Histoplasmosis presenting as bilateral adrenal masses: cytomorphological diagnosis of three cases

Bilateral adrenal histoplasmosis presenting as adrenal mass mimicking malignancy in an immunocompetent patient

We report a case of a 78-year-old immunocompetent man who presented with worsening fatigue and lethargy for one month. He had also been complaining of cough and SOB for two months which had been attributed to his underlying COPD and possible pneumonia. CT showed bilateral pleural effusions, ground-glass opacities, cirrhosis, splenomegaly and bilateral adrenal masses which was highly suspicious for malignancy. After pheochromocytoma was ruled out, EUS-FNA guided biopsy was performed on the left adrenal gland. Histology was positive for yeast cells, with fungal staining (PAS) revealing narrow-based budding compatible with Histoplasma. The patient was treated with amphotericin and itraconazole. Our case is unique as he presented with hepatosplenomegaly, which is reported in less than a quarter of cases. Although typically a diagnosis in immunocompromised patients, a high index of clinical suspicion is required to diagnose disseminated histoplasmosis in an immunocompetent patient. The gold standard for diagnosis is fungal tissue culture. However results may take up to weeks. EUS-FNA guided biopsy of adrenal glands can aid in early definitive diagnosis and management.

Current perspective of adrenal histoplasmosis in India: A prospective study in a tertiary care hospital, Eastern India

PURPOSE

Adrenal histoplasmosis (AH) is an uncommon form of disseminated histoplasmosis caused by the dimorphic fungus Histoplasma capsulatum. Though, India is considered to be a non-endemic area for histoplasmosis, a high rise of AH cases is reported currently from various parts of India. Our study aimed to evaluate the current perspective of adrenal histoplasmosis in India by reviewing its clinical course, differential diagnosis, treatment, and mortality of our eleven confirmed cases of AH along with the review of authentic reported AH cases from India.

MATERIAL &METHOD

Clinical materials were taken from radiologically suspected all 15 cases either with unilateral or bilateral adrenal enlargement, referred between 2018 and 2020 for microbiological investigations. Fungal stain and fungal culture along with other tests for possible differential diagnosis with AH were conducted.

RESULT

Out of fifteen incidentaloma detected by radio-imaging, eleven cases of AH had been diagnosed in our hospital with yield of Rhodotorula spp. in one mimicking case. Nine of them were male (82%) and all were HIV nonreactive, which corroborates with the literature review. All of them had nonspecific clinical presentation of chronic abdominal pain, fever, weight loss, and anorexia. Four developed primary adrenal insufficiency, which are similar to the literature review (41%). On treatment with itraconazole and/or amphotericin B, all patients survived except one lost in follow-up.

CONCLUSION

Male preponderance and non-compromised immune status are two special characteristics of most AH though reasons are ill understood. So, mycological investigations are to be done for every such case.

A Twenty-First-Century Perspective of Disseminated Histoplasmosis in India: Literature Review and Retrospective Analysis of Published and Unpublished Cases at a Tertiary Care Hospital in North India

PURPOSE

Published literature lacks systematic studies on disseminated histoplasmosis in India, and previous reviews on its epidemiology in India were conducted two decades back. Thus, we review the Indian studies published in this century to understand the recent epidemiology of histoplasmosis in India and do a retrospective analysis of all cases diagnosed at our institute.

METHODS

A literature of review search was done in Pubmed/Medline and Scopus. Studies published during January 2001-December 2015 were considered along with retrospective analysis of cases presented to us. A distinction was made in the clinical presentation of immunocompetent and immunocompromised cases.

RESULTS

Ninety-five included studies described 204 cases, and 10 cases from our retrospective analysis were included. The mean age at presentation was 45.1 ± 15.4 years [range 3-83, median 45, interquartile range 37-55], and male-to-female ratio was 6:1. Most cases were reported from northern and northeastern states of India along the rivers Ganges, Yamuna and Brahmaputra and in people associated with agricultural activity. About 33% of cases were immunocompromised, out of which immunosuppression due to HIV was seen in 72% cases. The mean age of presentation was significantly lower in immunocompromised cases (37.9 vs. 49.2 years; p < 0.00001, Mann-Whitney test), and mortality was also higher (10 vs. 27.5%, p = 0.01, Fisher's exact test). Adrenal involvement was in significantly higher proportion of immunocompetent patients compared to immunocompromised population.

CONCLUSIONS

Disseminated histoplasmosis is being increasingly recognized in India. There is a need to undertake well-designed, analytical studies utilizing appropriate diagnostic modalities to understand the epidemiology of this neglected disease in proper perspective.

Bilateral adrenal histoplasmosis in an immunocompetent man from Texas

Disseminated histoplasmosis affecting the adrenal gland(s) of immunocompetent adults is a very rare infection. Here, we present a case of bilateral adrenal histoplasmosis in an immunocompetent, 62-year-old gentleman from Texas along with a brief review of the published literature. Given the risk of patient decompensation secondary to adrenal insufficiency and the wide availability of effective treatments, adrenal histoplasmosis must be considered even in immunocompetent adults who acquire adrenal masses.