Histoplasmosis and kidney disease in patients with AIDS

Acute Kidney Injury, Immune Thrombocytopenic Purpura, and the Infection That Binds Them Together: Disseminated Histoplasmosis

Untreated human immunodeficiency virus (HIV) can be complicated by opportunistic infections, including disseminated histoplasmosis (DH). Although endemic to portions of the United States and usually benign, DH can rarely act as an opportunistic infection in immunocompromised patients presenting with uncommon complications such as acute kidney injury and idiopathic thrombocytopenic purpura. We report a rare presentation of DH presenting with acute kidney injury and immune thrombocytopenic purpura in an immunocompromised patient with HIV.

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.

[Yeast urinary tract infections. Multicentre study in 14 hospitals belonging to the Buenos Aires City Mycology Network]

BACKGROUND

Urinary tract infections are a frequent ailment in patients in intensive care units. Candida and other yeasts cause 5-12% of these infections. The value of the finding of any yeast is controversial, and there is no consensus about which parameters are adequate for differentiating urinary infections from colonization or contamination.

AIMS

To analyse the epidemiological characteristics of patients with funguria, to determine potential cut-off points in cultures (to distinguish an infection from other conditions), to identify the prevalent yeast species, and to determine the value of a second urine sample.

METHODS

A multicentre study was conducted in intensive care units of 14 hospitals in the Buenos Aires City Mycology Network. The first and second samples of urine from every patient were cultured. The presence of white cells and yeasts in direct examination, colony counts, and the identification of the isolated species, were evaluated.

RESULTS

Yeasts grew in 12.2% of the samples. There was no statistical correlation between the number of white cells and the fungal colony-forming units. Eighty five percent of the patients had indwelling catheters. Funguria was not prevalent in women or in patients over the age of 65. Candida albicans, followed by Candida tropicalis, were the most frequently isolated yeasts. Candida parapsilosis and Candida glabrata appeared less frequently. The same species were isolated in 70% of second samples, and in 23% of the cases the second culture was negative.

CONCLUSIONS

It was not possible to determine a useful cut-off point for colony counts to help in the diagnosis of urinary infections. As in other publications, C. albicans, followed by C. tropicalis, were the most prevalent species.

Disseminated Histoplasmosis in a 13-year-old girl: a case report

BACKGROUND

Disseminated histoplasmosis is a rare fungal infection and most documented cases are in immune-compromised individuals such as those with acquired immuno-deficiency syndrome.

OBJECTIVE

To describe a case of disseminated histoplasmosis in an adolescent girl.

METHOD

We report a case of disseminated histoplasmosis in a 13-year-old adolescent girl. She was admitted for 16 days because of neck masses of 3 years duration, generalized body swelling of 3 months and reduction in urinary output of 2 months. She tested negative for human immunodeficiency virus antibodies.

RESULT

An autopsy was performed because a definitive diagnosis could not be made while the patient was still alive. The autopsy revealed central caseating areas in the lymph nodes and membranoproliferative glomerulonephritis. The periodic acid-Schiff staining technique for tissues showed viable yeast cells suggestive of histoplasmosis. Zeihl-Neelsen's staining for mycobacteria tuberculosis was negative.

CONCLUSION

Undiagnosed case of disseminated histoplasmosis while the patient was alive is being reported in a 13-year-old girl. Disseminated histoplasmosis should be considered as a differential diagnosis of childhood chronic infections and malignancies as in Nigeria.

Renal disease in AIDS: it is not always HIVAN

Human immunodeficiency virus (HIV) infection can cause a broad spectrum of clinical manifestations, ranging from an asymptomatic carrier state to severe immunodeficiency. The most common renal lesion, HIV-associated nephropathy (HIVAN), is a sclerosing glomerulopathy. However, potentially reversible causes of renal disease in HIV-infected patients should also be considered. We describe two cases of patients with acquired immune-deficiency syndrome (AIDS) who presented with rapidly progressive renal failure but were found to have reversible etiologies. The first case was found to have syphilis and the second, disseminated histoplasmosis; their renal injury resolved after initiation of a third-generation cephalosporin antibiotic and amphotericin B, respectively.

Histoplasma capsulatum recovery from the urine and a short review of genitourinary histoplasmosis

Although virtually any organ can be involved in disseminated histoplasmosis, the recovery of Histoplasma capsulatum from the urine is a rare finding. Here we describe that a renal transplant recipient had H. capsulatum recovered from urinary sediment. The organism was also recovered from urine cultures. The potential implications of this finding are discussed, and the literature on genitourinary histoplasmosis is reviewed.

Clinical and laboratory features of disseminated histoplasmosis in HIV patients from Brazil

OBJECTIVES

To identify the main clinical and laboratory features of disseminated histoplasmosis (DH) in human immunodeficiency virus (HIV) patients and compare them with those of HIV patients with other opportunistic diseases.

METHODS

Retrospective study of HIV patients comparing the clinical and laboratory data of patients with and without DH. Univariate and multivariate analyses were performed to verify the risk factors related to DH.

RESULTS

In total, 378 HIV patients were included, 164 with DH and 214 with other opportunistic diseases. Acute renal failure, respiratory insufficiency and septic shock were more frequent in DH patients, who also had a higher mortality (32%vs. 14%, P < 0.001). Independent risk factors for DH were: acute renal failure [odds ratio (OR) 5.2; 95% confidence interval (CI) 3.2-8.5; P < 0.001], splenomegaly (OR 3.4; 95% CI 1.19-9.9; P < 0.001), respiratory insufficiency (OR 2.7 95% CI 1.5-5.0; P < 0.001), proteinuria (OR 2.7; 95% CI 1.3-5.2; P = 0.03), hypotension (OR 2.5; 95% CI 1.2-5.0; P = 0.008), hepatomegaly (OR 2.4; 95% CI 1.2-4.8; P = 0.01), cutaneous lesions (OR, 1.9; 95% CI 1.0-3.3; P = 0.02) and weight loss (OR 1.8; 95% CI 1.0-3.1; P = 0.03).

CONCLUSION

Our results suggest that DH is a severe opportunistic disease with high mortality rate, which should be promptly recognized in order to provide early specific treatment.

HIV-1 infection and the kidney: an evolving challenge in HIV medicine

With the advent of highly active antiretroviral therapy (HAART), the incidence of opportunistic infections has declined substantially, and cardiovascular, liver, and renal diseases have emerged as major causes of morbidity and mortality in individuals with human immunodeficiency virus (HIV). Acute renal failure is common in HIV-infected patients and is associated with acute infection and medication-related nephrotoxicity. HIV-associated nephropathy is the most common cause of chronic kidney disease in HIV-positive African American populations and may respond to HAART. Other important HIV-associated renal diseases include HIV immune complex kidney diseases and thrombotic microangiopathy. The increasing importance of non-HIV-associated diseases, such as diabetes mellitus, hypertension, and vascular disease, to the burden of chronic kidney disease has been recognized, focusing attention on prevention and control of these diseases in HIV-positive individuals. HIV-positive individuals who experience progression to end-stage renal disease and who have undetectable HIV-1 viral loads while receiving HAART should be evaluated for renal transplant. Emerging evidence suggests that HIV-positive individuals may have graft and patient survival comparable to HIV-negative individuals. Several studies suggest that HIV-1 can potentially infect renal cells, and HIV transgenic mice have clarified the roles of a number of HIV proteins in the pathogenesis of HIV-associated renal disease. Host factors may modify disease expression at the level of cytokine networks and the renal microvasculature and contribute to the pathogenic effects of HIV-1 infection on the kidney.

Histoplasmosis: a clinical and laboratory update

Infection with Histoplasma capsulatum occurs commonly in areas in the Midwestern United States and Central America, but symptomatic disease requiring medical care is manifest in very few patients. The extent of disease depends on the number of conidia inhaled and the function of the host's cellular immune system. Pulmonary infection is the primary manifestation of histoplasmosis, varying from mild pneumonitis to severe acute respiratory distress syndrome. In those with emphysema, a chronic progressive form of histoplasmosis can ensue. Dissemination of H. capsulatum within macrophages is common and becomes symptomatic primarily in patients with defects in cellular immunity. The spectrum of disseminated infection includes acute, severe, life-threatening sepsis and chronic, slowly progressive infection. Diagnostic accuracy has improved greatly with the use of an assay for Histoplasma antigen in the urine; serology remains useful for certain forms of histoplasmosis, and culture is the ultimate confirming diagnostic test. Classically, histoplasmosis has been treated with long courses of amphotericin B. Today, amphotericin B is rarely used except for severe infection and then only for a few weeks, followed by azole therapy. Itraconazole is the azole of choice following initial amphotericin B treatment and for primary treatment of mild to moderate histoplasmosis.

Disseminated histoplasmosis in patients with AIDS in Panama: a review of 104 cases

We identified the incidence and primary clinical characteristics of histoplasmosis in patients with acquired immunodeficiency syndrome (AIDS) in our hospital. Disseminated histoplasmosis is a common and severe disease among patients with AIDS in Panama and should be suspected for patients with a CD4 cell count of <100 cells/ microL, fever, respiratory symptoms, weight loss, and diarrhea.

Two unusual presentations of urogenital histoplasmosis and a review of the literature

Two unusual clinical presentations of urogenital histoplasmosis are described. A review of the literature on urogenital histoplasmosis is provided.

Fungal infections of the genitourinary system: manifestations, diagnosis, and treatment

There is an increasing pool of immunocompromised patients who are at an increased risk to fungi infections, which now cause 8% of nosocomial infections. Premature infants and elderly, transplant, and HIV patients are prime candidates for invasive fungal infections. The genitourinary system can be a source or target of disseminated fungal infection. Although candidal species are the most frequent pathogen, other species such as aspergila, cryptoccoccus have become major pathogens. "Environmental fungi," which include blastomyces, coccidioides and histoplasma, have become more aggressive in the vulnerable patient.