|
Histoplasmosis is a pulmonary and hematogenous disease caused by Histoplasma capsulatum; it is often chronic and usually follows an asymptomatic primary infection. Symptoms are those of pneumonia or of nonspecific chronic illness. Diagnosis is by chest x-ray, identification of the organism in sputum or tissue, or both. Treatment, when necessary, is with amphotericin B or an azole.
(See also the Infectious Diseases Society of America's Practice Guidelines for the Management of Patients with Histoplasmosis.)
Histoplasmosis occurs worldwide.
In the US, the endemic area for histoplasmosis includes
Microfoci have been noted in other states, such as Florida.
H. capsulatum grows as a mold in nature or in culture at room temperature but converts to a small (1 to 5 μm in diameter) yeast cell at 37° C and during invasion of host cells. Infection follows inhalation of conidia (spores produced by the mycelial form of the fungus) in soil or dust contaminated with bird or bat droppings. Severe disease is more common after heavy, prolonged exposure and in men, infants, or people with compromised T-cell–mediated immunity.
Initial infection occurs in the lungs and usually remains there but may spread hematogenously to other organs if it is not controlled by normal cell-mediated host defenses. Progressive disseminated histoplasmosis is one of the defining opportunistic infections for AIDS.
Symptoms and Signs
Most histoplasmosis infections are asymptomatic or so mild that patients do not seek medical attention. The disease has 3 main forms.
Acute primary histoplasmosis is a syndrome with fever, cough, myalgias, chest pain, and malaise of varying severity. Acute pneumonia (evident on physical examination and chest x-ray) sometimes develops.
Chronic cavitary histoplasmosis is characterized by pulmonary lesions that are often apical and resemble cavitary TB. Manifestations are worsening cough and dyspnea, progressing eventually to disabling respiratory dysfunction. Dissemination does not occur.
Progressive disseminated histoplasmosis characteristically includes generalized involvement of the reticuloendothelial system, with hepatosplenomegaly, lymphadenopathy, bone marrow involvement, and sometimes oral or GI ulcerations. The course is usually subacute or chronic, with only nonspecific, often subtle symptoms (eg, fever, fatigue, weight loss, weakness, malaise); the condition of HIV-positive patients may inexplicably worsen. The CNS may become involved, causing meningitis or focal brain lesions. Adrenal infection is rare but may result in Addison's disease. Severe pneumonia is rare, but patients with AIDS may develop severe acute pneumonia with hypoxia suggesting Pneumocystis jirovecii infection, as well as hypotension, mental status changes, coagulopathy, or rhabdomyolysis.
Fibrosing mediastinitis, a chronic but rare form, ultimately causes circulatory compromise.
Patients with histoplasmosis may lose vision, but organisms are not present in ocular lesions, antifungal chemotherapy is not helpful, and the link to H. capsulatum infection is unclear.
Diagnosis
The index of suspicion must be high because symptoms are nonspecific. Chest x-rays should be done and may show the following:
Bronchiolavage or tissue biopsy may be necessary to obtain histology specimens; serologic tesing and culture of urine, blood, and sputum specimens are also done.
Microscopic histopathology can strongly suggest the diagnosis, particularly in patients with AIDS and extensive infections; in such patients, intracellular yeasts may be seen in Wright's- or Giemsa-stained peripheral blood or buffy coat specimens. Fungal culture confirms the diagnosis. Lysis-centrifugation or culture of buffy coat improves the yield from blood specimens.
A test for H. capsulatum antigen is sensitive and specific, particularly when simultaneous serum and urine specimens are tested; however, cross-reactivity with other fungi (Coccidioides immitis, Blastomyces dermatitidis, Paracoccidioides brasiliensis, Penicillium marneffei) has been noted.
Prognosis
The acute primary form is almost always self-limited, although very rarely, death occurs after massive infection. Chronic cavitary histoplasmosis can cause death due to severe respiratory insufficiency. Untreated progressive disseminated histoplasmosis has a mortality rate of > 90%.
Treatment
Acute primary histoplasmosis requires no antifungal therapy unless there is no spontaneous improvement after 1 mo; itraconazole 200 mg po once/day for 6 to 12 wk is then used. Fluconazole and other azoles are also effective. Severe pneumonia requires more aggressive therapy with amphotericin B.
For chronic cavitary histoplasmosis, itraconazole 200 mg po once/day or bid is given for 12 to 24 mo. Other azoles or amphotericin B is used if patients are seriously ill or do not respond to or tolerate itraconazole.
For severe disseminated histoplasmosis, amphotericin B 0.5 to 1.0 mg/kg IV once/day for 4 to 12 wk is the treatment of choice. Patients without AIDS can be switched to itraconazole 200 mg po once/day after they become afebrile and require no ventilatory or BP support. For mild disseminated disease, itraconazole 200 mg po once/day or bid for 9 mo can be used. In patients with AIDS, itraconazole is given indefinitely to prevent relapse. Fluconazole may be less effective, but voriconazole and posaconazole are very active against H. capsulatum and may be very effective in the treatment of patients with histoplasmosis. Further data and experience are required to determine which drug is the best in each clinical situation. Intermittent doses of IV amphotericin B can be used for chronic suppression in azole-intolerant patients with AIDS.
Last full review/revision April 2009 by Alan M. Sugar, MD
Content last modified April 2009
| 
