DISSEMINATED HISTOPLASMOSIS FOLLOWING LONG-TERM STEROID THERAPY FOR RETICULOSARCOMA

Chronic cavitary pulmonary histoplasmosis in a non-HIV and immunocompromised patient without overseas travel history

Korea is not known as an endemic area for Histoplasma. However, we experienced a case of histoplasmosis in a person who had never been abroad. A 65-year-old female was admitted to the hospital for evaluation of multiple lung nodules. A computed tomography (CT) scan of the chest showed multiple ill-defined consolidations and cavitations in all lobes of both lungs. The patient underwent a CT-guided lung biopsy, and a histopathology study showed findings compatible with histoplasmosis. Based on biopsy results and clinical findings, the patient was diagnosed with chronic cavitary pulmonary histoplasmosis. The patient recovered completely following itraconazole treatment. This is the first case report of pulmonary histoplasmosis unconnected with either HIV infection or endemicity in Korea.

A case of oral ulceration and disseminated histoplasmosis in HIV infection

A 51-year-old Malawian woman presented with persistent mouth ulceration and an eight-month history of non-specific respiratory symptoms. Histoplasma capsulatum was diagnosed on gum, gastric and lymph node biopsies. Identification of H. capsulatum prompted HIV testing and the patient tested positive with a CD4 count of 40 cells/mm(3). The diagnosis of histoplasmosis was delayed due to its unusual presentation.

Histoplasmosis of kidneys presenting as chronic recurrent renal disease

Histoplasmosis is a well-known infectious disease that can sometimes run a mysterious and unexpected course. A case is reported that presented as a chronic renal process, with right pyelocutaneous fistula and prolonged purulent discharge as well as focal calcifications of the left kidney with recurrent stone formation. Histopathologic examination of the right kidney, removed in 1975, showed noncaseating granulomas, but the precise diagnosis was not made until 1983, when histopathologic re-examination followed partial resection of the left kidney, for recurrent stone formation. This article emphasizes the difficulty in diagnosing a noncaseating granulomatous disease in general and histoplasmosis in particular, especially when the urogenital tract is involved, with isolated local manifestations. It underlines the progressive and damaging character of this chronic disease, the variety of its manifestations, and attempts to increase awareness of this potentially treatable disease.

Histoplasmosis in immunosuppressed patients

Infection with Histoplasma capsulatum in 58 patients whose immune responses were suppressed (Immunosuppressed patients) (16 from the present series and 42 described previously) was analyzed. The most common underlying diseases were Hodgkin's disease (29 per cent), chronic lymphocytic leukemia (19 per cent) and acute lymphocytic leukemia (17 per cent). Sixty-three per cent of the patients had received cytotoxic drugs, and 57 per cent had taken corticosteroids. Widely disseminated infection occurred in 88 per cent of the patients, with predominant involvement of lungs and organs of the reticuloendothelial system. Localized pulmonary infection was present in the remaining patients. The most useful diagnostic method was bone marrow biopsy with microscopic examination for the intracellular yeast form of H. capsulatum. Biopsy of oral lesions, lung, liver and lymph node also proved diagnostically helpful. Growth of H. capsulatum in culture was frequently too slow to be beneficial in diagnosing histoplasmosis in ill patients. Serologic methods were of little diagnostic help in this population of immunosuppressed patients. The response to amphotericin B therapy was excellent (6.7 per cent mortality rate) in those patients in whom the diagnosis was established early and in whom a full course of antifungal therapy could be given. In contrast, the mortality rate in patients who received no antifungal therapy or less than 1 g of amphotericin B was 100 per cent.

Left atrial myxoma infected with Histoplasma capsulatum

A patient is presented in whom a left atrial myxoma was found to be infected with Histoplasma capsulatum. Histoplasmosis has not been previously associated with this tumor, nor has any fungus without preceding bacterial endocarditis and long-term antibiotic therapy. The clinical course in foru previously reported cases of bacterially infected myxoma is reviewed. There have been 18 prior cases of Histoplasma endocarditis and in two the patients have survived. Their clinical presentation and response to therapy are also reviewed, and pertinent therapeutic conclusions drawn. The role of echocardiography in this patient's evaluation and the ultimate successful therapy are discussed.

Histoplasmosis. A review, and account of three patients diagnosed in Great Britain

Active histoplasmosis is rarely diagnosed in Great Britain. We present the illness records of three patients with disseminated histoplasmosis. In two patients the infection was discovered at necropsy and resulted in caseous destruction of the adrenal glands, and in one of these there was also fungal invasion of the liver and wall of the aorta. The third patient had Addison's disease and also a chronic tongue ulcer from which the fungus was cultured by biopsy.

The eight other patients with disseminated histoplasmosis and the six with active localized disease previously reported in Great Britain are reviewed.

The natural history of the disease, with emphasis on the prolonged incubation period of up to 18 years, is described. Granulomatous ulceration of the oropharynx and larynx and caseous destruction of the adrenal glands may be characteristic features.

Diagnosis usually requires a history of a stay in endemic regions. It is suggested by the clinical picture and positive complement fixation or precipitin tests and it is confirmed by culture of the fungus which may also be recognized in histological preparations. Histoplasmin skin tests are usually negative.

Standard treatment is with intravenous amphotericin B, but in our surviving patient a chronic tongue ulcer of nine years' duration showed considerable healing after 10 months' oral treatment with trimethoprim-sulphamethoxazole in combination.

Morbid anatomical and histological features of unusual infections

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Disseminated histoplasmosis occurring in association with systemic lupus erythematosus

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