Histoplasmosis as an isolated liver lesion: review and surgical therapy

Histoplasmosis is the most common cause of fungal infection in the Ohio River Valley of the United States. Ninety-nine per cent of patients exposed to histoplasmosis develop only subclinical infections. Liver involvement is common in disseminated histoplasmosis, which usually originates in the lungs. There has been only one prior case described in the literature of histoplasmosis presenting as an isolated liver mass. We report a rare case that presented as a solitary right-sided liver lesion invading the diaphragm, with review of the literature for therapy of histoplasmosis of the liver.

Progressive gastrointestinal histoplasmosis leading to colonic obstruction two years after initial presentation

A 37-yr-old man from Ecuador presented with abdominal pain, diarrhea, and weight loss. Endoscopy revealed duodenal histoplasmosis. The patient improved with antifungal therapy but was readmitted 2 yr later with diarrhea and fever. Colonoscopy revealed histoplasmosis lesions, including a constricting transverse colon lesion. The patient refused surgery and died of colonic perforation. We discuss the diagnosis and management of gastrointestinal histoplasmosis in this report.

Open retinotomy after submacular surgery

PURPOSE

To report persistent open retinotomy after submacular surgery in patients with presumed ocular histoplasmosis.

METHODS

Retrospective review. Five eyes of 5 patients with submacular choroidal neovascularization associated with presumed ocular histoplasmosis had pars plana vitrectomy, detachment of the posterior hyaloid, and surgical removal of the neovascular complex using the small retinotomy technique. All eyes were followed postoperatively for a mean of 47 months (range, 36 to 73 months).

RESULTS

In all 5 patients, the open retinotomy persisted after submacular surgery. No complications were associated with the presence of an open retinotomy.

CONCLUSION

Persistence of the retinotomy site may occur after submacular surgery. With follow-up of at least 36 months, no significant complication is associated with an open retinotomy site.

[Subretinal surgery for choroidal neovascularization]

BACKGROUND

Ten years have passed since subretinal surgery for choroidal neovascularization (CNV) was developed. Many reports regarding the visual outcome after subretinal surgery have been published, which have revealed the role of the subretinal surgery, including long-term visual outcome and surgical complications.

METHOD

Reports associated with subretinal surgery published in the past decade were used to clarify the indication for surgery, visual outcome, and surgical complications.

RESULTS

The visual prognosis for patients with surgically excited CNV is variable, depending on the underlying disease. Patients with widespread defects of Bruch's membrane and retinal pigment epithelium (RPE), such as age-related macular degeneration, are probably not good candidates for surgery from the standpoint of recovering good visual acuity. On the other hand, patients with focal abnormalities in Bruch's membrane and the RPE, such as presumed ocular histoplasmosis or idiopathic CNV, may be good candidates for surgery. However, it has not been proved that subretinal surgery is superior to photocoagulation or observation.

CONCLUSIONS

For the time being, we have to select patients for subretinal surgery on the basis of published reports. The Submacular Surgery Trial now being held in the United States will evaluate the role of subretinal surgery in the management of patients with choroidal neovascularization.

Choroidal neovascularization with granulomatous inflammation in ocular histoplasmosis syndrome

PURPOSE

To report pathologic examination of an excised choroidal neovascular membrane in a patient with ocular histoplasmosis syndrome that demonstrated granulomatous inflammation.

METHOD

Case report. A 50-year-old woman with sudden vision loss in her left eye demonstrated clinical and fluorescein angiographic findings characteristic of choroidal neovascularization secondary to ocular histoplasmosis syndrome.

RESULTS

Histopathologic examination of the surgically excised choroidal neovascular membrane disclosed granulomatous inflammation.

CONCLUSIONS

This case suggests an important role of mononuclear phagocytic cells as primary mediators of angiogenesis or modifiers of choroidal neovascularization. This association of choroidal neovascularization with granulomatous inflammation did not respond to treatment with systemic corticosteroids.

The development of choroidal neovascularization in pregnancy

PURPOSE

To evaluate the possible association between the development of choroidal neovascularization (CNV) and pregnancy.

METHODS

A retrospective review was performed of the clinical records of three patients who were pregnant at the time a choroidal neovascular membrane (CNVM) was diagnosed. The clinical presentations and treatment of the CNVM occurring in association with the pregnancies are described.

RESULTS

Each patient had a decrease in visual acuity during her pregnancy: one in the first trimester, one in the second trimester, and one in the third trimester. Two patients were diagnosed with CNV related to presumed ocular histoplasmosis syndrome (POHS) and one with an idiopathic CNVM. The two-patients with POHS showed progression of CNV after childbirth. All patients received laser photocoagulation directly to the site of the CNV. The two patients with ocular histoplasmosis experienced recurrence after treatment; one received further photocoagulation treatment, and the other underwent vitrectomy with removal of the CNVM.

CONCLUSIONS

Pregnancy and the immediate postpartum period may be associated with development or recurrence of CNV in POHS or idiopathic cases. This may be related to hormonal changes during pregnancy, or the cases described may reflect only a coincidental association. This report discusses possible causal factors and mechanisms.

[Pulmonary histoplasmosis exhibiting solitary pulmonary nodule resected by thoracoscopic surgery: a case report and review of the Japanese literature]

We reported a case of pulmonary histoplasmosis showing solitary nodular shadow. A 43-year-old man was referred to our hospital because of an abnormal shadow on chest X-ray films during a routine checkup. He had traveled to Honduras for 7 days. Chest computed tomographic (CT) scans showed a 13 x 12 mm nodular shadow with unclear margin in the left upper lobe (S3). Both transbronchial lung biopsy and CT guided transcutaneous needle biopsy failed to yield a definitive diagnosis. Thoracoscopic resection of the nodule was performed due to suspicion of lung cancer. Pathologically, the nodule displayed central caseous necrosis with many round yeast-like fungi. The fungi measured 3 to 4 microns in diameter and were well-stained by Grocott stain. Immunohistochemical staining was positive for anti-Histoplasma capsulatum antibody, resulting in the final diagnosis of pulmonary histoplasmosis. The patient's postoperative course was uneventful, and no recurrence was observed. Histoplasmosis is a rare disease in Japan. However, it is important to keep imported infectious diseases in mind when examining and treating patients who have a history of travel abroad.

Pulmonary histoplasmosis in a Japanese male: report of a case

A case of pulmonary histoplasmosis, which is rare in Japan, is reported herein. A 43-year-old man who had worked in Mexico for 2 years and had come back to Japan 3 months earlier, presented at our hospital because of an abnormal shadow on his chest roentogenogram with no symptoms. His chest roentogenogram as well as chest computed tomograms revealed a 2-cm-diameter nodule in the anterior basal segment of his right lung and an enlargement of the subcarinal lymph node. Although these pictures seemed to indicate an advanced lung cancer, no malignant cells were found based on the brushing cytology findings after bronchoscopy. An exploratory thoracoscopic tumor resection and biopsy of the enlarged lymph node led to a histological diagnosis of an abscess due to histoplasma. The hospital course was uneventful. Postoperatively, amphotericin B was administered for 1 year. This is the eighth case of pulmonary histoplasmosis reported in Japan. A pulmonary nodule together with mediastinal lymphoadenopathy seems to be characteristic in these patients. Histoplasmosis should therefore be considered in the differential diagnosis, since overseas travel has now become common-place for the Japanese.

[Inflammatory pseudotumor of the lung in hilus lymph node histoplasmosis]

The article deals with the case of an inflammatory pseudotumour of the lung in conjunction with histoplasmosis of the hilar lymph glands in a 35-year-old immunocompetent woman in a non-endemic area. She had been suffering from headaches and painful swelling of the lower legs, reddening and hyperthermia for 1.5 years. In addition to the above-mentioned symptoms she also complained of a typical flush syndrome which had begun a year later. The main paraclinical finding was a round mass in the right lung in chest radiography. After considering various differential diagnostic possibilities, thoracotomy and resection of the upper lobe of the right lung were performed. The histological diagnosis of the material removed was that of an inflammatory pseudotumour of the lung, combined with histoplasmosis of the hilar lymph glands. Following a postoperative period without complications, antimycotic treatment was performed. The discussion includes whether the simultaneous occurrence of these two diseases is coincidental or whether there is a causal relation between the two. The authors also discuss various treatments with reference to the relevant literature.

Multicenter VATS experience with mediastinal tumors

BACKGROUND

The use of video-assisted thoracic surgery for diagnosis and treatment of mediastinal tumors in a multiinstitution patient population is not well understood.

METHODS

We studied 48 cases from Cancer and Leukemia Group B thoracic surgeons. Of 21 men and 27 women, aged 41 +/- 16 years, 22 patients were asymptomatic. In the others, 92% of tumor-related symptoms improved or resolved after treatment. Five tumors involved the anterior compartment, 19 the middle, and 24 the posterior compartment. Diagnoses were typical for each compartment but also included uncommon problems such as superior vena cava hemangioma and a histoplasmosis cyst causing hoarseness. Of the lesions, a biopsy of 12 was done without excision and the rest were excised completely. Fifteen were cystic and 10 were malignant (8 biopsy only). Maximal dimensions were 5.2 +/- 3.3 cm.

RESULTS

Operations were briefer for 24 posterior (93 +/- 41 min) than 5 anterior (195 +/- 46 min, p < 0.01) or 19 middle mediastinal tumors (170 +/- 78 min, p < 0.01). Although 96% had vital mediastinal relations, only six open conversions were performed because of bleeding (n = 3), large size, impaired exposure, or rib attachments, and no patient had morbidity beyond that expected for the thoracotomy. Postoperative stay was shorter for the nonconversion group (3.2 +/- 2.8 versus 5.5 +/- 2.1 days, p = 0.05), as was chest tube duration (1.7 +/- 1.4 days versus 3.2 +/- 1.9 days, p = 0.03). There were no postoperative deaths or major complications, but 7 patients had minor complications. During a mean of 20 months of surveillance (range, 1 to 52 months), one cyst recurred (asymptomatic) as did one sarcoma that was excised.

CONCLUSIONS

Video-assisted thoracic surgery is a safe technique for benign mediastinal tumors, typically those in the middle and posterior mediastinum.

[Surgery of sub-foveal neovascular membranes]

BACKGROUND

To present the functional, angiographic and electron microscopic results of 3 patients who underwent surgical removal of a subfoveolar neovascularisation. These patients are representative of the most common indications for subfoveolar surgery.

MATERIAL AND METHOD

In one case, the neovascularization originated from an old chorioretinal scar close to the macula; in another case, it was associated with high myopia; in the last case the neovascularization was coupled with an age-related macular degeneration (ARMD). The 3 removal neovascular membranes were examined by electron microscopy. Indocyanine green and fluorescein angiographies were performed in all 3 cases before and after surgery.

RESULTS

Visual recovery was excellent in the case of neovasularization and old chorioretinitis scar; it was minimal in the case of high myopia; no objective improvement was found in the case of ARMD. Electron microscopic examination did not always allow to determine accurately if the neovascularization was located in the subretinal space or under the pigment epthelium.

CONCLUSIONS

These results match those already published: surgical prognosis is the best when neovascularization is in the subretinal space and when the pigment epithelium has not been damaged by the underlying disease or by the surgical maneuvers. Electron microscopic examination is not easy to interpret.

[A tropical pulmonary nodule]

The authors report a case of american pulmonary histoplasmosis discovered by chance on a chest radiograph in a non immunocompromised patient, back from a stay in French Guyana. Confronted with the negativity of usual mycotic research, diagnosis has been made thanks to wedge excision by video-assisted thoracic surgery. The authors briefly sum up the recent facts regarding this imported infection, stressing the interest of a direct approach by surgical practices not very invasive that allow to eliminate with certainty neoplasm or tuberculosis.

Perfusion of the subfoveal choriocapillaris affects visual recovery after submacular surgery in presumed ocular histoplasmosis syndrome

PURPOSE

To determine the relationship between the visual result and perfusion of the subfoveal choriocapillaris after surgical excision of subfoveal neovascularization in presumed ocular histoplasmosis syndrome.

METHODS

We reviewed the records of 38 eyes of 37 patients with gradable postoperative fluorescein angiograms and color photographs after surgical excision of a subfoveal neovascular membrane in presumed ocular histoplasmosis syndrome. The postoperative photographs and fluorescein angiograms were graded in a masked fashion for the presence of perfusion of the subfoveal choriocapillaris. We used preoperative and postoperative best-corrected visual acuities to determine the correlation between postoperative perfusion of the subfoveal choriocapillaris and both final visual acuity and visual improvement after surgery.

RESULTS

After surgery, the subfoveal choriocapillaris was perfused in 24 of the 38 eyes (63%) and nonperfused in 14 (37%). Best-corrected visual acuity improved by at least 2 Snellen lines in 17 of the 24 perfused eyes (71%) and two of the 14 nonperfused eyes (14%) (P = .0089). Best-corrected visual acuity of 20/100 or better was achieved in 18 of the perfused eyes (75%) and four nonperfused eyes (29%) (P = .0076).

CONCLUSION

Both final visual acuity and improvement in visual acuity were correlated with postoperative perfusion of the subfoveal choriocapillaris in patients with presumed occular histoplasmosis syndrome. Development of techniques to maintain or reestablish perfusion of the subfoveal choriocapillaris after surgery may improve visual outcome in these eyes.

Small bowel obstruction from gastrointestinal histoplasmosis in acquired immune deficiency syndrome

Disseminated histoplasmosis is a rare condition that is associated with an underlying immune disorder in approximately 25 per cent of patients. It often leads to GI histoplasmosis, but when the disease predominantly affects the GI tract few, if any, pulmonary symptoms appear. Although histoplasmosis of the gastrointestinal system has been described, it rarely causes a small bowel obstruction. In fact, a recent review of the English literature revealed 77 cases of gastrointestinal histoplasmosis, with only none having clinical presentation solely involving of the jejunum and ileum in acquired immune deficiency syndrome (AIDS) patients. At the time of urgent abdominal exploration, both patients had several areas of bowel strictures with subjacent mesenteric adenopathy. They required resection of small bowel segments. Pathology examination established the diagnosis of histoplasmosis, and both patients were discharged home after antifungal therapy.

Histoplasma capsulatum necrotizing myofascitis of the upper extremity

Necrotizing myofascial fungal infections of the upper extremity is a rare event even in immunocompromised hosts. We report the course of a renal transplant patient who developed extensive necrotizing myofascial infection of an upper extremity secondary to Histoplasma capsulatum. Initial, functional, upper limb salvage was achieved after aggressive surgical debridement and high doses of amphotericin B. The patient ultimately succumbed to systemic fungal sepsis. The etiology and treatment of these infections are discussed.

Scanning laser ophthalmoscope macular perimetry in the evaluation of submacular surgery

PURPOSE

Submacular surgery for choroidal neovascularization (CNV) is under investigation in the treatment of age-related macular degeneration (AMD) and the presumed ocular histoplasmosis syndrome. Four case studies are presented to demonstrate scanning laser ophthalmoscope (SLO) testing in the pre- and postsurgical evaluation of visual function in patients with subfoveal CNV secondary to AMD, presumed ocular histoplasmosis syndrome, and submacular hemorrhage secondary to AMD.

METHODS

Patients underwent a visual assessment pre- and 6 months postoperatively, consisting of low vision visual acuity measurement, SLO macular perimetry of dense and relative scotomas, and analysis of the preferred retinal locus for fixation (PRL) location and ability.

RESULTS

Visual acuity, dense and relative scotoma size and location, and PRL location were compared; and relationships between anatomic and functional changes were observed. Decreases in scotoma size and improvement in PRL location and ability usually corresponded with improved visual acuity. Preoperative scotoma and PRL location guided retinotomy site selection.

CONCLUSION

Scanning laser ophthalmoscope macular perimetry and PRL testing may be useful adjuncts in the visual assessment of submacular surgery and may advance under-standing of the effects of submacular surgery on visual function. In addition, this testing may be used to plan location of surgical interventions for macular diseases.

[Esophageal histoplasmosis. A case report]

The authors report a case of a patient with complaint of progressive disphagia. Stenoses of lower third of esophagus was revealed by radiological and endoscopic examinations. Fungi were showed in biopsy of lesion, with demonstration of Histoplasm capsulate by tissue culture. Endoscopic dilatation was performed because especific medical treatment failed but esophageal rupture was observed. Partial esophagectomy was performed with symptoms remission.

New findings in ocular histoplasmosis

The ocular histoplasmosis syndrome consists of punched-out, atrophic chorioretinal lesions, and peripapillary scarring in the absence of vitreal inflammation. Choroidal neovascularization is the cause of significant visual loss in involved eyes and is estimated to occur in up to 5% of affected eyes. An experimental primate model has given us a better understanding of the possible etiology and pathogenesis. Laser therapy for extrafoveal and juxtafoveal choroidal neovascularization has been shown to be effective. Recent advances in surgical technique and instrumentation have demonstrated the potential for the successful treatment of subfoveal choroidal neovascularization. The surgical specimens obtained from this approach have allowed for the study of the active process of neovascularization in this disease. This report summarizes our current knowledge regarding the pathogenesis and epidemiology of ocular histoplasmosis and the treatments currently utilized in the management of its associated choroidal neovascularization.

Long-term results of laser treatment in the ocular histoplasmosis syndrome

OBJECTIVE

To determine the long-term visual outcome, rate of persistent choroidal neovascularization, and rate of recurrent choroidal neovascularization in eyes undergoing laser photocoagulation for choroidal neovascularization secondary to ocular histoplasmosis syndrome.

DESIGN AND PATIENTS

One hundred one eyes with 5 to 16 years of follow-up that presented with choroidal neovascularization secondary to ocular histoplasmosis were retrospectively evaluated. Patients were grouped according to location of choroidal neovascularization and assignment to observation or laser photocoagulation.

MAIN OUTCOME MEASURES

Visual acuity outcome and loss for all groups were compared. The rates of persistent and recurrent choroidal neovascularization for the treated eyes were also evaluated.

RESULTS

Visual acuity of 20/40 or better was obtained in 71% of eyes with treated extrafoveal choroidal neovascularization and 68% with treated juxtafoveal choroidal neovascularization. Recurrent choroidal neovascularization was observed in 23% of treated eyes during a mean follow-up of 9.6 years.

CONCLUSION

Results support the long-term benefit of photocoagulation and need for careful follow-up.