndrome or haemophagocytic lymphohistiocytosis is a rare disease that is often fatal despite treatment. Haemophagocytic syndrome is caused by a dysregulation in natural killer T-cell function, resulting in activation and proliferation of lymphocytes or histiocytes with uncontrolled haemophagocytosis and cytokine overproduction. The syndrome is characterised by fever, hepatosplenomegaly, cytopenias, liver dysfunction, and hyperferritinaemia. Haemophagocytic syndrome can be either primary, with a genetic aetiology, or secondary, associated with malignancies, autoimmune diseases, or infections. Infections associated with haemophagocytic syndrome are most frequently caused by viruses, particularly Epstein-Barr virus (EBV). We present a case of EBV-associated haemophagocytic syndrome in a young adult with no known immunosuppression. We briefly review haemophagocytic syndrome and then discuss its associated infections, particularly EBV and other herpes viruses, HIV, influenza, parvovirus, and hepatitis viruses, as well as bacterial, fungal, and parasitic organisms.
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Affiliation(s)
- Nadine G Rouphael
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA 30303, USA.
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Stroup JS, Stephens JR, Baker DL, Lad M. Amphotericin B Formulation Confusion and Mortality in an HIV-Seropositive Patient. Hosp Pharm 2007. [DOI: 10.1310/hpj4206-532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Amphotericin B (AmB) is commonly used in patients with a human immunodeficiency virus (HIV)-positive diagnosis for the treatment of disseminated fungal infections such as Histoplasma spp. or Cryptococcus spp. Newer liposomal formulations of AmB have been introduced to the market to avoid the toxic effects of the traditional agent. With the introduction of these new agents, there is a risk of confusion between the agents in regards to dosing, which may lead to toxicity. We report the case of an HIV-seropositive patient who inadvertently received five times the dose of AmB deoxycholate for disseminated Histoplasma capsulatum and died.
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Affiliation(s)
- Jeffrey S. Stroup
- Medicine, Oklahoma State University Center for Health Sciences, Tulsa, OK
| | - Johnny R. Stephens
- Medicine, Oklahoma State University Center for Health Sciences, Tulsa, OK
| | - Damon L. Baker
- Medicine, Oklahoma State University Center for Health Sciences, Tulsa, OK
| | - Madhuri Lad
- Internal Medicine Resident, Oklahoma State University Medical Center, Tulsa, OK
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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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36
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Wang Z, Duarte AG, Schnadig VJ. Fatal Reactive Hemophagocytosis Related to Disseminated Histoplasmosis with Endocarditis: An Unusual Case Diagnosed at Autopsy. South Med J 2007; 100:208-11. [PMID: 17330695 DOI: 10.1097/smj.0b013e31802b2812] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Reactive hemophagocytic syndrome (RHS) is an uncommon life-threatening disorder. It is believed to be caused by widespread non-neoplastic proliferation and inappropriate activation of mature macrophages, resulting in excessive cytokine activation which leads to hematophagocytosis by cells of the macrophage-monocyte lineage and multiorgan dysfunction. RHS may be associated with infections caused by bacterial, viral and fungal organisms as well as lymphoproliferative disorders, nonhematopoietic malignancies, autoimmune diseases and some therapeutic drugs. Immunosuppression is a frequent underlying condition in RHS. The following case presentation describes a patient with a history of chronic hepatitis C, cryoglobulinemia, renal failure and Staphylococcus aureus perinephric abscess and bacteremia, who, at autopsy, was found to have disseminated histoplasmosis with fungal endocarditis and RHS.
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Affiliation(s)
- Zhiqin Wang
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555-0548, USA
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37
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Reactive Hemophagocytosis in a Patient With Systemic Lupus Erythematosus and Disseminated Histoplasmosis. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2007. [DOI: 10.1097/01.idc.0000227711.03883.8d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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38
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Guiot HM, Bertrán-Pasarell J, Tormos LM, González-Keelan C, Procop GW, Fradera J, Sánchez-Sergentón C, Méndez W. Ileal perforation and reactive hemophagocytic syndrome in a patient with disseminated histoplasmosis: the role of the real-time polymerase chain reaction in the diagnosis and successful treatment with amphotericin B lipid complex. Diagn Microbiol Infect Dis 2006; 57:429-33. [PMID: 17141457 DOI: 10.1016/j.diagmicrobio.2006.09.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Revised: 09/11/2006] [Accepted: 09/15/2006] [Indexed: 11/16/2022]
Abstract
The following case illustrates an ileal perforation and reactive hemophagocytic syndrome (RHS) resulting from disseminated histoplasmosis in a patient with Human Immunodeficiency Virus (HIV) from Puerto Rico. Although the diagnosis was established by histopathologic findings and a positive bone marrow culture, Histoplasma capsulatum-specific real-time Polymerase Chain Reaction (PCR) allowed to confirm the diagnosis from formalin-fixed, paraffin-embedded tissue. Interestingly, the Histoplasma antigens in both serum and urine samples were falsely negative. Amphotericin B lipid complex (Abelcet), followed by oral itraconazole, led to a successful response and resolution of symptoms. A short review of the clinical signs and symptoms, diagnostic tests, and therapeutic options for disseminated histoplasmosis is done, with emphasis on the role of Histoplasma-specific real-time PCR as a molecular diagnostic tool and the efficacy of treatment with one of the lipid formulations of amphotericin B.
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Affiliation(s)
- Humberto M Guiot
- Division of Infectious Diseases, Department of Medicine, University of Puerto Rico School of Medicine, San Juan, PR 00936, USA.
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Abstract
Understanding the uses and limitations of a battery of laboratory methods is essential to diagnose histoplasmosis. Antigen detection and serology are valuable adjuncts to histopathology and culture. Improvements incorporated into the second-generation Histoplasma antigen assay have increased its sensitivity and specificity for diagnosis of histoplasmosis. More recently, the antigen assay has been modified to provide quantitation, which improves reproducibility and facilitates monitoring antigen clearance during treatment. Furthermore, detection of antigen in bronchoalveolar lavage fluid increases the sensitivity for diagnosis of pulmonary histoplasmosis. Serological tests for antibodies are also useful, but may be falsely negative in immunosuppressed patients. In addition, elevated antibody titres persist for several years following initial infection, complicating their interpretation. Although histopathology may provide for rapid diagnosis, its sensitivity is < 50% in patients with disseminated disease and even lower in pulmonary histoplasmosis. Polymerase chain reaction has been described, but sensitivity is less than that of histopathology. Culture, although highly specific, has notable limitations, including insensitivity, a need for invasive procedures and delayed growth. This review provides the background for understanding the role of a battery of diagnostic methods in histoplasmosis. Tests facilitating a rapid diagnosis are expected to improve the outcome in patients with severe disease.
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Affiliation(s)
- L Joseph Wheat
- MiraVista Diagnostics and Mirabella Technologies, 4444 Decatur Blvd, Indianapolis, IN 46241, USA.
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40
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Gea-Banacloche JC, Opal SM, Jorgensen J, Carcillo JA, Sepkowitz KA, Cordonnier C. Sepsis associated with immunosuppressive medications: an evidence-based review. Crit Care Med 2005; 32:S578-90. [PMID: 15542967 DOI: 10.1097/01.ccm.0000143020.27340.ff] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for sepsis associated with immunosuppressive medications that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. DESIGN The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. METHODS The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. CONCLUSION Immunosuppressed patients, by definition, are susceptible to a wider spectrum of infectious agents than immunologically normal patients and, thus, require a broader spectrum antimicrobial regimen when they present with sepsis or septic shock. Special expertise managing immunosuppressed patient populations is needed to predict and establish the correct diagnosis and to choose appropriate empiric and specific agents and maximize the likelihood that patients will survive these microbial challenges.
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Couppié P, Sobesky M, Aznar C, Bichat S, Clyti E, Bissuel F, El Guedj M, Alvarez F, Demar M, Louvel D, Pradinaud R, Carme B. Histoplasmosis and acquired immunodeficiency syndrome: a study of prognostic factors. Clin Infect Dis 2003; 38:134-8. [PMID: 14679459 DOI: 10.1086/379770] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2003] [Accepted: 08/06/2003] [Indexed: 11/03/2022] Open
Abstract
We aimed to identify prognostic factors for AIDS-associated disseminated histoplasmosis. In a multivariate analysis, we found that dyspnea, a platelet count of <100,000 platelets/mm3, and lactate dehydrogenase levels of >2 times the upper limit of the normal range were significantly independently associated with the death of the patient during the first 30 days of antifungal treatment.
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Affiliation(s)
- Pierre Couppié
- Service de Dermatologie-Vénéréologie, Centre Hospitalier de Cayenne, French Guiana.
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42
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Bhatia S, Bauer F, Bilgrami SA. Candidiasis-associated hemophagocytic lymphohistiocytosis in a patient infected with human immunodeficiency virus. Clin Infect Dis 2003; 37:e161-6. [PMID: 14614689 DOI: 10.1086/379615] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2003] [Accepted: 07/20/2003] [Indexed: 11/03/2022] Open
Abstract
We describe a patient with acquired immunodeficiency syndrome who developed candidiasis-associated hemophagocytic lymphohistiocytosis (HLH), and we review the previously reported cases of this unusual clinical syndrome in patients infected with human immunodeficiency virus (HIV). HLH appears to follow a fulminant course in HIV-infected patients, which warrants an aggressive diagnostic and therapeutic approach. HIV itself may play a role in the pathogenesis of HLH, which is usually associated with opportunistic infections or malignancies. Therapy is usually directed at supportive care and treatment of the underlying disorders, although initiation of antiretroviral therapy may improve the eventual outcome in some cases.
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Affiliation(s)
- Shailender Bhatia
- University of Connecticut Health Center, Internal Medicine Residency Program, Farmington, Connecticut 06030, USA.
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43
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Masri K, Mahon N, Rosario A, Mirza I, Keys TF, Ratliff NB, Starling RC. Reactive hemophagocytic syndrome associated with disseminated histoplasmosis in a heart transplant recipient. J Heart Lung Transplant 2003; 22:487-91. [PMID: 12681429 DOI: 10.1016/s1053-2498(02)00817-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
We describe a patient who developed multi-organ failure with reactive hemophagocytic syndrome secondary to disseminated histoplasmosis 8 months after orthotopic heart transplantation. The patient responded fully to a prolonged course of therapy with amphotericin B and remains free of recurrence. Disseminated histoplasmosis and reactive hemophagocytic syndrome have rarely been described in the setting of cardiac transplantation and never before in combination.
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Affiliation(s)
- Kalil Masri
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure, Cleveland, Ohio 44195, USA
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44
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Prater MR, Ruiz De Gopegui R, Burdette K, Veit H, Feldman B. Bone marrow aspirate from a cat with cutaneous lesions. Vet Clin Pathol 2002; 28:52. [PMID: 12075524 DOI: 10.1111/j.1939-165x.1999.tb01044.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M. Renée Prater
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA.
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45
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Rao RD, Morice WG, Phyliky RL. Hemophagocytosis in a patient with chronic lymphocytic leukemia and histoplasmosis. Mayo Clin Proc 2002; 77:287-90. [PMID: 11888034 DOI: 10.4065/77.3.287] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We present a case of hemophagocytosis in the setting of a disseminated Histoplasma infection in a patient with B-cell chronic lymphocytic leukemia (CLL). A 68-year-old man with CLL presented with progressive pancytopenia and fevers after therapy with cyclophosphamide and fludarabine phosphate. Extensive evaluation for a source of infection revealed a pulmonary nodule. A biopsy specimen taken from the nodule showed granulomas containing Histoplasma organisms. A bone marrow biopsy specimen demonstrated disseminated histoplasmosis and intense hemophagocytosis. Antifungal therapy with amphotericin B was initiated, and the fevers and cytopenias resolved. Hemophagocytic syndrome is an uncommon condition with many origins. It is characterized by a proliferation of histiocytes with phagocytosis of formed elements of blood. Clinical manifestations include signs and symptoms of immune activation and decreased peripheral blood cell counts. This condition is often underdiagnosed because clinicians are unfamiliar with it.
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MESH Headings
- Aged
- Antineoplastic Agents/adverse effects
- Biopsy
- Bone Marrow Examination
- Diagnosis, Differential
- Echocardiography, Transesophageal
- Histiocytosis, Non-Langerhans-Cell/diagnosis
- Histiocytosis, Non-Langerhans-Cell/etiology
- Histiocytosis, Non-Langerhans-Cell/immunology
- Histoplasmosis/complications
- Histoplasmosis/diagnosis
- Histoplasmosis/drug therapy
- Histoplasmosis/immunology
- Humans
- Immunocompromised Host
- Immunohistochemistry
- Leukemia, Lymphocytic, Chronic, B-Cell/blood
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukocyte Count
- Male
- Tomography, X-Ray Computed
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Affiliation(s)
- Ravi D Rao
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA
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46
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Kumar N, Jain S, Singh ZN. Disseminated histoplasmosis with reactive hemophagocytosis: aspiration cytology findings in two cases. Diagn Cytopathol 2000; 23:422-4. [PMID: 11074651 DOI: 10.1002/1097-0339(200012)23:6<422::aid-dc13>3.0.co;2-f] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Two cases of disseminated histoplasmosis associated with reactive hemophagocytic syndrome are described. The clinical presentation was with prolonged unexplained fever and hepatosplenomegaly. On a strong clinical possibility of tuberculosis, antitubercular treatment was initiated in both patients. Lymph node (case 1), splenic (case 2), and bone marrow aspiration, however, showed sheets of proliferating histiocytes, and intracellular and extracellular histoplasma organisms. Aspiration cytology was thus valuable in establishing the final diagnosis. The patients had a fulminant clinical course and died of hemorrhagic shock within 48 hr of hospital admission before specific therapy could be initiated. Histoplasmosis can mimic tuberculosis clinically. There is a need for an increased awareness of the clinicopathological spectrum of histoplasmosis, especially its rarer manifestations as hemophagocytic syndrome. In suspected cases, aspirations from the lymph node, liver, and spleen can be performed safely and should be utilized for early diagnosis.
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Affiliation(s)
- N Kumar
- Cytopathology Laboratory, Department of Pathology, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
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47
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Elin RJ, Whitis J, Snyder J. Infectious Disease Diagnosis From a Peripheral Blood Smear. Lab Med 2000. [DOI: 10.1309/alpg-6uud-14b7-k6xp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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48
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Tiab M, Mechinaud F, Harousseau JL. Haemophagocytic syndrome associated with infections. Best Pract Res Clin Haematol 2000; 13:163-78. [PMID: 10942619 DOI: 10.1053/beha.2000.0066] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Haemophagocytic syndromes (HS) are the clinical manifestation of an increased macrophagic activity with haemophagocytosis. Pathophysiology is related to a deregulation of T-lymphocytes and excessive production of cytokines. The main clinicobiological features are fever, hepatosplenomegaly, adenopathies, skin rash, neurological features, cytopenias, hypertriglyceridaemia, hyperferritinaemia and coagulopathy. Diagnosis is based on examination of the bone marrow which shows benign histiocytes actively phagocytosing haemopoietic cells. Acquired HS are mostly associated with an underlying disease such as immunodeficiency, haematological neoplasias and autoimmune diseases. Infection-associated HS was originally described by Risdall in 1979, in viral disease. Since the initial description HS has also been documented in patients with bacterial, parasitic or fungal infections. Epstein-Barr virus (EBV) is the causative agent in most cases. In EBV-associated HS, which sometimes has a fatal course, unregulated T-cell reaction or uncontrolled B-cell proliferation may release cytokines. Management of HS consists of early diagnosis, careful screening for, and prompt treatment of, infections and detection and therapy of any underlying disease. Prognosis of infection-associated haemophagocytic syndrome (IAHS) is better than that in other types of secondary HS. Management of cytokine imbalance should be useful to improve the outcome and reduce the mortality rate in these cases.
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Affiliation(s)
- M Tiab
- Service de Médecine Interne Hématologie, Centre Hospitalier Départemental, La Roche-sur-Yon, France
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49
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Senger C, Gonzalez-Crussi F. Histiocytic-phagocytic infiltrates in the liver of an infant: a case clinically simulating perinatal hemochromatosis. J Pediatr Gastroenterol Nutr 1999; 29:215-20. [PMID: 10435663 DOI: 10.1097/00005176-199908000-00022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- C Senger
- Department of Pathology of the Children's Memorial Hospital and Northwestern University Medical School, Chicago, Illinois 60614, USA
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50
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 38-1998. A 19-year-old man with the acquired immunodeficiency syndrome and persistent fever. N Engl J Med 1998; 339:1835-43. [PMID: 9867564 DOI: 10.1056/nejm199812173392508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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