Disseminated histoplasmosis and human immunodeficiency virus infection

Rupioid histoplasmosis: first case reported in an AIDS patient in Argentina

Disseminated histoplasmosis is a relatively common AIDS-defining illness, occurring in almost 4% of patients living in endemic areas and it may be the first clinical expression of the HIV infection. A broad spectrum of clinical skin lesions associated with Histoplasma capsulatum infection have been described in AIDS patients, such as erythematous macules, papules, nodules, and pustules. Herpetic, acneiform, erythema multiforme-like, molluscum contagiosum-like, vasculitic, and exfoliative forms have also been reported. To our knowledge, this is the first case of disseminated histoplasmosis in an AIDS patient presented as a rupioid eruption.

Two specific strains of Histoplasma capsulatum causing mucocutaneous manifestations of histoplasmosis: preliminary analysis of a frequent manifestation of histoplasmosis in southern Brazil

OBJECTIVES

Skin lesions, uncommon in US cases (<10%), occur in 38-85% of cases reported from Latin America. Although these differences may reflect reporting bias, delayed diagnosis, or differences in host immune response among different ethnic groups, they also could result from genetic differences changing the pathobiology of the organism. It is possible that genetic differences among strains of H. capsulatum may influence the pathogenesis and clinical manifestations of histoplasmosis.

METHODS

We examined the clinical features of patients with mucocutaneous manifestations of histoplasmosis and performed genetic analysis based on nucleotide sequence variations in the internal transcribed spacer regions of rRNA genes of H. capsulatum isolates of patients. Two pairs of PCR primers were designed to develop and amplify the ITS regions of H. capsulatum, 5'-TACCCGGCCACCCTTGTCTA-3' and 5'-AGCGGGTGGCAAAGCCC-3'. These primers were based on the ITS sequence of Ajellomyces capsulatus, the ascomycetous teleomorph form of H. capsulatum, deposited in the GenBank (accession number U18363). Eight patients attending a tertiary-care hospital in southern Brazil were enrolled into the study. All case patients had skin cultures growing H. capsulatum at the mycology laboratory.

RESULTS

Six of eight (75%) patients were HIV-positive and presented involvement of multiples organs by H. capsulatum. Two HIV-negative patients did not present evidence of involvement of other organs besides mucosa and skin. ITS sequencing of a DNA H. capsulatum fragment of 485-bp from isolates of 8 patients revealed two distinct strains. The 2 distinct fragments (Hc1, Hc2) differed from each other at 7 positions in the ITS regions. They were identical to strains of H. capsulatum isolated in patients from Colombia and Argentina, but different from strains isolated in US. Hc1 and Hc2 were isolated in 5 patients and 3 patients, respectively, with mucocutaneous manifestations of histoplasmosis. Both Hc1 and Hc2 strains were isolated in HIV-infected and non-HIV-infected patients.

CONCLUSIONS

Mucocutaneous manifestations of histoplasmosis, which are frequently seen in Brazilian patients were caused by 2 specific strains in our institution. Those strains have been isolated in patients with these particular clinical features of histoplasmosis in Latin America. Our study suggests that unique pathogenic characteristics among the Latin American species of H. capsulatum might explain its increased dermatotropism.

Mucocutaneous manifestations of disseminated histoplasmosis in patients with acquired immunodeficiency syndrome: particular aspects in a Latin-American population

BACKGROUND

Mucocutaneous lesions in human immunodeficiency virus (HIV)-infected patients with disseminated histoplasmosis have a wide spectrum of clinical manifestations, making its diagnosis difficult. Studies have been restricted to case reports and series with small numbers of patients not specifically focusing on the dermatological aspects of histoplasmosis.

AIMS

To describe the characteristics of mucocutaneous lesions of disseminated histoplasmosis in HIV-infected patients.

METHODS

A retrospective and prospective study was conducted on 36 HIV-infected patients with mucocutaneous histoplasmosis in a tertiary-care hospital in Brazil.

RESULTS

Mucocutaneous histoplasmosis was diagnosed by histopathology in 33 of the 36 patients (91%) and/or culture in 23 (64%). Their CD4+ cell counts ranged from 2 to 103 cells/mm(3). The average number of different morphological types of lesions was three per patient. Despite the variability of the lesions, papules (50%), crusted papules (64%) and oral mucosal erosions and/or ulcers (58%) were the most frequent dermatological lesions. A diffuse pattern of distribution of the skin lesions was found in 58% of the cases. There was significant association between the CD4+ cell counts and the morphological variability of lesions per patient. Variation in the lesions seemed to be associated with higher CD4+ cell counts.

CONCLUSION

Doctors caring for HIV-infected patients should be aware of the wide spectrum of dermatological lesions observed in disseminated histoplasmosis and the importance of detecting and isolating the fungus in mucocutaneous tissues.

Acquired immunodeficiency syndrome-related oral and/or cutaneous histoplasmosis: a descriptive and comparative study of 21 cases in French Guiana

BACKGROUND

Oral or cutaneous acquired immunodeficiency syndrome (AIDS)-related histoplasmosis is a rare presentation of disseminated histoplasmosis.

OBJECTIVE

To describe this clinical presentation and to compare it with other forms of AIDS-related disseminated histoplasmosis.

METHODS

A cross-sectional study of patients with AIDS-related disseminated histoplasmosis was performed. CD4 counts and survival were compared between patients with oral or cutaneous histoplasmosis and patients with nonmucocutaneous disseminated histoplasmosis.

RESULTS

The mean CD4 lymphocyte count was lower in patients with mucocutaneous lesions than in patients with nonmucocutaneous disseminated histoplasmosis (29 vs. 72/mm3, P = 0.002). The proportion of survivors 1 month after diagnosis did not differ significantly between the two groups (13/21 vs. 32/45, P = 0.4). At 6 months, the proportion of survivors was significantly lower for patients with mucocutaneous lesions (6/21 vs. 22/39, P = 0.03).

CONCLUSIONS

These results suggest that mucocutaneous lesions occur at a later stage of human immunodeficiency virus infection, but are not, in themselves, associated with a higher level of mortality. The excess mortality at 6 months reflects deaths from other complications of severe immunodepression. This study confirms the polymorphism of mucocutaneous lesions, emphasizing the need for systematic testing for Histoplasma in all cases of mucocutaneous lesions in AIDS patients.

The cutaneous manifestations of HIV infection

Dermatologic disease is extremely common and varied in HIV-infected patients. While some cutaneous findings are nearly exclusive to HIV-seropositive individuals, many are found in the general population. However, HIV-infected individuals often have an increased prevalence or severity, atypical presentations, or difficulty with treatment of the disease. Immune reconstitution with HAART significantly reduces the prevalence of many dermatologic diseases, but also has associated cutaneous side effects. Correct and early diagnosis of skin disease in HIV-infected individuals allows for early management and improved quality of life. Because dermatologic manifestations may be the first clue of HIV infection, offering HIV testing to affected individuals can lead to early diagnosis and treatment of HIV infection and, ideally, a decrease in disease progression and transmission.

Disseminated cutaneous histoplasmosis in patients infected with human immunodeficiency virus

BACKGROUND

In the pre-AIDS era disseminated histoplasmosis was rare and the cutaneous manifestations thereof were reported infrequently. A range of unusual clinical manifestations of disseminated cutaneous histoplasmosis (DCH) in AIDS patients has been documented, but the cutaneous histopathological descriptions are short and incomplete. In addition, the histopathological spectrum of AIDS-associated DCH is poorly recognized.

METHODS

This is a prospective 32-month study of all HIV positive patients diagnosed with histoplasmosis in the Departments of Anatomical Pathology and Dermatology, Nelson R. Mandela School of Medicine and King Edward VIII Hospital, Durban, South Africa. Clinical distribution and morphology of the individual skin lesions and CD4+ lymphocyte counts in the peripheral blood were analysed in relation to the histopathological features of biopsied lesional tissue. Ultrastructural examination of tissue retrieved from the wax blocks of three cases that exhibited dermal karyorrhexis and collagen necrosis was undertaken. Fungal culture of lesional skin tissue was undertaken in all patients.

RESULTS

Twenty-one biopsies of papules (7), nodules (4), plaques (5), erythema multiforme-like lesions (2), vasculitic lesions (2) and exfoliative dermatitis (1) from 14 patients were examined. Of four biopsies (CD4 range: 120-128 cells/mm3) one and three demonstrated necrotizing and non-necrotizing granulomatous inflammation with a paucity of intrahistiocytic microorganisms. Seven biopsies (CD4 range: 2-56 cells/mm3) demonstrated diffuse dermal and intravascular accumulation of histiocytes densely parasitized by Histoplasma capsulatum var. capsulatum. Vasculitis, karyorrhexis or collagen necrosis was not present. Ten biopsies (CD4 range: 2-72 cells/mm3) demonstrated diffuse dermal karyorrhexis, collagen necrosis and interstitial, extracellular H. capsulatum var. capsulatum. Histiocytic disintegration and nuclear fragmentation and release of intact microorganisms and intact and ruptured lysosomes were identified ultrastructurally. Leucocytoclastic vasculitis was present in two biopsies of vasculitic clinical morphology. Microbiological culture confirmed histoplasmosis in all cases. Three patients died before treatment was commenced. Two patients died within the first two days of induction of therapy. Nine patients demonstrated dramatic healing of the cutaneous lesions.

CONCLUSIONS

Despite the clinicopathological spectrum of DCH and the attendant host immunocompromise, timely and appropriate treatment of DCH may be lifesaving and allows rapid healing of skin lesions. A high index of clinical suspicion and skin biopsies and culture are crucial for accurate diagnosis.

[Histoplasmosis due to Histoplasma capsulatum capsulatum and HIV infection]

PURPOSE

Histoplasmosis due to Histoplasma capsulatum is a granulomatous fungic infection which appears opportunistic and disseminated in immunocompromised patients, especially among HIV patients in whom it can lead to death. Histoplasmosis is endemic in numerous areas worldwide, but in Europe most of the cases reported are imported. We describe the clinical features and the available diagnosis methods issued from our experience in French Guyana.

METHODS

Contamination occurs by inhalation of spores contained in dust. Most endemic areas are located on the American continent, including the French West Indies, where the incidence of histoplasmosis among HIV patients in French Guyana varies from 1.2 to 2.2% per year. In non-immunocompromised patients, histoplasmosis is asymptomatic most of the time. In HIV patients, the disseminated form is common and may occur many years after exposure to the fungus.

RESULTS

Non-specific symptoms, similar to those of either tuberculosis or other opportunistic infections, may reveal disseminated histoplasmosis in patients with AIDS. Early treatment (amphotericin B or itraconazole) is effective; however, it should be followed by a lifelong antifungic treatment (itraconazole) to prevent relapse.

CONCLUSION

The infection should be suspected in any febrile HIV-infected patient with CD4 blood cell count < 200/mm3, if he/she ever travelled in an endemic zone. Direct examination of smear relating to clinical symptoms help guide diagnosis, while culture will confirm it after at least 4 weeks. Efficient serologic techniques for HIV-infected patients are not available in Europe.

Disseminated histoplasmosis and AIDS: clinical aspects and diagnostic methods for early detection

Disseminated histoplasmosis in AIDS patients is the focus of this paper. Cutaneous lesions are reported as a frequent clinical sign. Bone marrow aspiration and biopsy, blood cultures (lysis-centrifugation technique), bronchoalveolar lavage, and skin lesion scrapings are the most effective diagnostic methods. The identification of a specific antigen in blood and urine may be a rapid means of evaluation and follow-up of patients with this disease.

Update on the cutaneous manifestations of HIV infection. Clinical and pathologic features

Skin is the most commonly affected organ in patients with HIV. As such, cutaneous manifestations of HIV infection have been the subject of intense scrutiny as well as the topic of many articles. A broad range of infectious and noninfectious skin lesions may develop during the course of the disease. This article discusses the clinical and pathological cutaneous manifestations of HIV infection.

Update on cutaneous manifestations of HIV infection

The skin is affected in virtually all patients with HIV infection. Many articles and several books have been published that deal with these disorders for a number of reasons. First, cutaneous disease may serve as the initial or only problem that the patient suffers for much of the course of the HIV infection. Second, serious opportunistic infections may present for the first time in the skin, so that a skin lesion may be a harbinger of the patient's having a life-threatening illness. Third, skin disorders in these patients may appear unusual and hence may not be accurately diagnosed by clinical inspection alone. Furthermore, response to treatment may be poorer than expected. Thus, skin diseases in the HIV-infected patient are important and, in some cases, may be the most debilitating element of the patient's condition.

Oral histoplasmosis as an indicator of HIV infection

Histoplasmosis as a serious opportunistic infection in association with AIDS has assumed considerable importance. We have gathered 20 case reports from the literature of oral histoplasmosis in HIV-infected patients. In some cases, oral lesions appear to be the primary or only manifestation of disease. We report one such case of oral histoplasmosis in a bisexual man who was seen with ulcerations on the palate and proved to be infected by HIV.

Localised oral histoplasmosis lesions associated with HIV infection

Opportunistic fungal infections account for a significant amount of morbidity associated with HIV disease. We report here a case of localised oral histoplasmosis without evidence of disseminated disease in a patient who lacked stigmata of HIV disease at the time of initial presentation. The diagnosis is based on histology with special stains, complement fixing antibodies in serum, and culture of the organism from fresh tissues. Activation of subclinical disease following an infection in Uganda may explain the development of these exophytic oral lesions in this British resident.

Diagnosis and treatment of infectious diseases in HIV-infected hosts

Treatment of infectious diseases in patients with HIV infection is of primary importance in patient care. Viral, bacterial, parasitic, and fungal pathogens all may affect these patients. It is essential that accurate diagnoses be made and appropriate therapy be administered as early as possible.

Cutaneous histoplasmosis in a child with hyper-IgM

Immunodeficiency with hyperimmunoglobulinemia M is a rare disease characterized by very low levels of IgG and IgA and normal or high levels of serum IgM and IgD. Recurrent and severe systemic infections with pathogenic bacteria are frequent if immunoglobulin replacement therapy is not given. Histoplasmosis is a systemic granulomatous mycosis due to Histoplasma capsulatum and characterized by a particular affinity for the reticuloendothelial system. Glabrous skin involvement in histoplasmosis is highly unusual except in patients with advanced human immunodeficiency viral disease. Cutaneous histoplasmosis and granulomatous reaction were diagnosed in a 5-year-old boy with hyper-IgM disease. The lesion improved after oral ketoconazole therapy. To our knowledge, this is the first case of cutaneous histoplasmosis associated with hyper-IgM to be reported.

Histoplasma capsulatum infection in three AIDS patients living in Africa

Three AIDS patients are reported, 2 European and 1 African. All 3 developed Histoplasma capsulatum infection while living in Africa. Two developed a pulmonary infiltrate, and 2 had skin lesions. One patient was successfully treated with itraconazole, 400 mg daily; in a second patient, itraconazole was partially successful; the third patient was lost to follow-up before adequate treatment could be started. Histoplasma infection is probably an often undiagnosed complication in African AIDS patients.

Histoplasmose disseminada em pacientes com Síndrome de Imunodeficiência Adquirida (SIDA): estudo de 25 casos

São apresentados 25 casos de histoplasmose disseminada em pacientes com SIDA. O envolvimento mucocutâneo estabeleceu o diagnóstico de histoplasmose disseminada em 68% dos casos. Destacamos a importância da histoplasmose como infecção oportunística em paciente HIV positivo.