Histoplasmosis in Israeli travelers

Pulmonary histoplasmosis diagnosed in a Japanese woman after traveling to central and South America: A case report

Histoplasmosis is a fungal infection caused by Histoplasma capsulatum, and Japan is considered a non-endemic area for histoplasmosis. Most patients diagnosed with histoplasmosis in the past usually have exposure to caves and bat guano with travel history to endemic areas. Therefore, travel history and risk activities should be comprehensively assessed when suspecting histoplasmosis because this important information may be overlooked. Although few, possibilities of indigenous cases have also been suggested. Moreover, it is assumed that the number of travelers and endemic mycoses has decreased with the recent coronavirus disease 2019 epidemic. However, clinicians should carefully consider the differential diagnosis of histoplasmosis for travelers traveling to endemic areas. In this case report, we describe an immunocompetent Japanese woman who developed histoplasmosis due to a history of travel to an endemic country. Our case report suggests that clinicians should not exclude histoplasmosis from the differential diagnosis even in the absence of risk features such as activities or immunodeficiencies during travel.

Histoplasmosis Diagnosed in Europe and Israel: A Case Report and Systematic Review of the Literature from 2005 to 2020

Human histoplasmosis is a mycosis caused by two distinct varieties of a dimorphic fungus: Histoplasma capsulatum var. capsulatum and H. capsulatum var. duboisii. In Europe, it is usually imported by migrants and travellers, although there have been some autochthonous cases, especially in Italy; however, most European physicians are unfamiliar with its clinical and pathological picture, particularly among immunocompromised patients without HIV infection. This systematic review of all the cases of histoplasmosis reported in Europe and Israel between 2005 and 2020 identified 728 cases diagnosed in 17 European countries and Israel described in 133 articles. The vast majority were imported (mainly from Central and South America), but there were also seven autochthonous cases (six in Europe and one in Israel). The patients were prevalently males (60.4%), and their ages ranged from 2 to 86 years. The time between leaving an endemic region and the diagnosis of histoplasmosis varied from a few weeks to more than 40 years. Progressive disseminated histoplasmosis was the most frequent clinical picture among people living with HIV infection (89.5%) or a different immunocompromising condition (57.1%), but it was also recorded in 6.2% of immunocompetent patients. Twenty-eight cases were caused by Histoplasma duboisii. Immunocompromised patients without HIV infection had the worst outcomes, with a mortality rate of 32%.

Disseminated histoplasmosis in a heart transplant recipient from Saudi Arabia: A case report

Histoplasma is endemic in North and Central America. We describe a case of disseminated histoplasmosis in a heart transplant recipient outside the known endemic areas. A 68-year-old gentleman known to have dilated cardiomyopathy. He underwent left ventricular assist device (LVAD) implantation in India and 2 years later did heart transplant in King Faisal Specialist and Research Center Hospital. Six weeks post-transplant he presented with headache and fever. All investigations were negative, and he was discharged home. Four days after discharge he presented with headache, fever, blurred vision, and an episode of loss of consciousness. Examination showed an ill looking patient who is highly febrile. Repeated work up showed pancytopenia. A repeat LP was negative. Bone marrow biopsy showed Small intracellular organisms. Extended work up revealed a positive Histoplasma urinary antigen, positive Histoplasma PCR from the bone marrow biopsy. Patient was started on Liposomal Amphotericin followed by Itraconazole with marker clinical improvement. This is the first reported case of disseminated Histoplasmosis in Saudi Arabia. We postulate that the patient had reactivation of a latent infection acquired at the time of LVAD insertion in India rather than donor derived infection by the negative fungal culture and PCR done on the donor's lung granuloma tissue.

Subcutaneous Mycoses in Travelers

Purpose of Review

The increase in international travel in recent decades has contributed to the risk of acquiring diseases considered endemic to a region or country and the change in the epidemiology of these diseases. Endemic mycoses that may be acquired by travelers in the short or long term are endemic subcutaneous mycoses such as sporotrichosis and lobomycosis, while endemic systemic mycoses are a group of serious diseases including histoplasmosis and coccidioidomycosis. Herein, we review the current knowledge and highlight the most important aspects of these fungal infections in travelers.

Recent Findings

The most relevant advances in the study of these mycoses involve the epidemiological distribution; human mycoses can be fatal and there are few antifungal drugs available, increasing drug resistance, and a risk of emerging fungal diseases associated with climate change, as well as the increasing virulence, and the diagnostic strategies that may be limited in many countries.

Summary

Although endemic mycoses are relatively rare, they should be considered as potentially travel-related illnesses. A recent or late trip to an endemic country may guide the clinical suspicion, an early diagnosis, and the institution of effective therapy.

Immunodiagnostic Assays for the Investigation of Fungal Outbreaks

Fungal pathogens can affect humans, animals, and plants, and they can be found in the environment or as part of the host microbiome. Fungal diseases present a broad clinical spectrum, ranging from superficial to invasive infections, and can cause outbreaks. During an outbreak investigation, the laboratory plays an essential role in verifying the diagnosis and helping to confirm the source of the outbreak. Immunodiagnostic assays are important tools and often relied upon for the diagnosis of fungal infections, since the gold standard assays of culture and histopathology are time-consuming and often require invasive procedures. Immunodiagnostic assays range from complement fixation and immunodiffusion to enzyme immunoassays and, most recently, to point-of-care lateral flow devices. In general, these assays provide results faster and offer good analytical performance. These characteristics make immunodiagnostic assays good laboratory tools for outbreak investigations. The aim of this review is to describe the principles, advantages, limitations, and availability of immunodiagnostics assays in outbreak investigations, based on the experience of a reference laboratory.

Timely Diagnosis of Histoplasmosis in Non-endemic Countries: A Laboratory Challenge

Human histoplasmosis is a fungal infection caused by the inhalation of microconidia of the thermally dimorphic fungi Histoplasma capsulatum. Autochthonous cases of histoplasmosis have been diagnosed in almost every country, but it is considered an endemic infection in specific areas of the world. Many of them are popular travel destinations or the source of migratory movements. Thus, the vast majority of the registered cases in non-endemic countries are imported. They correspond to people having been exposed to the fungus in endemic locations as immigrants, expatriates, transient workers or tourists, with reported cases also associated to organ donation. Misdiagnosis and delays in initiation of treatment are not uncommon in cases of imported histoplasmosis. They are associated to high fatality-rates specially in patients with compromised cellular immunity in which progressive disseminated forms develop. The diagnosis of this infection in non-endemic countries is hampered by the lack of clinical suspicion and a dearth of available diagnostic tools adequate to offer rapid and accurate results. Non-culture-based assays such as nucleic-acid amplification tests present as a suitable alternative in this situation, offering improved sensitivity and specificity, shortened turnaround time, and increased biosafety by avoiding culture manipulation. In non-endemic regions, molecular techniques are being used mainly in laboratories from countries that have registered an increase in the incidence of imported cases. However, the number of published techniques is limited and lack consensus. Efforts are currently under way to standardize nucleic acid amplification-based techniques for its implementation in areas registering a rising number of imported cases.

Acute histoplasmosis in travelers: a retrospective study in an Italian referral center for tropical diseases

Purpose: Histoplasmosis is a fungal infection acquired through inhalation of Histoplasma capsulatum microconidia, mostly present in the Americas. Both immunocompetent and immunocompromised patients can present a wide spectrum of signs/symptoms, ranging from mild disease to a severe, disseminated infection. The aim of this observational study is to describe histoplasmosis cases diagnosed in travelers and their clinical/radiological and therapeutic pattern.Methods: Retrospective study at the Department of Infectious - Tropical Diseases and Microbiology (DITM) of Negrar, Verona, Italy, between January 2005 and December 2015.Results: Twenty-three cases of acute histoplasmosis were diagnosed, 17 of which belong to the same cluster. Seven of the 23 patients (30.4%) were admitted to hospital, four of whom underwent invasive diagnostic procedures. Thirteen patients (56.5%) received oral itraconazole. All patients recovered, although nine (39.1%) had radiological persisting lung nodules at 12 month follow up.Conclusions: Clinical, laboratory and radiological features of histoplasmosis can mimic other conditions, resulting in unnecessary invasive diagnostic procedures. However, a history of travel to endemic areas and of exposure to risk factors (such as visits to caves and presence of bats) should trigger the clinical suspicion of histoplasmosis. Treatment may be indicated in severe or prolonged disease.

Histoplasmosis in an elderly polish tourist - a case report

BACKGROUND

Histoplasmosis is a mycosis caused by soil-based fungus Histoplasma capsulatum endemic in the USA, Latin America, Africa and South-East Asia. The disease is usually self-resolving, but exposure to a large inoculum or accompanying immune deficiencies may result in severe illness. Symptoms are unspecific with fever, cough and malaise as the most common. Thus, this is a case of disease which is difficult to diagnose and very rare in Europe. As a result, it is usually not suspected in elderly patients with cough and dyspnea.

CASE PRESENTATION

This is a case of a 78-year-old patient, admitted to our department due to respiratory failure, cough, shortness of breath, fever and weight loss with no response to antibiotics administered before the admission. Chest CT revealed numerous reticular and nodular infiltrations with distribution in all lobes. The cytopathology of BAL showed small parts of mycelium and numerous oval spores. Considering clinical presentation and history of travel to Mexico before onset of disease, pulmonary histoplasmosis was diagnosed. After introduction of antifungal treatment rapid improvement was achieved in terms of both clinical picture and respiratory function.

CONCLUSIONS

Since the risk of Histoplasma exposure in Europe is minimal, patients, who present with dyspnea, fever and malaise are not primarily considered for diagnosis of histoplasmosis. However, taking into account increasing popularity of travelling, also by elderly or patients with impaired immunity, histoplasmosis should be included into differential diagnosis.

Acute histoplasmosis in immunocompetent travelers: a systematic review of literature

Background

Histoplasmosis is a fungal infection highly endemic in the American continent. The disease can be severe in immunocompromised subjects. In immunocompetent subjects the clinical manifestations are variable. Aim of this work was to review the cases of acute histoplasmosis in immunocompetent travelers reported in literature.

Methods

A systematic review of literature was conducted. Electronic search was performed in Pubmed and LILACS. Two reviewers independently extracted data on demographic, clinical and radiological features, and treatment. Cases were classified according to Wheat’s definitions.

Results

Seventy-one studies were included in the analysis, comprising a total of 814 patients. Twenty-one patients diagnosed at the Centre of Tropical Diseases, Negrar (VR), Italy were also included. The most common travel destination was Central America (168 people, 29.8%); the most common way of exposure to histoplasma was the exploration of caves and/or contact with bat guano (349 people, 60.9%). The multivariate logistic regression model showed association between the development of disseminated histoplasmosis (DH) and activities that involved the exploration of caves and/or the contact with bats’ guano (adjusted OR: 34.20 95% CI: 5.29 to 220.93) or other outdoor activities (adjusted OR: 4.61 95% CI: 1.09 to 19.56). No significant difference in the attack rate between countries of destination was observed (p-value: 0.8906, Kruskal-Wallis test).

Conclusions

Histoplasmosis often causes no or mild symptoms in immunocompetent individuals, although a severe syndrome may occur. The infection can mimic other diseases, and the epidemiological risk of exposure is an important clue to raise the index of suspicion.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3476-z) contains supplementary material, which is available to authorized users.

Epidemiological aspects of travel-related systemic endemic mycoses: a GeoSentinel analysis, 1997-2017

Background

International travel has increased in the past few decades, placing more travellers at risk of acquiring systemic endemic mycoses. There are limited published data on systemic endemic mycoses among international travellers. We report epidemiological characteristics of non-migrant, international travellers who acquired systemic endemic mycoses during travel.

Methods

We analysed records of non-migrant international travellers with a confirmed diagnosis of histoplasmosis, coccidioidomycosis, paracoccidioidomycosis, blastomycosis or talaromycosis reported from 1997 through 2017 to GeoSentinel, a global surveillance network now consisting of 70 travel or tropical medicine centres in 31 countries.

Results

Sixty-nine records met the inclusion criteria. Histoplasmosis was most frequently reported; the 51 travellers with histoplasmosis had the lowest median age (30 years; range: 8-85) and shortest median duration of travel (12 days; range: 5-154). Coccidioidomycosis was reported in 14 travellers; travellers with coccidioidomycosis were older (median 62 years; range: 22-78) and had the longest median number of days between return from travel and presentation to a GeoSentinel site (55 days; range: 17-273). Almost all travellers with coccidioidomycosis were exposed in the USA. Other systemic endemic mycoses were less frequently reported, including blastomycosis (three travellers) and talaromycosis (one traveller).

Conclusions

Although relatively rare, systemic endemic mycoses should be considered as potential travel-related infections in non-migrant international travellers. Epidemiological exposures should be used to guide diagnostic evaluations and treatment.

Case Report: Histoplasmosis: First Autochthonous Case from Israel

We present an autochthonous Histoplasma infection in Israel. The patient presented with hoarseness and weight loss. Pathology findings and molecular tests confirmed the diagnosis, and the patient responded to antifungal therapy. Because the patient had an atypical presentation of histoplasmosis, it is likely that other more typical cases have gone unreported. To our knowledge, no other cases have been previously reported from Israel or the Middle East region.

Importance of a Travel History in Evaluation of Respiratory Infections

PURPOSE OF REVIEW

International travel has increased at a fast pace and will continue to rapidly rise. Concomitantly, with this increase in travel is the increase in post travel-related diseases, such as respiratory illnesses. Identifying the cause of the posttravel respiratory illness is a complex challenge for many healthcare professionals because similar presentations occur for both infectious and noninfectious causes. Not only is diagnosis important but also transmission prevention. In the last two decades, there have been several severe infectious respiratory syndromes that have spread through international travel causing epidemics in many countries.

RECENT FINDINGS

A detailed travel history with the chronology of symptoms paired with the patient's medical risk factors and exposures along with some basic knowledge of infectious respiratory illnesses will help facilitate clinical decision making. This framework will help create a broad, but appropriate differential diagnosis to guide clinical workup, prevent delays in diagnosis, and implement the appropriate precautions to prevent transmission if appropriate.

SUMMARY

The foundation to diagnosing a travel-related respiratory illness lies within integrating the patient's travel history, comorbid conditions, clinical presentation, exposures, and mode of transmission. A timely and accurate diagnosis benefits not only the patient but also the surrounding community to prevent further individual transmission, epidemics, and pandemics.