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Friesen JN, Allman A, Abu Saleh O. 50-Year-Old Man With Fevers, Cough, and Night Sweats. Mayo Clin Proc 2024; 99:821-826. [PMID: 38551539 DOI: 10.1016/j.mayocp.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 05/05/2024]
Affiliation(s)
- Joelle N Friesen
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Alexandra Allman
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Omar Abu Saleh
- Advisor to residents and Consultant in Infectious Disease, Mayo Clinic, Rochester, MN.
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2
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Morton M, Vanguru V, Shin JS, Ronnachit A. Haemophagocytic lymphohistiocytosis secondary to disseminated histoplasmosis in an immunocompetent patient. Med Mycol Case Rep 2024; 43:100635. [PMID: 38425787 PMCID: PMC10904178 DOI: 10.1016/j.mmcr.2024.100635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024] Open
Abstract
Haemophagocytic lymphohistiocytosis secondary to Histoplasma infection is rare and almost always occurs in immunocompromised hosts. We report a 32-year-old immunocompetent man presenting with a nonspecific febrile illness found to have disseminated histoplasmosis and associated haemophagocytic lymphohistiocytosis. The diagnosis was confirmed on histopathological examination and PCR of liver and bone marrow biopsies. He was successfully treated with steroids, intravenous immunoglobulin and itraconazole.
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Affiliation(s)
- Mallory Morton
- Department of Infectious Diseases, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
- Department of Medicine, Campbelltown Hospital, Campbelltown, NSW, 2560, Australia
| | - Vinay Vanguru
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
| | - Joo-Shik Shin
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
- Faculty of Medicine, University of Sydney, Sydney, NSW, 2006, Australia
| | - Amrita Ronnachit
- Department of Infectious Diseases, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
- Faculty of Medicine, University of Sydney, Sydney, NSW, 2006, Australia
- Macfarlane Burnet Institute, Melbourne, VIC, 3004, Australia
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3
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Alagha Z, Bills E, Al-Hiari M, Abdeen AM, Zeid F. Survival Against the Odds-Hemophagocytic Lymphohistiocytosis Amidst the Shadows of Disseminated Histoplasmosis: A Case Report and Literature Review. J Investig Med High Impact Case Rep 2024; 12:23247096241258074. [PMID: 38813977 PMCID: PMC11141221 DOI: 10.1177/23247096241258074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/25/2024] [Accepted: 05/11/2024] [Indexed: 05/31/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) secondary to Histoplasma capsulatum is rare, impacting <1% globally, with a mortality rate of up to 31%. Herein, we present a rare case of HLH secondary to H capsulatum, affecting a 57-year-old female with rheumatoid arthritis. Extensive investigations were unrevealing and despite broad-spectrum antibiotics, her condition worsened, leading to respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support, shock requiring multiple vasopressors, and acute kidney injury (AKI) requiring hemodialysis. Diagnosis confirmed disseminated histoplasmosis (DHP), prompting Amphotericin B and methylprednisolone treatment, resulting in significant improvement and discharge with posaconazole therapy. Secondary HLH, primarily arising from severe infections like DHP, is discussed. Limited research exists on this condition in human immunodeficiency virus (HIV)-seronegative individuals. Diagnosis involves HLH-2004 and HScore criteria. Managing histoplasmosis-associated HLH remains challenging due to multiorgan failure risks and treatment complexities and needs further research.
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Affiliation(s)
| | - Ean Bills
- Joan C. Edwards School of Medicine, Huntington, WV, USA
| | | | | | - Fuad Zeid
- Joan C. Edwards School of Medicine, Huntington, WV, USA
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Chen L, Hu D, Zhang C, Wu T, Cheng X, Hagen F, Zhu H, Deng S. Histoplasmosis: An epidemiological and clinical update in China, review and a case report. Mycology 2023; 15:101-109. [PMID: 38558846 PMCID: PMC10976997 DOI: 10.1080/21501203.2023.2259934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/11/2023] [Indexed: 04/04/2024] Open
Abstract
Histoplasmosis is a systemic mycosis caused by the dimorphic fungus in the genus Histoplasma. Histoplasmosis is overlooked in China. This study aims to provide an epidemiological and clinical update on histoplasmosis in China by literature review. We reviewed cases of histoplasmosis reported in recent 11 years and described a case of histoplasmosis-triggered hemophagocytic lymphohistiocytosis (HLH) in an immunocompetent patient. A total of 225 cases of histoplasmosis diagnosed in China between 2012 and 2022 were involved in this study, compared with 300 cases reviewed from 1990 to 2011, an increasing number of cases of histoplasmosis have been diagnosed in the last 11 years. The majority of cases of histoplasmosis were autochthonous cases, mainly from provinces Sichuan (56/225, 24.9%), Hunan (50/225, 22.2%), Guangdong (31/225, 13.8%), and Yunnan (24/225, 10.7%). Higher incidence (52.5%, 53/99) of histoplasmosis occurred in immunocompetent patients which is similar to those from the previous 21 years, and the prevalence of the disease did not vary highly over time. Of note, the number of histoplasmosis cases is increasing, and the geographic distribution is shifting southwards over time. Improved awareness is critically important for informing clinical practice in China.
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Affiliation(s)
- Lihua Chen
- Department of Medicine Laboratory, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Danyang Hu
- Life Science College, University of Essex, Colchester, UK
| | - Congming Zhang
- Department of hematology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Tianrui Wu
- Department of Medicine Laboratory, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Xiangning Cheng
- Department of Medicine Laboratory, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Ferry Hagen
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands
| | - Hui Zhu
- Department of Gynaecology and Obstetrics, The First Hospital of Suzhou University, Suzhou, China
| | - Shuwen Deng
- Medical Center in The People’s Hospital of SND, Suzhou, China
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5
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Omo-Ogboi AC, Shirai S, Ur Rehman A, Ederhion JO, Buja M. A Rare Case of Disseminated Histoplasmosis With Hemophagocytic Lymphohistiocytosis Mimicking a Flare of Systemic Lupus Erythematosus in a Middle-Aged Man: A Case Report. Cureus 2023; 15:e46068. [PMID: 37900471 PMCID: PMC10604590 DOI: 10.7759/cureus.46068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Disseminated histoplasmosis is a progressive granulomatous disease caused by Histoplasma capsulatum, which is an intracellular dimorphic fungus endemic to the Ohio and Mississippi River valleys in the United States. It is usually thought to be due to the failure of the activation of the T-cell-mediated immune response. Hemophagocytic lymphohistiocytosis (HLH) is a rare but potentially fatal condition, in which histiocytes and lymphocytes build up in and damage organs and other blood cells. We present a 37-year-old man with a past medical history of systemic lupus erythematosus (SLE) complicated by lupus nephritis on immunosuppressive therapy who presented to the emergency department with hypotension and was admitted for acute kidney injury. Prior to the presentation, he had persistent fever, myalgias, cough, mild shortness of breath, and back pain. Computed tomography (CT) chest shows "eggshell" calcification; microbiology evaluation of peripheral blood smear revealed intracellular organism, morphologically consistent with H. capsulatum; and urine histoplasmosis antigen test confirmed the diagnosis of histoplasmosis. HLH diagnosis was made clinically after "clinical and testing criteria" were evaluated. Despite further management, he developed coagulopathy and sepsis, which led to his death. At autopsy, we found organomegaly of the liver, spleen, and kidneys. Microscopically, these enlarged organs show old fibrotic granulomas and granulomatous inflammation with suspected fungal organisms. Gomori's methenamine silver special stain confirmed these fungal organisms to be consistent with Histoplasma species (3-5 micron budding yeasts). This case highlights that physicians should be aware of the diagnostic challenge that disseminated histoplasmosis with HLH could pose in a patient with SLE, especially in patients on immunosuppression. Failure to recognize the infection promptly could lead to grievous complications and possibly death.
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Affiliation(s)
- Allen C Omo-Ogboi
- Department of Pathology and Laboratory Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, USA
| | - Sara Shirai
- Department of Pathology and Laboratory Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, USA
| | - Asad Ur Rehman
- Department of Pathology and Laboratory Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, USA
| | - Joyce O Ederhion
- Department of Neuroscience and Immunology, University of Roehampton, London, GBR
| | - Maximilian Buja
- Department of Pathology and Laboratory Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, USA
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Korzhuk A, Kovalenko I, Rajak K, Cuevas M, Golubykh K, Sangillo M, Toom S, Ramesh N. Sepsis in Immunocompromised Host and a Hematologic Complication. Chest 2023; 164:e47-e55. [PMID: 37558336 DOI: 10.1016/j.chest.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 03/02/2023] [Accepted: 03/06/2023] [Indexed: 08/11/2023] Open
Abstract
CASE PRESENTATION A 43-year-old Puerto Rican man with a kidney transplant presented to the ED with 2 weeks of flu-like symptoms, nausea, and vomiting. He had plasma exchange therapy 2 months before for acute transplant rejection and has been tolerating a heightened immunosuppressive regimen. CT scans characterized opacities as possibly early tree-in-bud opacities (Fig 1A). Patient remained stable throughout hospital stay with an unremarkable workup and was discharged with doxycycline for nonspecific pneumonia.
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Affiliation(s)
- Anatoliy Korzhuk
- Department of Medicine, West Palm Beach VA Medical Center, West Palm Beach, FL.
| | | | - Kripa Rajak
- Department of Medicine, UPMC Harrisburg, Harrisburg, PA
| | - Martin Cuevas
- Department of Medicine, UPMC Harrisburg, Harrisburg, PA
| | | | | | - Sudhamshi Toom
- Department of Hematology and Medical Oncology, UPMC Hillman Cancer Center, Pittsburg, PA
| | - Navitha Ramesh
- Department of Pulmonary and Critical Care Medicine, UPMC Central Pennsylvania, Harrisburg, PA
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Zhang Y, Cheng Z, Hu Y, Tang LV. Management of Complex Infections in Hemophagocytic Lymphohistiocytosis in Adults. Microorganisms 2023; 11:1694. [PMID: 37512867 PMCID: PMC10383929 DOI: 10.3390/microorganisms11071694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive immune system activation and inflammatory response due to a variety of primary and secondary factors that can cause a range of clinical symptoms and, in severe cases, life-threatening conditions. Patients with HLH are at increased risk of infection due to their abnormal immune function as well as chemotherapy and immunosuppressive therapy at the time of treatment. At the same time, the lack of specific clinical features makes complex infections in HLH challenging to diagnose and treat. The management of complex infections in HLH requires a multidisciplinary and integrated approach including the early identification of pathogens, the development of anti-infection protocols and regimens, and the elimination of potential infection factors. Especially in HLH patients with septic shock, empirical combination therapy against the most likely pathogens should be initiated, and appropriate anti-infective regimens should be determined based on immune status, site of infection, pathogens, and their drug resistance, with timely antibiotic adjustment by monitoring procalcitonin. In addition, anti-infection prophylaxis for HLH patients is needed to reduce the risk of infection such as prophylactic antibiotics and vaccinations. In conclusion, complex infection in HLH is a serious and challenging disease that requires vigilance, early identification, and timely anti-infective therapy.
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Affiliation(s)
- Yi Zhang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
| | - Zhipeng Cheng
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
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Ehrlichiosis-Associated Hemophagocytic Lymphohistiocytosis: A Case Series and Review of the Literature. Case Rep Hematol 2023; 2023:5521274. [PMID: 36846547 PMCID: PMC9946753 DOI: 10.1155/2023/5521274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/18/2023] Open
Abstract
Background Human monocytic ehrlichiosis (HME) is a potentially life-threatening tick-borne illness. HME-associated hemophagocytic lymphohistiocytosis (HLH) is a rare entity with a paucity of published literature regarding treatment and outcome. We present the clinical features, treatment, and outcomes of 4 patients at our institutions with HME-associated HLH. This review also summarizes the current literature regarding the presentation, treatment, and outcome of this infection-related HLH. Methods We searched the PubMed database for case reports and case series. All cases were diagnosed according to the HLH-04 criteria. Results Four cases of HME-associated HLH were included from our institutions. The literature review yielded 30 additional cases. About 41% of the cases were in the pediatric population; 59% were female; and all patients had fever, cytopenia, and elevated ferritin. Most patients were immunocompetent; all but one patient with available data were treated with doxycycline, and eight of the patients with available data received the HLH-94 treatment protocol. The mortality rate was 17.6%. Conclusions HME-associated HLH is a rare but serious syndrome with significant mortality. Early treatment with doxycycline is critical, but the role of immunosuppressive therapy is individualized.
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Two Cases of Hemophagocytic Lymphohistiocytosis Associated with Disseminated Histoplasmosis Presented with Transient Pancytopenia. Case Rep Med 2022; 2022:9521128. [PMID: 36620355 PMCID: PMC9812595 DOI: 10.1155/2022/9521128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022] Open
Abstract
Transient pancytopenia due to reactive bone marrow suppression often occurs in hemophagocytic lymphohistiocytosis (HLH), a syndrome resulting from excessive immune activation following a severe infection. We reported two cases with pancytopenia and disseminated histoplasmosis accompanied by HLH, initially suspected to be blood malignancies. Our first case documented the relevance between the improvement of pancytopenia and the clearance of Histoplasma capsulatum in serial bone marrow aspirations. The second case showed immense Histoplasma engulfment by the macrophage in relation to a severe clinical condition, followed by improvement of clinical symptoms in accordance with the recovery of pancytopenia. These two cases highlighted the importance of comprehensive and critical analysis for cases with concurrent pancytopenia and severe infection, since it may be that the pancytopenia underlies the severe infection or vice versa.
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Cirotski DS, Cunningham MT, Loew T, Panicker J. Hemophagocytic Lymphohistiocytosis Syndrome Secondary to Disseminated Histoplasmosis in a Presumably Immunocompetent Adolescent: A Novel Case. Pediatr Hematol Oncol 2022; 39:755-761. [PMID: 35476626 DOI: 10.1080/08880018.2022.2055246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Daniel S Cirotski
- University of Kansas School of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Mark T Cunningham
- Department of Pathology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Thomas Loew
- Division of Pediatric Hematology/Oncology, University of Kansas School of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jyoti Panicker
- Division of Pediatric Hematology/Oncology, University of Kansas School of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
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Hofmann E, Mühlethaler K, Pollak M, Ott D, Bienz N, Zimmerli S, Hirzel C. Travel related histoplasmosis – a diagnostic challenge in a patient with tumor necrosis factor alpha (TNF-α) inhibitor therapy. Trop Dis Travel Med Vaccines 2022; 8:21. [PMID: 36104715 PMCID: PMC9476690 DOI: 10.1186/s40794-022-00178-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/11/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction In a non-endemic setting, disseminated histoplasmosis is a rare travel-related health problem of immunosuppressed returnees from endemic regions. Methods We describe the case of a 68-year-old man with rheumatoid arthritis and tumor necrosis factor alpha (TNF-α) inhibitor treatment-related immunodeficiency, who suffered from disseminated histoplasmosis after traveling to Brazil. Based on this case, we discuss challenges and pitfalls associated with the diagnosis of disseminated histoplasmosis in a non-endemic setting. Results The disease mimicked a hemophagocytic lymphohistiocytosis (HLH) like syndrome. Histoplasma capsulatum was microscopically detected in bronchoalveolar fluid and bone marrow aspirate smears, but was initially misclassified as Leishmania spp., another class of pathogens, which may cause HLH like syndromes in immunocompromised individuals. Discussion Since the clinical symptoms of histoplasmosis are nonspecific and physicians in non-endemic regions might not be familiar with this disease pattern, there is a risk of delayed diagnosis of travel related cases. Taking a thorough travel history is key in unclear cases of illness in immunocompromised patients.
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Updates on Histoplasmosis in Solid Organ Transplantation. CURRENT FUNGAL INFECTION REPORTS 2022; 16:165-178. [PMID: 36097519 PMCID: PMC9453730 DOI: 10.1007/s12281-022-00441-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/03/2022]
Abstract
Purpose of Review Recent Findings Summary
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Touza M, Mutyala M, Chowdhury S, Slim J. An Unusual Case of Secondary Hemophagocytic Lymphohistiocytosis in a Patient Diagnosed With Triple Infection: COVID-19, HIV, and Histoplasmosis. Cureus 2022; 14:e26428. [PMID: 35915696 PMCID: PMC9337782 DOI: 10.7759/cureus.26428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
In this study, we present a unique instance of a patient who developed hemophagocytic lymphohistiocytosis secondary to a triple infection with coronavirus disease 2019 (COVID-19), HIV, and histoplasmosis. We emphasize the proinflammatory dysregulations driving the severity of COVID-19 infection in this setting and highlight the importance of early diagnosis and targeted therapy of underlying conditions as a method to increase the chance of survival.
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Adamian CMC, de Lima Mota MA, Martins AAF, Aragão MC, Carvalho MS, Meneses GC, Silva Júnior GBD, Leitão TDMJS, De Francesco Daher E. Progressive disseminated histoplasmosis in HIV-positive patients. Int J STD AIDS 2022; 33:544-553. [PMID: 35343333 DOI: 10.1177/09564624221076605] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Histoplasmosis is the most common endemic mycosis among people living with advanced HIV infection. PURPOSE Describe general aspects and challenges of this disease and its association with HIV. RESEARCH DESIGN Review of literature. STUDY SAMPLE Articles found using different combinations of terms including "disseminated histoplasmosis" and AIDS/HIV or immunosuppression in PubMed, Scopus, WHO Global health library, and Scielo database. ANALYSIS We look for information on epidemiology, pathogenesis, diagnosis, and treatment of histoplasmosis in AIDS patients. RESULTS Histoplasmosis is caused by Histoplasma capsulatum, a dimorphic fungus encountered throughout the world, mainly in soil enriched with bat and bird excreta. Progressive disseminated histoplasmosis is the main presentation of this mycosis in people living with advanced HIV and is fatal if left untreated. Symptoms include a systemic disease characterized by fever, weight loss, night sweats, skin manifestations, hepatomegaly, splenomegaly, and septic shock. Diagnostic tests include culture, visualization of H. capsulatum by direct and histopathological examination, serology, antigen, molecular, and skin testing. Patients with disseminated disease require aggressive and prolonged treatment to eradicate the pathogen and include amphotericin B and itraconazole. In many low income countries of endemic regions, histoplasmosis in HIV-positive patients is often undiagnosed or misdiagnosed as another opportunistic infection, due to the similarity in clinical manifestations and to the paucity of better diagnostic tests. CONCLUSION Histoplasmosis remains a neglected disease. Few studies about the disease and expensive treatments make it difficult to reduce the morbidity and mortality of this condition. Public health services and physicians must be aware of histoplasmosis' burden among the HIV-positive population.
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Affiliation(s)
- Caio Manuel Caetano Adamian
- Medical Sciences Post-Graduate Program, Department of Internal Medicine, 28121Federal University of Ceará, Fortaleza, Brazil
| | - Matheus Alves de Lima Mota
- Medical Sciences Post-Graduate Program, Department of Internal Medicine, 28121Federal University of Ceará, Fortaleza, Brazil.,School of Medicine, 28128University of Fortaleza, Fortaleza, Brazil
| | - Augusto Adler Freire Martins
- Medical Sciences Post-Graduate Program, Department of Internal Medicine, 28121Federal University of Ceará, Fortaleza, Brazil
| | - Matheus Cardoso Aragão
- Medical Sciences Post-Graduate Program, Department of Internal Medicine, 28121Federal University of Ceará, Fortaleza, Brazil
| | - Marina Santos Carvalho
- Medical Sciences Post-Graduate Program, Department of Internal Medicine, 28121Federal University of Ceará, Fortaleza, Brazil
| | | | | | | | - Elizabeth De Francesco Daher
- Medical Sciences Post-Graduate Program, Department of Internal Medicine, 28121Federal University of Ceará, Fortaleza, Brazil
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Disseminated histoplasmosis and hemophagocytic lymphohistiocytosis in a patient receiving TNF-alpha inhibitor therapy. IDCases 2022; 29:e01603. [PMID: 36039152 PMCID: PMC9418189 DOI: 10.1016/j.idcr.2022.e01603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/16/2022] [Accepted: 08/16/2022] [Indexed: 11/23/2022] Open
Abstract
Histoplasmosis commonly presents as an asymptomatic or self-limited infection in immunocompetent patients, but immunocompromised hosts may present with severe and disseminated disease. Herein, we present a 26-year-old male with history of ulcerative colitis receiving long-term TNF-alpha inhibitor therapy who presented with six months of diarrhea and recently fever and hematochezia. On admission, he was febrile and hypotensive, with initial workup revealing pancytopenia and imaging reporting pulmonary infiltrates, pancolitis, and enlarged mesenteric lymph nodes. Disseminated histoplasmosis was ultimately diagnosed after examination of the colonic biopsy. Bone marrow biopsy was also consistent with the diagnosis of histoplasmosis but also demonstrated hemophagocytic lymphohistiocytosis. The patient was ultimately treated with amphotericin B, intravenous immunoglobulin, etoposide, and corticosteroids.
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Fogelson B, Patel K, Spoons J, Stephens S, Edwards M. Hemophagocytic lymphohistiocytosis secondary to disseminated histoplasmosis, cytomegalovirus viremia, and nontuberculous mycobacteria bacteremia in a patient with recently diagnosed AIDS. IDCases 2022; 29:e01612. [PMID: 36051987 PMCID: PMC9424532 DOI: 10.1016/j.idcr.2022.e01612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/19/2022] [Accepted: 08/20/2022] [Indexed: 11/30/2022] Open
Abstract
A 30-year-old Honduran male with recently diagnosed AIDS presented with a 1-month history of worsening abdominal pain, diarrhea, and fever. Initial investigations were notable for Cytomegalovirus viremia and diffuse lymphadenopathy. Axillary lymph node biopsy demonstrated necrotizing lymphadenitis with disseminated histoplasmosis. Despite aggressive antimicrobial therapy he continued to clinically deteriorate raising suspicion for hemophagocytic lymphohistiocytosis. The patient met 5 of 8 HLH-2004 diagnostic criteria and was successfully treated with dexamethasone and etoposide per the HLH-94 protocol. Despite the high mortality rates and poor clinical outcomes of hemophagocytic lymphohistiocytosis in patients living with HIV/AIDS, this case demonstrates that this high-risk patient population can be successfully treated and survive acquired hemophagocytic lymphohistiocytosis. Furthermore, our case stresses the importance of maintaining a broad differential diagnosis in patients living with HIV/AIDS who present with sepsis.
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Hemophagocytic lymphohistiocytosis secondary to progressive disseminated histoplasmosis presenting as cellulitis. Med Mycol Case Rep 2021; 33:18-20. [PMID: 34307009 PMCID: PMC8258778 DOI: 10.1016/j.mmcr.2021.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/16/2021] [Accepted: 06/18/2021] [Indexed: 11/24/2022] Open
Abstract
Histoplasmosis-associated hemophagocytic lymphohistiocytosis is a rate but lethal disease in immunocompromised hosts. Unusual clinical presentations make diagnosing invasive fungal infection even more challenging. Here we present a case of hemophagocytic lymphohistiocytosis secondary to progressive disseminated histoplasmosis presenting as cellulitis in a patient with systemic lupus erythematous. A high index of suspicion combined with histopathology and molecular diagnostic techniques are important to establish an accurate and timely diagnosis of opportunistic infections in immunocompromised patients.
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Abstract
Histoplasmosis is one of the commonest endemic mycoses in the Americas yet is often underdiagnosed and neglected as a public health priority. This review outlines the evolving understanding of its epidemiology and the clinical syndromes of histoplasmosis, in addition to up-to-date diagnostic and treatment guidelines. A focus on histoplasmosis in advanced HIV is included. The challenges pertinent to histoplasmosis management in Latin America, with recommendations made through international expert consensus are discussed.
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Affiliation(s)
- Ana Belén Araúz
- Department of Infectious Diseases, Pasteur Suite, Ealing Hospital, London North West University Healthcare NHS Trust, Uxbridge Road, London, UB1 3HW, UK; Infectious Diseases Department, Hospital Santo Tomas, Avenida Balboa, Panama City, Panama
| | - Padmasayee Papineni
- Infectious Diseases Department, Hospital Santo Tomas, Avenida Balboa, Panama City, Panama.
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19
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McKinsey DS. Treatment and Prevention of Histoplasmosis in Adults Living with HIV. J Fungi (Basel) 2021; 7:jof7060429. [PMID: 34071599 PMCID: PMC8229061 DOI: 10.3390/jof7060429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 05/22/2021] [Accepted: 05/25/2021] [Indexed: 11/16/2022] Open
Abstract
Histoplasmosis causes life-threatening disseminated infection in adult patients living with untreated HIV. Although disease incidence has declined dramatically in countries with access to antiretroviral therapy, histoplasmosis remains prevalent in many resource-limited regions. A high index of suspicion for histoplasmosis should be maintained in the setting of a febrile multisystem illness in severely immunosuppressed patients, particularly in persons with hemophagocytic lymphohistiocytosis. Preferred treatment regimens for initial therapy include liposomal amphotericin B for severe disease, or itraconazole for mild to moderate disease. Subsequently, itraconazole maintenance therapy should be administered for at least one year and then discontinued if CD4 count increases to ≥150 cells/µL. Antiretroviral therapy, which improves outcome when administered together with an antifungal agent, should be instituted immediately, as the risk of triggering Immune Reconstitution Syndrome is low. The major risk factor for relapsed infection is nonadherence. Itraconazole prophylaxis reduces risk for histoplasmosis in patients with CD4 counts <100/µL but is not associated with survival benefit and is primarily reserved for use in outbreaks. Although most patients with histoplasmosis have not had recognized high-risk exposures, avoidance of contact with bird or bat guano or inhalation of aerosolized soil in endemic regions may reduce risk. Adherence to effective antiretroviral therapy is the most important strategy for reducing the incidence of life-threatening histoplasmosis.
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Affiliation(s)
- David S McKinsey
- Metro Infectious Disease Consultants, Kansas City, MO 64132, USA
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20
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Dean O, Anjum S, Hess B, Hammoud DA, Athas D, Wheat J, Williamson PR. Central Nervous System Histoplasma-Associated Post-infectious Inflammatory Response Syndrome (Histo-PIIRS). J Clin Immunol 2021; 41:545-551. [PMID: 33387157 PMCID: PMC7776302 DOI: 10.1007/s10875-020-00954-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 12/22/2020] [Indexed: 11/25/2022]
Abstract
We present a case of central nervous system (CNS) histoplasmosis in a previously healthy adult with hepatitis C (HCV) presenting with neurological symptoms refractory to antifungal therapy and ventriculoperitoneal (VP) shunting 4 months after initial diagnosis. Persistent symptoms were thought to be inflammatory rather than infectious given negative cerebrospinal fluid (CSF) and serum fungal antigens. The patient promptly improved after initiation of corticosteroid therapy. Elevated CSF cytokines and regional enhancement on brain MRI resolved with corticosteroid treatment. This is the first case of Histoplasma-associated post-infectious inflammatory response syndrome (Histo-PIIRS) documented by CSF cytokine reduction in response to corticosteroid therapy.
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Affiliation(s)
- Owen Dean
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bld 10, Rm 11C208, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Seher Anjum
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bld 10, Rm 11C208, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Bryan Hess
- Division of Infectious Diseases, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Dima A Hammoud
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Deena Athas
- Division of Infectious Diseases, Gundersen Health System, La Crosse, WI, USA
| | | | - Peter R Williamson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bld 10, Rm 11C208, 9000 Rockville Pike, Bethesda, MD, 20892, USA.
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21
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Nguyen D, Nacher M, Epelboin L, Melzani A, Demar M, Blanchet D, Blaizot R, Drak Alsibai K, Abboud P, Djossou F, Couppié P, Adenis A. Hemophagocytic Lymphohistiocytosis During HIV Infection in Cayenne Hospital 2012-2015: First Think Histoplasmosis. Front Cell Infect Microbiol 2020; 10:574584. [PMID: 33072627 PMCID: PMC7542182 DOI: 10.3389/fcimb.2020.574584] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/19/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction: Haemophagocytic Lymphohistiocytosis (HLH), during HIV infection is a rare complication with a poor prognosis. There are few data on HLH within the Amazon region. The objective was to describe epidemiological, clinical and therapeutic features of HIV-related HLH in French Guiana. Methods: A retrospective analysis of adult HIV patients at Cayenne hospital with HLH between 2012 and 2015. A diagnosis of HLH was given if the patient presented at least 3 of 8 criteria of the HLH-2004 classification. Results: Fourteen cases of HLH were tallied during the study period. The mean age was 46 years with a sex ratio of 1.8. The most frequent etiology of HLH was an associated infection (12/14). Confirmed disseminated histoplasmosis, was found in 10 of 14 cases, and it was suspected in 2 other cases. The CD4 count was below 200/mm3 in 13/14 cases. An HIV viral load >100,000 copies/ml was observed in 13/14 cases. An early treatment with liposomal amphotericin B was initiated in 12/14 cases. The outcome was favorable in 12/14 of all cases and in 10/12 cases involving histoplasmosis. Case fatality was 2/14 among all cases (14.3%) et 1/10 among confirmed disseminated histoplasmosis with HLH (10%). During the study period 1 in 5 cases of known HIV-associated disseminated histoplasmosis in French Guiana was HLH. Conclusion: Histoplasmosis was the most frequent etiology associated with HLH in HIV-infected patients in French Guiana. The prognosis of HLH remains severe. However, a probabilistic empirical first line treatment with liposomal amphotericin B seemed to have a favorable impact on patient survival.
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Affiliation(s)
- Duc Nguyen
- Centre d'Investigation Clinique Antilles Guyane, INSERM 1424, Centre Hospitalier de Cayenne, Cayenne, French Guiana
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Mathieu Nacher
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
- COREVIH Guyane, Centre Hospitalier de Cayenne, Cayenne, French Guiana
- DFR Santé, Université de Guyane, Cayenne, French Guiana
| | - Loic Epelboin
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Alessia Melzani
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Magalie Demar
- DFR Santé, Université de Guyane, Cayenne, French Guiana
- UMR TBIP, Université de Guyane, Cayenne, French Guiana
- Laboratory, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Denis Blanchet
- UMR TBIP, Université de Guyane, Cayenne, French Guiana
- Laboratory, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Romain Blaizot
- Service de Dermatologie-Vénéréologie, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Kinan Drak Alsibai
- Service d'Anatomopathologie, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Philippe Abboud
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Félix Djossou
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
- UMR TBIP, Université de Guyane, Cayenne, French Guiana
| | - Pierre Couppié
- DFR Santé, Université de Guyane, Cayenne, French Guiana
- Service de Dermatologie-Vénéréologie, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Antoine Adenis
- Centre d'Investigation Clinique Antilles Guyane, INSERM 1424, Centre Hospitalier de Cayenne, Cayenne, French Guiana
- COREVIH Guyane, Centre Hospitalier de Cayenne, Cayenne, French Guiana
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A Case of Hemophagocytic Lymphohistiocytosis Secondary to Disseminated Histoplasmosis. Case Reports Hepatol 2020; 2020:6901514. [PMID: 32884850 PMCID: PMC7455843 DOI: 10.1155/2020/6901514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/30/2020] [Accepted: 08/14/2020] [Indexed: 11/23/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare condition characterized by a pathologic immune dysregulation resulting in extreme inflammation. Clinical manifestations are varied but can include severe multiorgan failure and death. HLH has been associated with malignancies, autoimmune diseases, and infections, such as histoplasmosis. Histoplasmosis commonly has subclinical manifestations but can also present in its disseminated form. We present the case of an immunocompromised patient with worsening liver function caused by hepatic histoplasmosis that later triggered HLH with severe multiorgan dysfunction.
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Hemophagocytic Lymphohistiocytosis (HLH) in a Patient with Disseminated Histoplasmosis. Case Rep Hematol 2020; 2020:5638262. [PMID: 32765915 PMCID: PMC7387958 DOI: 10.1155/2020/5638262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/08/2020] [Accepted: 07/01/2020] [Indexed: 11/18/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare condition characterized by an overwhelming inflammatory cascade activation which is often associated with rapid progression and high mortality. It may be familial with an underlying genetic mutation or triggered by infection, malignancy, and autoimmune disease. Disseminated histoplasmosis caused by histoplasma capsulatum is a granulomatous fungal disease seen typically in immunocompromised patients with varied clinical manifestations and requires long-term antifungal therapy. We present the case of a 61-year-old immunocompromised female with significant travel history who came with fever, pancytopenia, and liver failure raising suspicion for HLH that prompted a bone marrow biopsy procedure. Hemophagocytic figures consistent with HLH and numerous encapsulated fungi resembling histoplasma were visualized. She was treated with intravenous (IV) liposomal amphotericin B. Etoposide chemotherapy and interleukin-1 (IL-1) antagonist anakinra were deferred in order to limit her immunosuppression, and treatment was focused on antifungal therapy.
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