New clinical and histological patterns of acute disseminated histoplasmosis in human immunodeficiency virus-positive patients with acquired immunodeficiency syndrome

Progressive disseminated histoplasmosis in children living with HIV: a case series study

Progressive disseminated histoplasmosis (PDH) is thought to be on the top of the list of AIDS-defining illnesses in South America. Reported experience in children is very scarce. The aim of this study was to describe the clinical characteristics, management, and outcomes of children living with HIV presenting with PDH in Ecuador. We did a retrospective study using collected data on medical records of children living with HIV attended in Francisco Icaza Bustamante Children's Hospital (Guayaquil) between 1997 and 2019. The inclusion criteria consisted of patients under 18 years of age at admission with documented HIV infection and laboratory-confirmed diagnosis of PDH. Twenty-four children living with HIV were attended due to laboratory-confirmed PDH. Median CD4 cell count was 39 cells/mm³ (p25-p75 21-155) between 1 and 5 years and 22 cells/mm³ (p25-p75 10-57) for those aged 6 years and over. Fever (96%) was the most common clinical manifestation, followed by hepatomegaly (75%), cough (67%), weight loss (63%), diarrhea (63%), and abdominal distension (58%). Most significant laboratory findings were hypoalbuminemia (90%), hypertransaminasemia (78%), and pancytopenia (46%). Intravenous treatment with amphotericin B deoxycholate was started in all but one case in which diagnosis was postmortem. All these 23 patients were discharged after being hospitalized for a median of 68 days (p25-p75 48-90). Two children showed relapse during follow-up, one of whom died during the hospitalization of this second episode of PDH.Conclusion: Clinical manifestations and laboratory findings of PDH in children living with HIV seem similar to those seen in adults, and low CD4 cell count appears to be the most important risk factor. What is Known: • Since 1987, progressive disseminated histoplasmosis has been considered an AIDS-defining illness and, although underdiagnosis is frequent, is thought to be on the top of the list of AIDS-defining illnesses in South America. • Reported experience in children is very scarce. What is New: • Clinical manifestations and laboratory findings of progressive disseminated histoplasmosis in children living with HIV seem similar to those seen in adults. • Low CD4 cell count to be the most important risk factor.

Cutaneous Histoplasmosis in HIV Seronegative Patients: A Clinicopathological Analysis

BACKGROUND

Diagnosis of extrapulmonary histoplasmosis in HIV seronegative and immunocompetent patients is often challenging, so a high index of suspicion is required. Cutaneous manifestation of infection shows a wide spectrum of lesions including erythematous plaques; maculopapules; crusted, verrucous, or desquamative papules and nodules; abscesses; and mucocutaneous ulcers among others. Due to the variations in its clinical presentation, histopathology plays a very important role in the detection of spores and the confirmation of diagnosis.

OBJECTIVES

The aim of our study was to analyze clinicopathological characteristics of cutaneous manifestations of biopsy-proven histoplasmosis in HIV seronegative individuals. We also examined the utility of Fite stain for the diagnosis of Histoplasma capsulatum on tissue biopsy sections.

METHODS

This was a retrospective, observational study on 7 patients who were HIV seronegative and clinically manifested with isolated cutaneous lesions or disseminated disease. Skin biopsy from the lesions was performed on all 7 patients. In addition to H&E staining and special stains for detecting fungus, Fite staining was performed on all of the cases to study its utility in detecting H. capsulatum spores.

RESULTS

The skin lesions were widely disseminated in all patients and the most common cutaneous lesions were papules, present in all 7 patients. On review of the H&E-stained slides, the most common pattern was histiocytic lobular panniculitis-like infiltrate observed in 4 cases. Fite stain highlighted the yeast as magenta-colored spores on a blue background in all cases, except for 1 with a granulomatous pattern.

CONCLUSION

A primary cutaneous manifestation of H. capsulatum infection in non-HIV-infected individuals is extremely rare. Fite stain could aid in differentiating the spores of H. capsulatum from those of other fungi, Cryptococcus and Candida in particular.

Disseminated Histoplasmosis as AIDS-presentation. Case Report and Comprehensive Review of Current Literature

Progressive disseminated histoplasmosis (PDH) is an AIDS-defining illness with a high lethality rate if not promptly treated. The wide range of its possible clinical manifestations represents the main barrier to diagnosis in non-endemic countries. Here we present a case of PDH with haemophagocytic syndrome in a newly diagnosed HIV patient and a comprehensive review of disseminated histoplasmosis focused on epidemiology, clinical features, diagnostic tools and treatment options in HIV-infected patients.

Correlation of CD4 counts with clinical and histopathological findings in disseminated histoplasmosis: a 10-year retrospective study

BACKGROUND

Disseminated cutaneous histoplasmosis (DCH) is one of the manifestations of systemic histoplasmosis infection in HIV-positive patients. Interaction between host immune status and histoplasmosis infection is still poorly understood. It is thought that immune status, represented by CD4 counts, may be correlated with clinical and histopathological findings.

OBJECTIVE

To correlate the CD4 counts with the different clinical and histopathological findings in cutaneous histoplasmosis.

METHODS

This was a serial case report of seven HAART-treated HIV positive patients with disseminated histoplasmosis observed within the period of January 2004 through December 2014 from the Dermatology and Venereology Department, Cipto Mangunkusumo Hospital, Jakarta, Indonesia. The patients came with different complaints and clinical findings. CD4 counts were recorded prior to lesion biopsy.

RESULTS

The CD4 counts were independent from clinical morphology and distribution of lesions. Lower CD4 counts were associated with the presence of intraepidermal yeast-like cells, whereas there is the ability of forming granulomas at higher CD4 counts.

CONCLUSION

CD4 count correlates to histopathological findings of cutaneous histoplasmosis.

Serious fungal infections in Ecuador

There is a dearth of data from Ecuador on the burden of life-threatening fungal disease entities; therefore, we estimated the burden of serious fungal infections in Ecuador based on the populations at risk and available epidemiological databases and publications. A full literature search was done to identify all epidemiology papers reporting fungal infection rates. WHO, ONU-AIDS, Index Mundi, Global Asthma Report, Globocan, and national data [Instituto Nacional de Estadística y Censos (INEC), Ministerio de Salud Pública (MSP), Sociedad de Lucha Contra el Cáncer (SOLCA), Instituto Nacional de Donación y Trasplante de Órganos, Tejidos y Células (INDOT)] were reviewed. When no data existed, risk populations were used to estimate frequencies of fungal infections, using previously described methodology by LIFE. Ecuador has a variety of climates from the cold of the Andes through temperate to humid hot weather at the coast and in the Amazon basin. Ecuador has a population of 15,223,680 people and an average life expectancy of 76 years. The median estimate of the human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) population at risk for fungal disease (<200 CD4 cell counts) is ∼10,000, with a rate of 11.1% (1100) of histoplasma, 7% (700) of cryptococcal meningitis, and 11% (1070) of Pneumocystis pneumonia. The burden of candidemia is 1037. Recurrent Candida vaginitis (≥4 episodes per year) affects 307,593 women aged 15-50 years. Chronic pulmonary aspergillosis probably affects ∼476 patients following tuberculosis (TB). Invasive aspergillosis is estimated to affect 748 patients (∼5.5/100,000). In addition, allergic bronchopulmonary aspergillosis (ABPA) in asthma and severe asthma with fungal sensitization (SAFS) were estimated to affect 26,642 and 45,013 people, respectively. Our estimates indicate that 433,856 (3%) of the population in Ecuador is affected by serious fungal infection.

Diagnostic Methods for Histoplasmosis: Focus on Endemic Countries with Variable Infrastructure Levels

Diagnosis of histoplasmosis remains challenging in resource-limited regions where HIV/AIDS is epidemic and histoplasmosis is endemic. Early and rapid detection of histoplasmosis is essential to preventing morbidity and mortality, yet few diagnostic options are available in low-resource areas of the world. The aim of this review is to provide an overview of the current status of the diagnosis of histoplasmosis, including an update on recent developments and utilization of new technologies. We discuss the specific diagnostic challenges faced in endemic regions, emphasizing the need for greater availability and standardization of rapid diagnostics for this endemic and neglected disease. While significant progress has been made in the development of new methods, clinical utility must be established by means of formal and extensive clinical studies.

Colonic involvement in disseminated histoplasmosis of an immunocompetent adult: case report and literature review

BACKGROUND

Histoplasmosis is a common opportunistic fungal infection that is observed almost exclusively in immunodeficient patients, especially those with AIDS. Immunocompetent individuals that suffer from histoplasmosis are rarely reported, especially those with disseminated lesions, such as disseminated histoplasmosis. The observation of disseminated histoplasmosis with prominent gastrointestinal involvement, no respiratory symptoms (which is presumed to be the portal of infection), gastrointestinal pathological changes, and minor digestive system disorders make this case study exceedingly rare.

CASE PRESENTATION

We report the case of a 33-year-old immunocompetent male who presented with fever and weight loss. Based on investigations, the patient showed pancytopenia, hepatosplenomegaly, bone marrow involvement and marked colonic involvement. Finally, disseminated histoplasmosis was diagnosed and confirmed by stained smears of fine needle aspirates and biopsy from lesions in the bone marrow and colon. The patient showed appreciable regression of lesions following prompt treatment with amphotericin B deoxycholate, and was treated thereafter with oral itraconazole following discharge from hospital.

CONCLUSION

Disseminated histoplasmosis could be underestimated in immunocompetent patients. A high degree of clinical suspicion is essential in both immunocompromised and immunocompetent patients, regardless of pulmonary symptoms, and whether in endemic or non-endemic areas. Early and accurate diagnosis is extremely important for the appropriate treatment of infection and to improve disease outcome.

Colonic involvement in disseminated histoplasmosis of an immunocompetent adult: case report and literature review

BACKGROUND

Histoplasmosis is a common opportunistic fungal infection that is observed almost exclusively in immunodeficient patients, especially those with AIDS. Immunocompetent individuals that suffer from histoplasmosis are rarely reported, especially those with disseminated lesions, such as disseminated histoplasmosis. The observation of disseminated histoplasmosis with prominent gastrointestinal involvement, no respiratory symptoms (which is presumed to be the portal of infection), gastrointestinal pathological changes, and minor digestive system disorders make this case study exceedingly rare.

CASE PRESENTATION

We report the case of a 33-year-old immunocompetent male who presented with fever and weight loss. Based on investigations, the patient showed pancytopenia, hepatosplenomegaly, bone marrow involvement and marked colonic involvement. Finally, disseminated histoplasmosis was diagnosed and confirmed by stained smears of fine needle aspirates and biopsy from lesions in the bone marrow and colon. The patient showed appreciable regression of lesions following prompt treatment with amphotericin B deoxycholate, and was treated thereafter with oral itraconazole following discharge from hospital.

CONCLUSION

Disseminated histoplasmosis could be underestimated in immunocompetent patients. A high degree of clinical suspicion is essential in both immunocompromised and immunocompetent patients, regardless of pulmonary symptoms, and whether in endemic or non-endemic areas. Early and accurate diagnosis is extremely important for the appropriate treatment of infection and to improve disease outcome.

Detection of microorganisms in granulomas that have been formalin-fixed: review of the literature regarding use of molecular methods

Granuloma is an organized aggregate of immune cells that under the microscope appear as epithelioid macrophages. A granuloma can only be diagnosed when a pathologist observes this type of inflammation under the microscope. If a foreign body or a parasite is not observed inside the granuloma, stains for acid-fast bacilli and fungi are ordered since mycobacteria and fungi are frequently the cause of this type of inflammation. It is calculated that 12 to 36% of granulomas do not have a specific etiology and many have wondered if with new molecular methods we could reduce this number. This paper will summarize the frequently known causes of granulomas and will present the recent literature regarding the use of molecular techniques on tissue specimens and how these have helped in defining causative agents. We will also briefly describe new research regarding formation and function of granulomas and how this impacts our ability to find an etiologic agent.