Practice guidelines for the management of patients with histoplasmosis. Infectious Diseases Society of America

Histoplasmosis peritonitis in an immunocompetent patient: case report

Histoplasmosis is a fungal infection most frequently seen in immunocompromised patients. It is endemic in Central and South America and in Africa. The infection is usually asymptomatic in a healthy individual. Extrapulmonary dissemination can be seen in immunocompromised hosts. Gastrointestinal manifestations frequently involve the terminal ileum and cecum, mimicking Crohn's disease or malignancy. We describe the case of a 36-year-old healthy man from Cameroon, living in Switzerland for 13 years and without any medical nor surgical history, who presented peritonitis not responding to antibiotics. CT-scan showed bowel obstruction and signs of peritonitis. We opted for an explorative laparoscopy, which was converted to laparotomy with extensive adhesiolysis. Diagnostic of histoplasmosis was confirmed by histology and PCR analysis on biopsy. To our knowledge, this is the first described case of peritonitis as main outcome of a disseminated histoplasmosis involving the peritoneum in an immunocompetent patient.

Histoplasmosis Masquerading as Second Primary in Head and Neck Tumours - A Case Report

Histoplasmosis is a chronic granulomatous disease seen in immunocompromised individuals, rarely immunocompetent patients. We report disseminated histoplasmosis involving adrenal glands and oral cavity with synchronous squamous cell carcinoma of right pyriform fossa. With early diagnosis and treatment he recovered well.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03962-4.

Polyfunctional Antigen Specific CD4+ T cell Responses in Patients With Human Immunodeficiency Virus/AIDS and Histoplasmosis Immune Reconstitution Inflammatory Syndrome

In the combination antiretroviral era, there are limited data regarding the pathogenesis of histoplasmosis immune reconstitution inflammatory syndrome (IRIS) in people with human immunodeficiency virus (HIV). We immunologically characterized 10 cases of histoplasmosis, 4 of whom developed histoplasmosis IRIS. CD4+ T cells in histoplasmosis IRIS demonstrated a significant polyfunctional cytokine response to histoplasma antigen.

Septic shock, hyperferritinemic syndrome, and multiple organ dysfunction without respiratory failure in a patient with disseminated histoplasmosis and advanced HIV disease

AIDS-related disseminated histoplasmosis (DH) can cause septic shock and multiorgan dysfunction with mortality rates of up to 80%. A 41-year-old male presented with fever, fatigue, weight loss, disseminated skin lesions, low urine output, and mental confusion. Three weeks before admission, the patient was diagnosed with HIV infection, but antiretroviral therapy (ART) was not initiated. On day 1 of admission, sepsis with multiorgan dysfunction (acute renal failure, metabolic acidosis, hepatic failure, and coagulopathy) was identified. A chest computed tomography showed unspecific findings. Yeasts suggestive of Histoplasma spp. were observed in a routine peripheral blood smear. On day 2, the patient was transferred to the ICU, where his clinical condition progressed with reduced level of consciousness, hyperferritinemia, and refractory septic shock, requiring high doses of vasopressors, corticosteroids, mechanical ventilation, and hemodialysis. Amphotericin B deoxycholate was initiated. On day 3, yeasts suggestive of Histoplasma spp. were observed in the bone marrow. On day 10, ART was initiated. On day 28, samples of peripheral blood and bone marrow cultures revealed Histoplasma spp. The patient stayed in the ICU for 32 days, completing three weeks of intravenous antifungal therapy. After progressive clinical and laboratory improvement, the patient was discharged from the hospital on oral itraconazole, trimethoprim-sulfamethoxazole, and ART. This case highlights the inclusion of DH in the differential diagnosis of patients with advanced HIV disease, septic shock and multiorgan dysfunction but without respiratory failure. In addition, it provides early in-hospital diagnosis and treatment and comprehensive management in the ICU as determining factors for a good outcome.

Hepatic Histoplasmosis: An Update

Histoplasma capsulatum is the most common cause of endemic mycosis in developing countries. It is a self-limited and asymptomatic disease in immunocompetent individuals but remains a frequent cause of opportunistic infection in patients with compromised immune status. Liver involvement as a part of disseminated histoplasmosis is well known. However, liver infection as a primary manifestation of histoplasmosis without evidence of primary lung involvement is rare. In conclusion, clinicians should be aware of isolated histoplasmosis affecting the hepatobiliary system, and careful evaluation is warranted to confirm the diagnosis. Given the appropriate clinical context, histoplasmosis should be considered in both immunocompetent and immunocompromised patients, regardless of pulmonary symptoms, in non endemic as well as endemic areas.

Two-stage exchange Arthroplasty for knee Periprosthetic joint infection exhibit high infection recurrence rate in patients with chronic viral hepatitis

BACKGROUND

Currently, there is little evidence about the outcome of two-stage exchange arthroplasty for the treatment of knee periprosthetic joint infection (PJI) in patients with chronic viral hepatitis. To evaluate it, we set the primary outcome as infection recurrence, and the secondary outcome as the difference between patients diagnosed with hepatitis B virus or hepatitis C virus.

PATIENTS AND METHODS

Between June, 2010 and December, 2016, 172 patients with knee PJIs were treated with two-stage exchange arthroplasty at our institute. Treatment success was defined using Delphi-based consensus. These patients were further divided into groups with or without chronic hepatitis. Variables were analyzed, including age, sex, comorbidities, microbiology, and operative methods. Minimum follow-up was 12 months (mean, 35 months; range, 12-85 months).

RESULTS

Of the 172 knee PJI patients, 25 were identified with chronic hepatitis. The infection recurrence rate in the hepatitis group (28%, 7 in 25) was significantly higher than that in the non-hepatitis group (9.5%, 14 in 147), p = 0.017. However, there was no significant difference in the infection recurrence rates between patients with HBV (24%, 4 in 16) and HCV (33.3%, 3 in 9). Regarding the outcomes of patients with infection recurrence, 4 of the non-hepatitis patients were treated with the debridement, antibiotic treatment, irrigation, and retention of prosthesis (DAIR) procedure, with a success rate of 75%. The other 17 patients (7 with hepatitis and 10 without) were treated with repeated two-stage exchange arthroplasty with 100% infection elimination rate until the final follow-up.

CONCLUSIONS

Knee PJI patients with chronic hepatitis have higher infection recurrence rate after two-stage exchange arthroplasty (28%).

Histoplasmosis in Inflammatory Bowel Disease with Tumor Necrosis Factor-Alpha Inhibitors: Safe to Continue Biologics?

BACKGROUND

The advent of tumor necrosis factor-α (TNF-α) inhibitor therapy has transformed inflammatory bowel disease management; however, these medications carry a boxed warning for risk of serious infections, including invasive fungal infections.

AIMS

We aimed to study the clinical features, severity, and outcomes of histoplasmosis in patients on TNF-α inhibitors for IBD.

METHODS

We performed a retrospective review of IBD patients receiving TNF-α inhibitors who developed histoplasmosis from January 1, 2001, to May 31, 2018. Patients with drug indications other than ulcerative colitis or Crohn's disease were excluded. IBD was diagnosed histologically, radiographically, or endoscopically.

RESULTS

We identified 49 patients (median age 44 years; range 19-76) with histoplasmosis on TNF-α inhibitors. Patients with disseminated disease had a median urine antigen of 10.76 ng/mL compared with pulmonary disease alone 0.375 ng/mL (p < 0.001). Charlson Comorbidity Index and urine antigen levels showed a trend toward predicting disease severity (p > 0.05). Median length of stay was 9.5 days. Itraconazole was used for maintenance in all patients. Median follow-up was 4.7 years. Total treatment duration ranged from 3 to 15 months. TNF-α inhibitor therapy was continued in nine and resumed in ten patients after completing antifungals. Three deaths occurred (6%).

CONCLUSIONS

Histoplasmosis outcomes were mostly favorable. Many patients were young with few comorbidities; however, those with more comorbidities experienced more severe histoplasmosis. Compared to prior studies, many of these patients resumed or continued biologic therapy. There were no histoplasmosis recurrences after resuming TNF-α inhibitor therapy. Vigilance for disseminated fungal infections in this patient population is essential.

Voriconazole versus Itraconazole for the Initial and Step-Down Treatment of Histoplasmosis: A Retrospective Cohort

BACKGROUND

Itraconazole is the preferred azole for histoplasmosis in the current Infectious Diseases Society of America guidelines. Voriconazole is increasingly used as treatment for histoplasmosis; it has in-vitro activity against Histoplasma capsulatum and has shown success in case reports and small case series but may have a lower barrier to resistance. No comparative studies have been published.

METHODS

We constructed a single-center retrospective cohort of adult patients diagnosed with histoplasmosis from 2002 to 2017. Individual charts were reviewed to gather clinical information including demographics, clinical features, immune status, treatments, and mortality. Patients were categorized based on initial choice of azole, either as initial treatment or as step-down therapy from amphotericin B. Initial therapies with other azoles were excluded. Mortality was compared using a multivariable Cox proportional hazards with Heaviside function at 42 days.

RESULTS

We identified 261 cases of histoplasmosis from 2002 to 2017. After excluding patients not treated with itraconazole or voriconazole, 194 patients remained. 175 (90%) patients received itraconazole and 19 (10%) received voriconazole. There were no significant demographic differences between patient populations receiving either azole as their initial azole treatment. Death at 180 days occurred in 41 patients (23.4%) in the itraconazole group and 6 patients (31.6%) in the voriconazole group. Patients on voriconazole had a statistically significant increase in mortality during the first 42 days after initiation of treatment when compared to patients receiving itraconazole (HR 4.30 [95% CI 1.3-13.9, p 0.015]) when controlled for other risk factors.

CONCLUSION

Voriconazole in histoplasmosis was associated with increased mortality in the first 42 days compared to itraconazole.

Continuous ambulatory peritoneal dialysis-associated Histoplasma capsulatum peritonitis: a case report and literature review

Background

Fungal peritonitis (FP) is a rare complication of peritoneal dialysis. We herein describe the second case in Asia of Histoplasma capsulatum peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD).

Case presentation

An 85-year-old woman with end-stage renal disease (ESRD) who had been on CAPD for 3 years and who had a history of 3 prior episodes of peritonitis presented with intermittent abdominal pain for 2 weeks and high-grade fever for 3 days. Elevated white blood cell (WBC) count and rare small oval budding yeasts were found in her peritoneal dialysis (PD) fluid. From this fluid, a white mold colony was observed macroscopically after 7 days of incubation, and numerous large, round with rough-walled tuberculate macroconidia along with small smooth-walled microconidia were observed microscopically upon tease slide preparation, which is consistent with H. capsulatum. The peritoneal dialysis (PD) catheter was then removed, and it also grew H. capsulatum after 20 days of incubation. The patient was switched from CAPD to hemodialysis. The patient was successfully treated with intravenous amphotericin B deoxycholate (AmBD) for 2 weeks, followed by oral itraconazole for 6 months with satisfactory result. The patient remains on hemodialysis and continues to be clinically stable.

Conclusion

H. capsulatum peritonitis is an extremely rare condition that is associated with high morbidity and mortality. Demonstration of small yeasts upon staining of PD fluid, and isolation of slow growing mold in the culture of clinical specimen should provide important clues for diagnosis of H. capsulatum peritonitis. Prompt removal of the PD catheter and empirical treatment with amphotericin B or itraconazole is recommended until the culture results are known.

Disseminated Histoplasmosis in HIV-Infected Patients: A Description of 34 Years of Clinical and Therapeutic Practice

Disseminated histoplasmosis is the main AIDS-defining infection of French Guiana. We aim to describe our therapeutic experience for 349 patients with disseminated histoplasmosis between 1 January 1981 and 10 January 2014 in French Guiana. Survival, delays for treatment initiation, duration of induction therapy, and associated initial treatments are described. The death rate was 14.9 per 100 person-years, with an early drop in survival. Among those who died, >1/3 died within a year of HIV diagnosis, and ¾ of all patients with histoplasmosis had been diagnosed for HIV within a year. As induction treatment, 29% received liposomal amphotericin B, 12.9% received deoxycholate amphotericin B, 54% received itraconazole alone, and 21.8% received liposomal amphotericin B and itraconazole. The median delay between symptoms-onset and hospitalization was 19.5 days (IQR = 5–105). Liposomal amphotericin B or itraconazole was initiated shortly after admission. Treatment initiation was often presumptive for liposomal amphotericin B (27%) and itraconazole (20%). The median duration of liposomal amphotericin B treatment was 7 days (IQR = 5–11 days). The present study shows that ¾ of the patients were profoundly immunocompromised and had been diagnosed for HIV within the past year. Antifungal treatment was often initiated presumptively on admission. Over time there was a significant gradual decline in early death.

Primary Central Nervous System Infection by Histoplasma in an Immunocompetent Adult

Central nervous system (CNS) infection by Histoplasma capsulatum is a rare disease in immunocompromised individuals in endemic areas. About one quarter of cases result from hematogenous dissemination. A 23-year-old upholsterer with chronic occipital headache had developed intracranial hypertension and dizziness, incoordination with ataxic gait, and acute confusion 5 months prior to admission. Laboratory examinations and chest roentgenogram were normal. Postcontrast T1-weighted MRI of the brain revealed a multiple ring-enhancing cerebellar, brain stem and parietal lobe lesions, and meningeal contrast enhancement. Cerebrospinal fluid culture was positive for H. capsulatum species complex, which was confirmed by phylogenetic analysis. Thirteen years after the diagnosis and treatment, there was no H. capsulatum recurrence; sequels related to complications due to the ventriculoperitoneal shunt. This case shows a primary neurological presentation of cerebral histoplasmosis, without meningitis or disseminated disease in nonimmune-compromised patient. The authors propose a categorization of the diagnosis of CNS histoplasmosis. Routine diagnostics of sibling species within the H. capsulatum complex proved to be difficult.

Viral, bacterial, and fungal infections of the oral mucosa: Types, incidence, predisposing factors, diagnostic algorithms, and management

For millions of years, microbiota residing within us, including those in the oral cavity, coexisted in a harmonious symbiotic fashion that provided a quintessential foundation for human health. It is now clear that disruption of such a healthy relationship leading to microbial dysbiosis causes a wide array of infections, ranging from localized, mild, superficial infections to deep, disseminated life-threatening diseases. With recent advances in research, diagnostics, and improved surveillance we are witnessing an array of emerging and re-emerging oral infections and orofacial manifestations of systemic infections. Orofacial infections may cause significant discomfort to the patients and unnecessary economic burden. Thus, the early recognition of such infections is paramount for holistic patient management, and oral clinicians have a critical role in recognizing, diagnosing, managing, and preventing either new or old orofacial infections. This paper aims to provide an update on current understanding of well-established and emerging viral, bacterial, and fungal infections manifesting in the human oral cavity.

A Unique Case of Cryptococcus and Histoplasmosis Co-infection in an HIV-negative Male on Chronic Steroid Therapy

Histoplasmosis and cryptococcosis are systemic fungal diseases frequently encountered in immunocompromised hosts, particularly in patients with HIV/AIDS with low CD4 counts. However, co-infection with histoplasmosis and cryptococcosis is an uncommon clinical scenario, hence carrying the risk of under diagnosis by medical professionals. For instance, when one infection is identified, most health professionals will have a low suspicion for an additional co-infection. Here, we report the case of a 71-year-old gentleman with a new diagnosis of myasthenia gravis (MG) requiring recent steroid therapy who presented with recurrent respiratory symptoms despite treatment for community acquired pneumonia. Bronchoscopy and bronchoalveolar lavage (BAL) were performed; BAL samples revealed presence of Cryptococcus neoformans and histoplasma antigen (Ag). Serum cryptococcal Ag and urine histoplasma Ag returned positive as well. The patient then required inpatient treatment with amphotericin B, with eventual transition to oral fluconazole at discharge. Pulmonology and Infectious disease consults assisted in appropriate diagnosis and management of this rare presentation. Given the high prevalence of immunocompromised states in a myriad of medical co-morbidities, it is important to highlight this case to create awareness regarding possibility of concomitant systemic fungal diseases.

Catheter based treatments for fibrosing mediastinitis

Fibrosing mediastinitis is a rare, often debilitating and potentially lethal disease characterized by an exuberant fibroinflammatory response within the mediastinum. Patients typically present with insidious symptoms related to compression of adjacent structures including the esophagus, heart, airways, and cardiac vessels. Fibrosing mediastinitis is most often triggered by Histoplasmosis infection; however, antifungal and anti-inflammatory therapies are largely ineffective. While structural interventions aimed at alleviating obstruction can provide significant palliation, surgical interventions are challenging with high mortality and clinical experience with percutaneous interventions is limited. Here, we will review the presentation, natural history, and treatment of fibrosing mediastinitis, placing particular emphasis on catheter-based therapies.

Environmental and Wilderness-Related Risk Factors for Histoplasmosis: More Than Bats in Caves

INTRODUCTION

Histoplasma capsulatum is a dimorphic fungus that causes histoplasmosis, a sporadic endemic mycosis with environmental, occupational, and wilderness exposure-related risk factors. The objectives of this review are to describe these risk factors, to alert clinicians to the different presenting manifestations of histoplasmosis, and to recommend effective management and prevention strategies.

METHODS

Internet search engines were queried with keywords to select articles for review over the study period, 1950 to 2018. Articles selected for review included case series, epidemiologic analyses of surveillance data, clinical and laboratory updates, immunologic investigations, and observational and longitudinal studies. Articles excluded from review included systemic mycosis reviews and clinicopathologic conference reports.

RESULTS

The principal transmission mechanism of histoplasmosis is by inhalation of spores aerosolized by soil disruption, resulting in pneumonic infections ranging from asymptomatic to disseminated. Although histoplasmosis is more common in endemic regions, nonendemic regions have reported increasing autochthonous and imported cases. Immunocompromised persons are at significantly increased risks of contracting histoplasmosis. Environmental and wilderness-related risk factors for histoplasmosis include bird and bat watching, cave and cave entrance exploration, and bamboo removal and burning. Occupational risk factors for histoplasmosis include road construction, roofing, bridge and water tower work, demolition, and masonry.

CONCLUSIONS

Histoplasmosis can result in considerable morbidity. Increased awareness of disease risk factors among the public and the international healthcare community will improve the timely diagnosis and treatment of histoplasmosis and prevent disease progression and dissemination.

Histoplasmosis of the Head and Neck in the Immunocompetent Patient: Report of 2 Cases

Histoplasmosis of the head and neck is rarely seen in immunocompetent patients. We report 2 new cases of histoplasmosis of the head and neck in immunocompetent patients, one an 80-year-old man and the other a 57-year-old man. The older man presented with oral cavity histoplasmosis; his symptoms included pain, dysphagia, and ulcerative lesions. The younger man had laryngeal histoplasmosis, which resulted in hoarseness and dyspnea. We discuss the methods of diagnosis and the classic findings in histoplasmosis, including the microscopic appearance of caseating granulomas, the results of periodic acid–Schiff staining and Gomori staining, and antibody detection of histoplasmosis. We also review the treatment options with antifungals, including amphotericin B and the oral conazole drugs. With an accurate diagnosis and proper treatment, both of our patients recovered well and their symptoms resolved. Because their symptoms overlapped with those of other, more common disease processes, an accurate diagnosis of these patients was essential to treating their infection.

Recurrent Pneumonia due to Fibrosing Mediastinitis in a Teenage Girl: A Case Report with Long-Term Follow-Up

A teenage girl was evaluated for recurrent right pneumonia. The evaluation revealed a calcified mediastinal mass that compressed the right intermediate and middle lobar bronchi, as well as the right pulmonary artery and veins. The clinical picture together with imaging studies and borderline positive serology testing suggested a diagnosis of fibrosing mediastinitis associated with histoplasmosis. This rare condition is characterized by the local proliferation of invasive fibrous tissue within the mediastinum due to a hyperimmune reaction to Histoplasma capsulatum. Antifungal and anti-inflammatory therapies are usually ineffective, and surgical intervention contains a high morbidity risk. Palliative surgery and stenting of the compressed airway have been suggested. In the past, the prognosis was thought to be poor, but recent studies demonstrate a more positive outcome. Our patient had been radiologically and functionally stable under follow-up for over thirteen years and has married and delivered two healthy children, both following an uneventful pregnancy.

Fatal gastrointestinal histoplasmosis 15 years after orthotopic liver transplantation

We report a case of ileo-colonic Histoplasmosis without apparent respiratory involvement in a patient who had previously undergone an orthotopic liver transplant (OLT) for primary biliary cholangitis 15 years earlier. The recipient lived in the United Kingdom, a non-endemic region for Histoplasmosis. However, she had previously lived in rural southern Africa prior to her OLT. The patient presented with iron deficiency anaemia, diarrhoea, abdominal pain and progressive weight loss. She reported no previous foreign travel, however, it later became known that following her OLT she had been on holiday to rural southern Africa. On investigation, a mild granulomatous colitis primarily affecting the right colon was identified, that initially improved with mesalazine. Her symptoms worsened after 18 mo with progressive ulceration of her distal small bowel and right colon. Mycobacterial, Yersinia, cytomegalovirus and human immunodeficiency virus infections were excluded and the patient was treated with prednisolone for a working diagnosis of Crohn’s disease. Despite some early symptom improvement following steroids, there was subsequent deterioration with the patient developing gram-negative sepsis and multi-organ failure, leading to her death. Post-mortem examination revealed that her ileo-colonic inflammation was caused by Histoplasmosis.

Natural Antimicrobial Peptides as Inspiration for Design of a New Generation Antifungal Compounds

Invasive fungal infections are associated with high mortality rates, despite appropriate antifungal therapy. Limited therapeutic options, resistance development and the high mortality of invasive fungal infections brought about more concern triggering the search for new compounds capable of interfering with fungal viability and virulence. In this context, peptides gained attention as promising candidates for the antimycotics development. Variety of structural and functional characteristics identified for various natural antifungal peptides makes them excellent starting points for design novel drug candidates. Current review provides a brief overview of natural and synthetic antifungal peptides.

Gastrointestinal Histoplasmosis: A Case Series

Histoplasmosis is an invasive mycosis caused by inhalation of the spores of dimorphic fungi Histoplasma capsulatum. The disease manifests in the lung as acute or chronic pulmonary histoplasmosis and in severe cases gets disseminated in multiple organs like skin, adrenal gland, central nervous system, lymph node, liver, spleen, bone marrow, and gastrointestinal tract. It occurs most commonly in immunodeficient patients like HIV-positive patients and transplant recipients, while immunocompetent hosts are affected rarely. In cases of gastrointestinal histoplasmosis, the samples are collected for culture and biopsy should be sent for histopathological examination for definitive diagnosis. We conducted a retrospective study of colonic biopsies performed in the department of gastroenterology in a tertiary care hospital of north India from January 2014 to December 2015. Five cases of colonic histoplasmosis were diagnosed on histopathology out of which 4 patients were from north India while 1 patient was from Myanmar. The patients presented with various complaints, including loose stools, diarrhea, altered bowel habits, and gastrointestinal bleeding. The prognosis is very good after early and aggressive treatment while the disease is fatal if it remains untreated. In our study, 2 patients died within few days of diagnosis due to delay in the diagnosis, dissemination, and associated complications. Other patients were started on amphotericin B deoxycholate and are under follow-up. An early diagnosis of gastrointestinal histoplasmosis is important as appropriate treatment leads to long-term survival while untreated cases are almost fatal.

Management of Opportunistic Infections in Solid-Organ Transplantation

Solid-organ transplantation is often the last alternative in many patients with end-stage organ disease. Although advances in immunosuppressive regimens, surgical techniques, organ preservation, and overall management of transplant recipients have improved graft and patient survival, infectious complications remain problematic. Bacterial, fungal, viral, and parasitic infections are implicated after transplantation depending on numerous factors, such as degree of immunosuppression, type of organ transplant, host factors, and period after transplantation. Proper prophylactic and treatment strategies are imperative in the face of chronic immunosuppression, nosocomial and community pathogens, emerging drug resistance, drug-drug interactions, and medication toxicities. This review summarizes the pathophysiology, incidence, prevention, and treatment strategies of common post-transplant infections.

Prevalence and lethality among patients with histoplasmosis and AIDS in the Midwest Region of Brazil

Histoplasmosis is a systemic mycosis that is considered an important public health problem. In this work, we performed a descriptive, observational, cross-sectional and retrospective study with a secondary data analysis of medical records from 2000 to 2012 at a tertiary hospital. The study sample consisted of 275 patients with laboratory-confirmed Disseminated Histoplasmosis (DH)/AIDS. The results showed that the prevalence of DH associated with AIDS was 4.4%. The majority of patients were young adult men with fever in 84.2%, cough in 63.4%, weight loss in 63.1%, diarrhoea in 44.8% and skin manifestations in 27.6% of patients. In the overall cohort, the CD4 counts were low, but not significantly different in survivors and non-survivors. Higher levels of urea and lower levels of haemoglobin and platelets were observed in non-survivor patients (<.05). The global lethality was 71.3% (196/275). The results with high prevalence and lethality highlight the need to adopt measures to facilitate early diagnosis, proper treatment and improved prognosis.

Fungal Opportunistic Infections in HIV Disease

Fungal pathogens can lead to many of the complications seen in advanced HIV disease and are commonly identified in HIV-infected populations with decreased immune function. Common fungal organisms affecting individuals with AIDS include Cryptococcus neoformans, various Candida species, and Histoplasma capsulatum. While infection with these organisms can be fatal, appropriate identification and management of the condition can result in reduced mortality and the opportunity for effectivemanagement of HIV disease with highly active antiretroviral therapy. This article describes the clinical presentation and treatment of 3 fungal infections common in the immunocompromised individual with AIDS. Current antifungal therapy for themanagement of these infections is discussed. In addition, the role of newer antifungal agents in the setting of these conditions is reviewed.

Isolated Pancreatic Histoplasmosis: An Unusual Suspect of Pancreatic Head Mass in an Immunocompetent Host

Histoplasmosis is endemic to the Mississippi and Ohio River valley regions in the US. It usually affects patients with underlying immunodeficiency but can also be seen in immunocompetent hosts. Although gastrointestinal involvement is common in the setting of disseminated histoplasmosis, isolated gastrointestinal involvement is uncommon. We report a case of isolated pancreatic histoplasmosis in an immunocompetent patient, presenting as painless jaundice and pancreatic head mass.

Diseases Transmitted by Birds

Although many people these days actually work very hard at leisure time activities, diseases are most commonly acquired from birds during the course of work in the usual sense of the term, not leisure. However, travel for pleasure to areas where the diseases are highly endemic puts people at risk of acquiring some of these bird-related diseases (for example, histoplasmosis and arbovirus infections), as does ownership of birds as pets (psittacosis).

Characterization of host and microbial determinants in individuals with latent tuberculosis infection using a human granuloma model

Granulomas sit at the center of tuberculosis (TB) immunopathogenesis. Progress in biomarkers and treatment specific to the human granuloma environment is hindered by the lack of a relevant and tractable infection model that better accounts for the complexity of the host immune response as well as pathogen counterresponses that subvert host immunity in granulomas. Here we developed and characterized an in vitro granuloma model derived from human peripheral blood mononuclear cells (PBMCs) and autologous serum. Importantly, we interrogated this model for its ability to discriminate between host and bacterial determinants in individuals with and without latent TB infection (LTBI). By the use of this model, we provide the first evidence that granuloma formation, bacterial survival, lymphocyte proliferation, pro- and anti-inflammatory cytokines, and lipid body accumulation are significantly altered in LTBI individuals. Moreover, we show a specific transcriptional signature of Mycobacterium tuberculosis associated with survival within human granuloma structures depending on the host immune status. Our report provides fundamentally new information on how the human host immune status and bacterial transcriptional signature may dictate early granuloma formation and outcome and provides evidence for the validity of the granuloma model and its potential applications.

IMPORTANCE

In 2012, approximately 1.3 million people died from tuberculosis (TB), the highest rate for any single bacterial pathogen. The long-term control of TB requires a better understanding of Mycobacterium tuberculosis pathogenesis in appropriate research models. Granulomas represent the characteristic host tissue response to TB, controlling the bacilli while concentrating the immune response to a limited area. However, complete eradication of bacteria does not occur, since M. tuberculosis has its own strategies to adapt and persist. Thus, the M. tuberculosis-containing granuloma represents a unique environment for dictating both the host immune response and the bacterial response. Here we developed and characterized an in vitro granuloma model derived from blood cells of individuals with latent TB infection that more accurately defines the human immune response and metabolic profiles of M. tuberculosis within this uniquely regulated immune environment. This model may also prove beneficial for understanding other granulomatous diseases.

In vitro antifungal susceptibility profile and correlation of mycelial and yeast forms of molecularly characterized Histoplasma capsulatum strains from India

The antifungal susceptibility profiles of the mycelial and yeast forms of 23 Histoplasma capsulatum strains from pulmonary and disseminated histoplasmosis patients in India are reported here. The MIC data of this dimorphic fungus had good agreement between both forms for azoles, amphotericin B, and caspofungin. Therefore, the use of mycelial inocula for H. capsulatum antifungal susceptibility testing is suggested, which is less time-consuming vis-à-vis the yeast form, which requires 6 to 8 weeks for conversion.

Cognitive impairment and memory loss associated with histoplasmosis: a case study

Histoplasmosis is a rare disease caused by inhalation of the fungus Histoplasma capsulatum. It can spread via cerebral circulation to the central nervous system as a manifestation of a disseminated infection; particularly in patients with immune suppression, which can result in isolated ring-enhancing lesions and inflammation in the brain. Of the reported disseminated histoplasmosis cases (approximately 1 in 2000 per year), only 5-20% have evidence of central nervous system involvement. This paper reviews a single case study of a 57-year-old female diagnosed with disseminated CNS histoplasmosis. Patient's complaints included reduced short-term memory, word-finding problems, and difficulty organizing, making decisions, getting lost while driving, recalling names, retaining information while reading, and slowed processing speed. There was also a history of mild depression and anxiety. Direct testing revealed deficits in multiple cognitive domains including complex attention, processing speed, semantic fluency, visual scanning, motor speed, set-shifting, naming, nonverbal memory, and verbal memory. Neuropsychological deficits suggest cortical and subcortical brain dysfunction, including anterior, temporal, and mesial-temporal regions. This case illustrates the need for neuropsychologists to understand histoplasmosis, the related pathophysiology, and the neuropsychological impact; particularly with the potential for delayed progression.

Disseminated histoplasmosis in HIV-infected patients: determinants of relapse and mortality in a north-eastern area of Brazil

Many relapses and deaths resulting from disseminated histoplasmosis (DH) in acquired immunodeficiency syndrome (AIDS) patients have been observed in an endemic area in north-eastern Brazil. The objective of this study was to evaluate the risk factors associated with the clinical outcomes of DH/AIDS coinfection in patients from the state of Ceará, Brazil. A retrospective cohort of AIDS patients, after their hospital discharge due to first DH episode in the period 2002-2008, was followed until December 31, 2010, to investigate the factors associated with relapse and mortality. A total of 145 patients were evaluated in the study. Thirty patients (23.3%) relapsed and the overall mortality was 30.2%. The following variables were significantly (P < 0.05) associated with relapse and overall mortality (univariate analysis): non-adherence to highly active antiretroviral therapy (HAART), irregular use of an antifungal, non-recovery of the CD4+ count and having AIDS before DH; histoplasmosis relapse was also significantly associated with mortality. In the multivariate analysis, non-adherence to HAART was the independent risk factor that was associated with both relapse (Adj OR = 6.28) and overall mortality (Adj OR = 8.03); efavirenz usage was discovered to be significant only for the overall mortality rate (Adj OR = 4.50). Adherence to HAART was the most important variable that influenced the outcomes in this specific population.

Recent advances in antifungal pharmacotherapy for invasive fungal infections

Invasive fungal infections carry significant morbidity and mortality. Candida species have become one of the most frequent causes of bloodstream infections, and infections caused by molds such as Aspergillus are becoming more frequent in immunocompromised patients. As this population grows, more invasive fungal infections can be anticipated. In the past, treatment options have been limited for many of these infections due to toxicity and efficacy concerns with the available antifungals. Fortunately, the past few years have brought exciting developments in antifungal pharmacotherapy. Lipid-based formulations of amphotericin B were introduced in the 1990s to attenuate adverse effects caused by amphotericin B deoxycholate (Fungizone, Bristol-Myers Squibb). Most recently, the echinocandins have been added to our antifungal regimen with the introduction of caspofungin (Cancidas, Merck and Co.) and voriconazole (Vfend, Pfizer), a new triazole, has come to market. The introduction of the echinocandins has invigorated the discussion about combination antifungal therapy. Evidence-based studies using these new agents are accumulating, and they are assuming important roles in the pharmacotherapy of invasive fungal infections in seriously ill and complex patients.

Infectious Diseases

The objectives of this chapter are to provide a brief understanding of the following:1.

Clinical evaluation of infectious diseases and altered immune disorders, including physical examination and laboratory studies

2.

Various infectious disease processes, including etiology, pathogenesis, clinical presentation, and management

3.

Commonly encountered altered immune disorders, including etiology, clinical presentation, and management

4.

Precautions and guidelines that a physical therapist should implement when treating a patient with an infectious disease process or altered immunity

Histoplasmosis in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS): multicenter study of outcomes and factors associated with relapse

Although discontinuation of suppressive antifungal therapy for acquired immunodeficiency syndrome (AIDS)-associated histoplasmosis is accepted for patients with immunologic recovery, there have been no published studies of this approach in clinical practice, and minimal characterization of individuals who relapse with this disease. We performed a multicenter retrospective cohort study to determine the outcome in AIDS patients following discontinuation of suppressive antifungal therapy for histoplasmosis. Ninety-seven patients were divided into a physician-discontinued suppressive therapy group (PD) (38 patients) and a physician-continued suppressive therapy group (PC) (59 patients). The 2 groups were not statistically different at baseline, but at discontinuation of therapy and at the most recent follow-up there were significant differences in adherence to therapy, human immunodeficiency virus (HIV) RNA, and urinary Histoplasma antigen concentration. There was no relapse or death attributed to histoplasmosis in the PD group compared with 36% relapse (p < 0.0001) and 5% death (p = 0.28) in the PC group. Relapse occurred in 53% of the nonadherent patients but not in the adherent patients (p < 0.0001). Sixty-seven percent of patients with initial central nervous system (CNS) histoplasmosis relapsed compared to 15% of patients without CNS involvement (p = 0.0004), which may be accounted for by nonadherence. In addition, patients with antigenuria above 2.0 ng/mL at 1-year follow-up were 12.82 times (95% confidence interval, 2.91-55.56) more likely to relapse compared to those with antigenuria below 2.0 ng/mL. Discontinuation of antifungal therapy was safe in adherent patients who completed at least 1 year of antifungal treatment, and had CD4 counts >150 cells/mL, HIV RNA <400 c/mL, Histoplasma antigenuria <2 ng/mL (equivalent to <4.0 units in second-generation method), and no CNS histoplasmosis.

Histoplasmosis mimicking primary lung cancer or pulmonary metastases

OBJECTIVE

To describe the main clinical and radiological characteristics of patients with histoplasmosis mimicking lung cancer.

METHODS

This was a retrospective descriptive study based on the analysis of the medical records of the 294 patients diagnosed with histoplasmosis between 1977 and 2011 at the Mycology Laboratory of the Santa Casa Sisters of Mercy Hospital of Porto Alegre in the city of Porto Alegre, Brazil. The diagnosis of histoplasmosis was established by culture, histopathological examination, or immunodiffusion testing (identification of M or H precipitation bands). After identifying the patients with macroscopic lesions, as well as radiological and CT findings consistent with malignancy, we divided the patients into two groups: those with a history of cancer and presenting with lesions mimicking metastases (HC group); and those with no such history but also presenting with lesions mimicking metastases (NHC group).

RESULTS

Of the 294 patients diagnosed with histoplasmosis, 15 had presented with lesions mimicking primary neoplasia or metastases (9 and 6 in the HC and NHC groups, respectively). The age of the patients ranged from 13 to 67 years (median, 44 years). Of the 15 patients, 14 (93%) presented with pulmonary lesions at the time of hospitalization.

CONCLUSIONS

The clinical and radiological syndrome of neoplastic disease is not confined to malignancy, and granulomatous infectious diseases must therefore be considered in the differential diagnosis.

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.

What is the success of treatment of hip and knee candidal periprosthetic joint infection?

BACKGROUND

Fungal infection at an arthroplasty site is rare and poses a therapeutic challenge. To the best of our knowledge, no reports have been published thus far on the success rate of prosthesis reimplantation after fungal prosthetic joint infections.

QUESTIONS/PURPOSES

We asked: (1) What is the success rate in terms of infection eradication using a two-stage exchange arthroplasty in patients with hip or knee fungal periprosthetic joint infections, particularly focusing on Candida infections? (2) What patient-, infection-, and treatment-related variables are associated with the success or failure of treatment?

METHODS

From January 2000 to December 2010, 16 patients with hip or knee candidal periprosthetic joint infections were treated with two-stage exchange arthroplasty at our institute. Treatment success was defined as a well-functioning joint without relapse of candidal infection after prosthesis reimplantation, while treatment failure was defined as uncontrolled or relapse of candidal infection or mortality. Variables, including age, sex, comorbidities, microbiology, antimicrobial agents used, and operative methods, were analyzed. Minimum followup was 28 months (mean, 41 months; range, 28-90 months).

RESULTS

At latest followup, the treatment failed to eradicate the infection in eight of the 16 patients, and there were four deaths related to fungemia. Four patients required permanent resection arthroplasty owing to uncontrolled or recurrent candidal infections. All eight patients (50% successful rate) who had their infections eradicated and successful prosthesis reimplantation had prolonged treatment with oral fluconazole before (mean, 8 months) and after (mean, 2.2 months) prosthesis reimplantation. The antifungal therapy correlated with successful treatment. Renal insufficiency, hypoalbuminemia, anemia, and chronic obstructive pulmonary disease were significantly more prevalent in the treatment-failure group than in the treatment-success group.

CONCLUSIONS

Half of the patients treated with two-stage exchange arthroplasty for fungal periprosthetic joint infections had recurrence or lack of control of the infection. A prolonged antifungal therapy appeared to be essential for successful treatment of candidal periprosthetic joint infections. The presence of renal insufficiency, hypoalbuminemia, anemia, or chronic obstructive pulmonary disease might be associated with a poor outcome.

Brazilian guidelines for the management of candidiasis - a joint meeting report of three medical societies: Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia and Sociedade Brasileira de Medicina Tropical

Candida infections account for 80% of all fungal infections in the hospital environment, including bloodstream, urinary tract and surgical site infections. Bloodstream infections are now a major challenge for tertiary hospitals worldwide due to their high prevalence and mortality rates. The incidence of candidemia in tertiary public hospitals in Brazil is approximately 2.5 cases per 1000 hospital admissions. Due to the importance of this infection, the authors provide a review of the diversity of the genus Candida and its clinical relevance, the therapeutic options and discuss the treatment of major infections caused by Candida. Each topography is discussed with regard to epidemiological, clinical and laboratory diagnostic and therapeutic recommendations based on levels of evidence.

Chronic and subacute meningitis

PURPOSE OF REVIEW

This article describes the background, clinical presentation, diagnosis, and treatment of selected etiologies of subacute and chronic meningitis. Key diagnostic considerations when evaluating a patient presenting with chronic inflammation of the CNS are discussed, and several specific infectious, neoplastic, and autoimmune etiologies are reviewed in detail.

RECENT FINDINGS

With recent advancement in serologic and CSF diagnostic testing, specific infectious, neoplastic, or autoimmune etiologies of chronic meningitis can be identified. Eliminating previous diagnostic uncertainty of chronic inflammation in the CNS has led to rapid and specific treatment regimens that ultimately improve patient outcomes. Recent advances in imaging have also aided clinicians in both their diagnostic approach and the detection of inflammatory complications such as hydrocephalus, hemorrhage, and ischemic stroke.

SUMMARY

Meningitis is defined as inflammation involving the meninges of the brain and spinal cord. Meningitis can be categorized as acute, subacute, or chronic based on duration of inflammation. This article focuses on the most common causes of subacute and chronic meningitis. Chronic meningitis is commonly defined as inflammation evolving during weeks to months without resolution of CSF abnormalities. Determining the time course of meningitis is important for creating a differential diagnosis. Most organisms causing acute meningitis rarely persist more than a few weeks. Although numerous etiologies of subacute and chronic meningitis have been identified, this article focuses on the most common etiologies: (1) infectious, (2) autoimmune, and (3) neoplastic.

Photoletter to the editor: Disseminated histoplasmosis with initial oral manifestations

Histoplasmosis is a systemic fungal disease that may present in a variety of clinical manifestations. Involvment of the oral mucosa is very rare and may occur as part of disseminated histoplasmosis or as isolated involvement. We present a patient with disseminated histoplasmosis, in whom oral lesions were the initial manifestation of the disease.

Systemic mycoses in immunodepressed patients (AIDS)

Infectious and noninfectious skin diseases are observed in about 90% of HIV patients, and their incidence increases and is more severe as the immune system weakens. Cutaneous manifestations are considered good clinical predictors for the immunological condition of the patient with AIDS and the introduction of highly effective antiretroviral therapy totally changed the prognosis of the mycoses, among other diseases associated with AIDS, permitting longer survival and acceptable level of quality of life for these patients. This contribution describes the systemic mycoses that are more frequent in the seropositive population, that is, patients with HIV/AIDS, which are cryptococcosis, histoplasmosis, coccidioidomycosis, blastomycosis, paracoccidioidomycosis, sporotrichosis, penicilliosis, and aspergillosis. Their causative agents, mode of transmission, clinics, laboratorial diagnosis and therapy, in the aspects related to immunodepressed patients, are reviewed.