Histoplasmosis

Histoplasmosis is caused by Histoplasma capsulatum, a thermal dimorphic fungus, in endemic areas, isolated from soil contaminated with bird or bat droppings.

Infection presumably taken place by inhalation of conidia.

Mycelia a naturally infectious form with characteristic appearance, microconidial & macroconidial.

They convert into small budding cells & are engulfed by phagocytes in lungs then proliferates and undergoes lymphohematogenous spread to other organs.

Histoplasmosis symptoms & signs:

Most patients- mild or asymptomatic.

Symptoms usually appear 1–4 weeks after exposure.

mild influenza-like illness, fever, chills, sweats, headache, anorexia, myalgia, dry cough, dyspnea, and mild chest pain often lasting 1–4 days.

Moderately-severe patients, atypical pneumonia- fever, cough, mild central chest pain for 5–15 days.

Arthralgia or arthritis, often erythema nodosum 5–10%.

several forms of histoplasmosis:

Acute pulmonary histoplasmosis- mild influenza-like illness to severe pneumonia- 1 week to 6 months.
Progressive disseminated histoplasmosis- in HIV infection (with CD4 cell counts < 100 cells/ mcL) or in diseases with impaired cellular immunity, taking tumor necrosis factor (TNF)-alpha inhibitors. fever & multiple organ involvement. Chest X-ray miliary pattern. May be fulminant- septic shock, respiratory failure, coagulopathy, and multiorgan failure, may death. Symptoms- fever, dyspnoea, cough, loss of weight, and Ulcers of mucous membranes of the oropharynx. Liver and spleen are enlarged, all organs involved, & adrenal glands (may leads to adrenal insufficiency).
Chronic pulmonary histoplasmosis- older patients with chronic lung disease. Chest X-ray- complex apical cavities, nodules, & infiltrates.
Complications of pulmonary histoplasmosis- granulomatous mediastinitis- mediastinal lymph nodes enlargement & fibrosing mediastinitis, excessive fibrotic response & compromise of pulmonary vascular structures.

Histoplasmosis Investigations:

anemia of chronic disease.

Bone marrow involvement- pancytopenia in disseminated forms. Marked elevated LD and ferritin. Mild elevated serum AST.

In pulmonary involvement, sputum culture- rarely positive except in chronic disease.

Antigen testing of bronchoalveolar lavage fluid- may helpful in acute disease.

Combination of serum & urine polysaccharide antigen assays- 83% sensitivity for diagnosis of acute pulmonary histoplasmosis.

urine antigen assay- sensitivity > 90% in disseminated disease (immunocompromised cases).

Blood cultures- by lysis centrifugation methods or bone marrow cultures in immunocompromised cases with acute disseminated disease- positive > 80%.

Culture from blood or tissue- low sensitivity, weeks may be needed for growth.

Histologic tissue examination- yeast with narrow based budding.

Histoplasma Antigen- urine > serum > BAL.

Histoplasma serology IgG and IgM

Histoplasma antigen CSF

Fungal culture of CSF

Histoplasmosis Treatment:

Mild to moderately severe nonmeningeal disseminated disease in immunocompromised or immunocompetent & progressive localized disease- oral itraconazole, response in 80%.

Severe disseminated disease & meningitis- Intravenous liposomal amphotericin B.

Rituximab & corticosteroids, may slow progression of fibrosing process.

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