Unusual manifestations of disseminated Histoplasmosis in patients responding to antiretroviral therapy

Incidence and Trends in Immune Reconstitution Inflammatory Syndrome Associated With Histoplasma capsulatum Among People Living With Human Immunodeficiency Virus: A 20-Year Case Series and Literature Review

BACKGROUND

Histoplasmosis is among the main acquired immunodeficiency syndrome (AIDS)-defining conditions in endemic areas. Although histoplasmosis has a worldwide distribution, histoplasmosis-associated immune reconstitution inflammatory syndrome (IRIS) in people living with human immunodeficiency virus (PLHIV) is rarely reported.This study aimed to describe the incidence and features of histoplasmosis-associated IRIS in a cohort of PLHIV.

METHODS

A retrospective multicenter study was conducted in French Guiana from 1 January 1997 to 30 September 2017. The target population was represented by PLHIV who presented an episode of histoplasmosis within 6 months after antiretroviral therapy initiation. We used a consensual IRIS case definition, submitted to the agreement of 2 experts. Each case was described using a standardized questionnaire, and all patients gave informed consent.

RESULTS

Twenty-two cases of histoplasmosis-associated IRIS were included (14 infectious/unmasking and 8 paradoxical), with an overall incidence rate of 0.74 cases per 1000 HIV-infected person-years (95% confidence interval, 0.43-1.05). Mean age was 40.5 years. The ratio of males to females was 1:4. Median time to IRIS was 11 days (interquartile range 7-40 days) after antiretroviral therapy initiation. The main clinical presentation was fever, without any specific pattern, and disseminated disease. We reported 2 severe cases and partial or complete recovery at 1 month was the rule. Twenty-two cases were identified in the literature with similar characteristics.

CONCLUSIONS

Histoplasmosis-associated IRIS incidence was low but generated significant morbidity in PLHIV. In endemic areas, screening for latent or subclinical histoplasmosis should be implemented before antiretroviral therapy initiation.

Progressive disseminated histoplasmosis in the HIV population in Europe in the HAART era. Case report and literature review

INTRODUCTION

In highly endemic areas, up to 20 % of human immunodeficiency virus (HIV)-infected persons will develop progressive disseminated histoplasmosis (PDH). Europe is not endemic to histoplasmosis, and the disease is mainly found in immigrants often co-infected with HIV.

METHODS

We present a case of a patient with HIV and PDH highlighting the possible diagnostic difficulties that may arise in a non-endemic area and review the literature of histoplasmosis in the context of HIV infection with special focus on Europe.

DISCUSSION

When cellular immunity wanes (usually at CD4 T-lymphocyte counts <150 cells/μL) histoplasma infection, acquired earlier, can reactivate and disseminate. PDH is an acquired immune deficiency syndrome(AIDS)-defining disease and a life-threatening infection, with a clinical spectrum ranging from an acute, fatal course with lung infiltrates and respiratory failure, shock, coagulopathy and multi-organ failure, to a more subacute disease with focal organ involvement, pancytopenia and hepatosplenomegaly. Mortality rates remain high for untreated patients, but early diagnosis, proper antifungal treatment and early initiation of antiretroviral therapy have improved the prognosis.

CONCLUSION

European infectious diseases physicians, microbiologists and pathologists must be aware of histoplasmosis, particularly when facing HIV-infected immigrants from endemic areas. This is increasingly important due to migration and travel activities from these areas.

Pulmonary complications of immune reconstitution inflammatory syndromes in HIV-infected patients

Immune reconstitution inflammatory syndrome (IRIS) describes a paradoxical worsening of clinical status related to recovery of the immune system, as can occur after the initiation of highly active antiretroviral therapy (HAART) in HIV-infected patients. Most commonly, IRIS results from opportunistic infections that can unmask or develop paradoxical worsening following HAART. Cancers, autoimmune conditions and sarcoidosis have also been associated with IRIS. Pulmonary complications may be frequently encountered. This article reviews the types and clinical presentation of IRIS, with a focus on the pulmonary manifestations. Management and outcome of IRIS are considered.

Thoracic manifestations of immune restoration syndromes in AIDS

Immune restoration syndromes (IRS) in AIDS constitute a group of illness characterized by a pathologic inflammatory response in patients with late-stage AIDS who start highly active antiretroviral therapy. Although there is no standardized definition or therapy, IRS have partial immune restoration associated with an increase in their CD-4 cell count and a decrease in their viral load. Patients with IRS show a paradoxical reaction that is, clinical worsening rather than improvement on therapy, associated with a recognized or occult infection. Symptoms include new or worsening fever, lymphadenopathy, pulmonary, visceral, central nervous system, or cutaneous disease which may be severe and occasionally life threatening and must be differentiated from disease progression. In this paper, we review the clinical and associated thoracic imaging findings of IRS associated with specific infections including mycobacterial and fungal infections, cytomegalovirus, Pneumocystis jiroveci pneumonia and also Kaposi sarcoma and sarcoidosis. Recognition of the imaging findings in the appropriate clinical setting presents an opportunity to make a timely diagnosis. With appropriate management, IRS usually does not alter long-term prognosis.

Clinical Practice Guidelines for the Management of Patients with Histoplasmosis: 2007 Update by the Infectious Diseases Society of America

Evidence-based guidelines for the management of patients with histoplasmosis were prepared by an Expert Panel of the Infectious Diseases Society of America. These updated guidelines replace the previous treatment guidelines published in 2000 (Clin Infect Dis 2000; 30:688–95). The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them. Since 2000, several new antifungal agents have become available, and clinical trials and case series have increased our understanding of the management of histoplasmosis. Advances in immunosuppressive treatment for inflammatory disorders have created new questions about the approach to prevention and treatment of histoplasmosis. New information, based on publications from the period 1999–2006, are incorporated into this guideline document. In addition, the panel added recommendations for management of histoplasmosis in children for those aspects that differ from aspects in adults.

Immune reconstitution syndrome associated with opportunistic mycoses

Host immunity is essential in facilitating the eradication of infection. However, immunological recovery and an imbalance characterised by either suboptimum or excessive expression of immune responses can also be harmful to the host. Inflammatory responses triggered by rapid resolution of immunosuppression can lead to a series of localised and systemic reactions, termed immune reconstitution syndrome (IRS), that are often misconstrued as failure of specific antifungal therapy to eliminate the offending fungal pathogen. Recognition of IRS has become increasingly relevant in the context of our current use of potent immunosuppressive agents and immunostimulators that allow rapid manipulation of the immune system. Whereas the conceptual principles of IRS underscore the adverse effects of an overzealous and dysregulated immune response, they also support a role of immunotherapies to augment immunity if induction of endogenous responses is inadequate for the control of infection.

Hiccup and neurosurgeons: a report of 4 rare dorsal medullary compressive pathologies and review of the literature

OBJECTIVE

The aim of this study was to present 4 rare cases of medullary compressive lesions presenting with IH, to discuss the indications for neurosurgical decompression in such cases, and to review the possible etiologies of IH briefly.

METHODS

The reported cases include (1) a 19-year-old adolescent boy and a 21-year-old man with Chiari I malformation and cervical syrinx compressing or tightening the cervico-medullary junction; (2) a 35-year-old man with ependymoma extending from the lower half of the fourth ventricle to C1/C2 junction and compressing this part of the medulla; and (3) a 16-year-old adolescent boy who was referred to the emergency department in severe distress because of IH, occurring as a result of a distal PICA aneurysm located on the floor of the lower triangle of the fourth ventricle.

RESULTS

Surgical decompression in all the cases was successful in withholding the hiccups.

CONCLUSION

The dorsal medullary area is not an unusual location for genesis of hiccup. When encountering a case of IH, appropriate CNS imaging studies should be included in the evaluation protocol.

Dermatologic adverse effects of antiretroviral therapy: recognition and management

Despite the decrease in opportunistic infections associated with HIV in the highly active antiretroviral treatment (HAART) era, a significant number of patients still present with skin pathology, some of which can be attributed directly or indirectly to antiretroviral therapy. The non-nucleoside reverse transcriptase inhibitors exhibit a class effect with regard to skin adverse manifestations, and the spectrum of disease can vary from a mild morbilliform rash to Stevens-Johnson syndrome. Certain protease inhibitors are associated with rash, and indinavir causes retinoid-like manifestations such as paronychia, alopecia, ingrown toe-nails, and curling of straight hair. Abacavir, a nucleoside reverse transcriptase inhibitor, is notorious for causing a hypersensitivity reaction in select patients. The fusion inhibitor enfuvirtide causes injection-site reactions in the overwhelming majority of patients, although a new method of delivery has decreased the rate and severity of these reactions. A syndrome of lipoatrophy with or without lipohypertrophy, often termed lipodystrophy, has been described in patients receiving HAART. Potential management of lipoatrophy includes switching antiretrovirals and surgical treatment with facial fillers. Lastly, skin manifestations of the immune reconstitution inflammatory syndrome, including herpes zoster and warts, must be recognized and treated accordingly. In the evaluation of the individual HIV-infected patient receiving antiretroviral therapy who presents with a skin disorder, clinicians should consider the CD4 cell count as a marker of the degree of immunodeficiency, the specific antiretrovirals used, and the timing of the initiation of antiretroviral therapy in order to formulate a rational differential diagnosis. Management should be individualized based on the specific drug that is implicated and the severity of the reaction.

Dermatologic Manifestations of the Immune Reconstitution Inflammatory Syndrome

The immune reconstitution inflammatory syndrome (IRIS) represents a diverse range of immunopathologic reactions resulting in clinical deterioration that may occur as immune function is partially restored in HIV-infected patients receiving highly active antiretroviral therapy. Approximately half of IRIS events are dermatologic, and dermatologic IRIS is described in relation to a wide range of conditions, the commonest being herpes zoster and herpes simplex. Most cases of IRIS result in mild and moderate symptoms, but non-dermatologic manifestations related to IRIS have resulted in death. This article covers certain general issues related to IRIS and then focuses on the spectrum of dermatologic manifestations.