Moffitt AM Report 5/8/17: Disseminated Histoplasmosis

Thank you Evan for presenting a case of an elderly, immunocompetent woman who presented with chronic symptoms of fatigue/fevers, found on admission to have pulmonary nodules, a splenic granuloma, and retinal hemorrhage, with concern for disseminated histoplasmosis!

Love, SamMy

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KEY POINTS

  • Histoplasmosis is the most prevalent endemic mycosis in the US. Disseminated histoplasmosis is a progressive, extrapulmonary infection that occurs mostly in immunosuppressed patients or patients at the extremes of age. However, chronic progressive disseminated histoplasmosis occurs uncommonly in immunocompetent patients.
  • Treatment is indicated for all patients with disseminated histoplasmosis.
  • Urinary histo antigen test has 75% sensitivity in immunocompetent hosts vs 85% sensitivity in immunocompromised hosts

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MORE ON DISSEMINATED HISTOPLASMOSIS
(HIV-Negative Patients)

  • Most common symptoms of disseminated histoplasmosis are fever, fatigue, and weight loss!
  • Diagnosis of disseminated histoplasmosis requires a high index of suspicion, based on evidence for disseminated disease!
    • Peripheral lymphadenopathy, hepatomegaly, splenomegaly, skin lesions, mucosal lesions, AMS, neurologic abnormalities
    • Anemia, leukopenia, and thrombocytopenia suggesting BM or spleen involvement
    • Transaminitis
    • CXR is abnormal in 70% of patients, usually showing diffuse interstitial or reticulonodular infiltrates
    • CSF: lymphocytic pleocytosis, elevated protein, low glucose
    • Abdomen: hepatosplenomegaly, adrenal enlargement
  • Diagnosis: When concerned about disseminated histo, send both urine AND serum antigen tests to achieve the highest sensitivity!
    • Urinary histo antigen test has 75% sensitivity in immunocompetent patients vs 85% sensitivity in immunocompromised patients
    • Serum histo antigen test has sensitivity of ~100%!
    • Antibody tests are positive in 90% of immunocompetent vs 70% of immunocompromised patients.
    • Blood cultures should be performed in ALL suspected cases. Cultures are positive in ~65% of cases using the lysis-centrifugation technique.
    • Role of PCR is uncertain.
  • Treatment:
    • Itraconazole is the treatment of choice for mild-moderate symptoms or for step-down therapy after amphotericin B administration
    • For patients who are ill enough to require hospitalization, use amphotericin

Evernote Link: https://www.evernote.com/shard/s338/sh/662b9924-5536-4e15-b704-365fdad887fc/6f5b413256dbf4327d62311a02591658

 

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