Histoplasmosis infection presenting as an isolated subcutaneous periarticular upper limb swelling in the immunosuppressed patient

Deep Fungal Infections of the Upper Extremity - A Review

Deep fungal infections are rare in the upper extremity. Vessel and nerve infection, synovitis, tenosynovitis, myofasciitis, arthritis and osteomyelitis have been discovered in literature. Treatment in most cases includes surgical procedure and antifungal agent use. Amputation is the final, most devastating for patient's functionality, solution. Intravenous antifungal drugs, frequently followed by oral administration, are important ancillary agents both for the initial treatment and the prevention of recurrence. We therefore performed a review of the current literature, in order to assemble the dispersed results of different studies and clarify the various aspects of upper extremity fungal infections.

Synovitis due to Histoplasma capsulatum: a case series and literature review

Musculoskeletal manifestations of Histoplasma capsulatum infection are uncommon but can mimic inflammatory arthritis. Early diagnosis of this complication is of critical importance in the era of potent immunosuppression for rheumatologic diseases. We conducted a retrospective chart review for patients with histoplasmosis and tenosynovitis, synovitis, or arthritis, diagnosed and treated at our institution between January 1, 2000, and December 31, 2019. We also reviewed the relevant literature. Four patients with biopsy-proven, culture-proven histoplasma tenosynovitis were identified at our institution. All four patients had wrist or hand involvement in an asymmetric pattern, and one patient had lower extremity involvement as well. Two patients were not immunocompromised at baseline. One patient underwent a lengthy evaluation and received immunosuppression for 4 years without improvement prior to the diagnosis of histoplasmosis. Histoplasma serologic tests varied among patients with localized infection. Pathologic findings revealed non-caseating granulomatous inflammation. Three patients recovered after 6-12 months of antifungal treatment. One patient still had recurrent infection despite 20 months of treatment. Histoplasma tenosynovitis and synovitis are rare causes of inflammatory arthritis. Infectious causes should be considered and carefully evaluated when patients present with asymmetric oligoarthritis. Early recognition is crucial for successful treatment, especially in patients with concomitant rheumatologic diseases receiving immunosuppressive treatment.

Upper extremity Histoplasma capsulatum treatment with isavuconazole

Extrapulmonary Histoplasma capsulatum infections in the immunocompetent population are rare and pose a diagnostic challenge. Upper extremity histoplasmosis without a primary lung infection is uncommon. It is possible to acquire it by inadvertent trauma with direct inoculation.

Our case describes an immunocompetent patient with progressive swelling with minimal pain in the wrist associated with a small puncture wound on the left dorsal forearm. The initial workup failed to identify a specific etiology. For the following six weeks, the patient experienced progressive worsening of symptoms, warranting a referral to an orthopedic

hand surgeon. Left lower extremity magnetic resonance imaging (MRI) findings were non-specific.

The surgeon performed a surgical exploration and debridement with the excision of hypertrophic tissue. Initial stains showed a granulomatous tissue but did not reveal an organism; however, a month later, mold was identified on the growth medium. The patient was initiated in isavuconazole empiric therapy. Four weeks later, a matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) confirmed the diagnosis as Histoplasma capsulatum. The patient had clinical remission with isavuconazole used as the United States Food and Drug Administration (FDA) off label use.

Histoplasmosis of the Upper Extremities: Clinical Case, Treatment Algorithm, and Systematic Review

Background: Histoplasmosis of the upper extremities is extremely rare, and there is no consensus in its management. The aim of this study was to present a case report and literature review of histoplasmosis in the upper extremities to provide the best treatment recommendation and to increase awareness of this disease. Methods: A systematic review of the literature was performed in PubMed, MEDLINE, and EMBASE databases with the search terms "(Tenosynovitis AND histoplasmosis)" OR "(Upper limbs AND histoplasmosis)" OR "(Upper extremities AND histoplasmosis)" OR "((finger OR arm OR hand OR forearm OR wrist) AND histoplasmosis)." Manuscripts were included in the study if they described diagnosis of histoplasmosis in the bone, joint, synovia, or tendons of the upper extremities. Results: In all, 14 manuscripts and 15 cases of histoplasmosis of the upper extremities from 1992 to 2015 met the inclusion criteria. Eight (53.3%) patients were diagnosed with tenosynovitis, 5 (33.3%) with osteomyelitis, 1 (6.7%) with carpal tunnel syndrome, and 1 (6.7%) with joint wrist abscess. Immunosuppression, travel history, previous diagnosis with histoplasmosis, and persistent symptoms may suggest infectious causes. Surgery and medical treatment together are recommended to optimize outcomes compared with single treatment alone. Conclusions: Histoplasmosis of the upper extremities may have various clinical presentations, including tenosynovitis, osteomyelitis, carpal tunnel syndrome, and joint wrist abscess. The type of surgical approach may depend on the etiology of disease. Increased awareness and knowledge of the clinical signs, symptoms, and effective treatment modalities will help decrease possible complications, such as tendon rupture and functional impairment of the upper extremities.

Deep Invasive Fungal Infection of the Hand in a Child Mimicking a Local Gigantism

Subcutaneous and deep fungal infections in the hand are rare among children. These are usually found in immunocompromised adults or in persons engaged in soil handling activities, due to direct exposure, especially in the tropics. Delay in diagnosis is usual because pyogenic and other granulomatous infections are considered first. The authors present the case of a healthy, immunocompetent 2½-year-old child who presented with progressive swelling of the right hand mimicking a localized gigantism of the entire hand. Multiple operative drainage procedures done previously had failed to resolve the condition. A biopsy established the presence of fungal hyphae, thus confirming the diagnosis of deep fungal infection of the hand and guided proper therapeutic intervention. A strong index of suspicion needs to be maintained in cases not responding to conventional antibacterial therapy, and both microbiologic and histopathologic samples need to be obtained to establish the diagnosis.

An Unusual Subcutaneous Mass in an Otherwise Healthy Patient: A Case Report of Localized Histoplasmosis Diagnosed on Excisional Biopsy

Patients are commonly referred to general surgery clinics for evaluation of soft-tissue masses of the trunk and extremities. The primary goal of surgical referral is to confirm the presence of a mass, to assess the need for additional imaging and/or testing, and to gauge amenability to surgical biopsy, whether incisional or excisional. This is a case of a 67-year-old woman who was referred to surgery clinic for a small soft-tissue mass near her left elbow that had increased in size and pain over the past year. The mass had been present for several years. After MRI imaging revealed a nonspecific process, an excisional biopsy was performed. Following a careful review of the patient's history, risk factors, and histological results, a diagnosis of localized subcutaneous Histoplasma capsulatum var. capsulatum infection was made. Without signs or symptoms of active, systemic disease, no further treatment was recommended. The patient was provided risk factor counseling for symptoms or signs of active histoplasmosis and outpatient follow-up. Histologically, most masses will return as benign and mesenchymal in origin. However, soft-tissue masses may arise from uncommon etiologies and a broad differential is needed to ensure appropriate management and recommendations.

Tenosynovitis of the wrist and thumb and carpal tunnel syndrome caused by Histoplasma capsulatum: case report and review of the literature

A patient presenting with acute carpal tunnel syndrome and swelling and pain in the wrist and thumb is presented. An open carpal tunnel release and tenosynovectomy were performed with biopsy specimen revealing infection with Histoplasma capsulatum. The case is discussed in context of the prior scant literature of tenosynovitis of the wrist and hand caused by histoplasmosis.

Mycobacterium haemophilum and Histoplasma capsulatum coinfection in a renal transplant patient

We report the case of a 22-year-old man who presented with a Mycobacterium haemophilum and Histoplasma capsulatum coinfection occurring 21 years after a living-donor-related renal transplant.