Bilateral adrenal histoplasmosis in immunocompetent patients

Histoplasmosis is a fungal infection caused by Histoplasma capsulatum, which commonly presents as transient pulmonary infection that usually subsides without treatment. Disseminated histoplasmosis may affect almost all systems, including the reticuloendothelial system, lungs, gastrointestinal tract, renal tract, central nervous system, bone marrow, and adrenal glands. Adrenal gland is frequently involved in disseminated histoplamosis but commonly present as unilateral mass; bilateral involvement is rare. It is also rare in immunocompetent hosts and only few cases have been reported in past. We report four cases of adrenal histoplasmosis with bilateral involvement. These cases were initially diagnosed cytopathologically on fine needle aspirations performed on adrenal glands. All these patients were immunocompetent and two of them also had associated adrenal insufficiency. Diagnosis of adrenal histoplasmosis can be easily made on fine needle aspiration cytology. Adrenal histoplasmosis can occur in immunocompetent individuals and should be considered in differential diagnosis of bilateral adrenal masses in immunocompetent individuals. Diagn. Cytopathol. 2011;39:294–296. © 2010 Wiley‐Liss, Inc.     

Cytodiagnosis of cutaneous histoplasmosis in HIV positive patient initially presenting with multiple umbilicated disseminated skin nodules

Histoplasmosis is usually an opportunistic fungal infection in patients with defective cell mediated immunity, and has been considered as one of the acquired immunodeficiency syndrome (AIDS) defining illness. However, cutaneous involvement in human immunodeficiency virus (HIV) positive patients is less common, and very rarely can be the initial presenting symptom for the diagnosis of AIDS. We present here an unusual case of multiple diffuse cutaneous nodular lesions predominantly in face, trunk, and upper extremities diagnosed initially on aspiration cytology as histoplasmosis. Subsequent serological test revealed positivity for HIV 1 and 2, along with a low CD4 count and low CD4:CD3 ratio. The cytomorphological features were further corroborated by histology and histochemical stains. Hence, cutaneous histoplasmosis can cause multiple wide spread nodular or umbilicated lesions in AIDS patients as the initial presentation. Fine needle aspiration cytology (FNAC) is a rapid, cost effective tool for diagnosis of the fungi from such lesions and initiating work up for immunocompromised states including AIDS. Diagn. Cytopathol. 2013. © 2011 Wiley Periodicals, Inc.     

Primary cutaneous aspergillosis,mimicking malignancy,a rare presentation in an immunocompetent patient

Aspergillus species are ubiquitous opportunistic molds that cause both allergic and invasive syndromes. A 65‐year‐old female, farmer by occupation, presented with left upper limb and trunk swelling for one year, associated with pain, tightening of skin, and vesicles with watery discharge. Local examination showed a diffuse swelling extending from left arm to forearm and lateral chest wall associated with edema, induration, and raised temperature. The swelling was firm to hard with superficial skin ulcers and black eschar. Hematological investigations of the patient showed raised total WBC count and peripheral blood eosinophilia. Patient had no history suggesting immunosuppression. Clinico‐radiological impression was left breast carcinoma with secondary skin involvement. fine‐needle aspiration cytology (FNAC) from the swelling showed inflammatory cells, necrosis, epitheloid cell granulomas, and giant cells along with branching hyphae of variable thickness, confirmed on Gomori Methenamine Silver stain as fungal hyphae. Culture was advised which identified the species as Aspergillius fumigatus. Primary cutaneous infection by A. fumigatus in an immunocompetent patient is unheard of. FNAC has an important role in resolving diagnostic dilemma in primary cutaneous aspergillosis, which may mimic malignancy as in our case.     

Neuroaspergillosis in an immunocompetent patient

Aspergillosis of the central nervous system (CNS) is an uncommon infection, mainly occurring in immunocompromised patients. We report a case of neuroaspergillosis caused by Aspergillus flavus in an immunocompetent patient presenting as a space-occupying lesion of the CNS. The patient was responding favorably to voriconazole at the time of this report.     

慢性播散型组织胞浆菌病2例

 目的 提高临床医生对慢性播散性组织胞浆菌病的认识和诊治水平,以便减少误诊,改善预后。方法 根据北京协和医院1980年~2012年诊断慢性组织胞浆菌病的2例临床和随诊资料,结合文献对该病的临床表现、组织病理学特点、诊断、治疗及预后进行分析。结果 2例患者均病程较长、首发症状缺乏特异性,多系统受累,无特殊疾病史。其中1例有消化道、肺和双肾上腺受累,另1例为肺和腹膜受累。早期均被误诊,确诊均依靠组织病理,抗真菌治疗效果好,未见复发。结论 慢性组织胞浆菌病少见且临床表现不特异,确诊依赖于典型的病理形态和特殊染色,积极治疗预后好。     

Maxillary African histoplasmosis: unusual diagnostic problems of an unusual presentation

Among bone lesions of African histoplasmosis, those affecting the jaw are relatively rare and concern, with other facial involvements, particularly infants and adolescent patients with an usual uncompromised immunologic status. As clinical and radiologic features are not specific, the differential diagnosis to other mandibular diseases is difficult. We report on a case of African histoplasmosis that involved the right mandibula of a 17-year-old Congolese boy with a persistent and fungiform cutaneous ulceration. As mycologic tests had not been carried out initially, the disease was histologically diagnosed on the basis of the presence of numerous intra-cytoplasmic large yeasts in a granulomatous lesion containing giant cells. As it is impossible to confront the histologic diagnosis with mycologic tests in such a situation, the problems of the differential diagnosis to other deep fungus infections and to some yeast-like foreign body-granulomas encountered at the microscopical level underline the importance of culturing organisms from lesions to confirm the histologic diagnosis. It is worth considering this pathology at least for three reasons: it usually mimicks a malignant jaw tumor; it may constitute a migrant pathology; and prognosis is commonly favorable with amphotericin B treatment.     

Disseminated histoplasmosis diagnosed by cross-reactivity with the Aspergillus galactomannan antigen in an HIV-positive patient

Invasive histoplasmosis is the most common AIDS-defining event in endemic regions such as South America. In non-endemic regions, less familiar to the diagnosis, invasive histoplasmosis can be mistakenly diagnosed as miliary tuberculosis leading to a high mortality rate. Here we present the case of an invasive histoplasmosis mistakenly diagnosed as tuberculosis. The diagnosis of histoplasmosis was considered later on, in light of patient's clinical deterioration and positive Aspergillus galactomannan antigens. This case highlights the importance of considering other opportunistic infections when facing a culture-negative miliary tuberculosis without clinical improvement despite anti-tuberculosis therapy. It also draws our attention to the tools available in non-endemic regions that can be helpful in the diagnosis of invasive histoplasmosis.     

Disseminated histoplasmosis diagnosed in the bone marrow of an HIV-infected patient: First case imported in Tunisia

Histoplasmosis is a fungal infection caused by a dimorphic fungus, Histoplasma capsulatum. We report a first case of disseminated histoplasmosis in a 34-year-old woman, infected with human immunodeficiency virus (HIV), originating from Ivory Coast and living in Tunisia for 4 years. She was complaining from fever, chronic diarrhoea and pancytopenia. The Histoplasma capsulatum var. capsulatum was identified by direct microscopic examination of the bone marrow. She was treated by Amphotericin B, relayed by itraconazole. Even though a regression of symptoms and normalization of blood cell count (BCC), the patient died in a respiratory distress related to CMV hypoxemic pneumonia.     

Unusual clinical presentation of Mycobacterium fortuitum infection in an immunocompetent woman

The Mycobacterium fortuitum group of rapidly growing nontuberculous mycobacteria is an uncommon cause of renal infection, particularly in otherwise healthy hosts. We describe a case of nephritis due to M. fortuitum in an immunocompetent woman with a clinical and radiological diagnosis of renal tuberculosis.     

Schizophyllum commune sinusitis in an immunocompetent host

Schizophyllum commune is widely distributed in the nature, but it rarely causes human infection. We have isolated this mould in a 46-year-old immunocompetent, non-diabetic patient with chronic sinusitis, previously treated with multiple antibiotics and topical steroid nasal drops with no response. Materials obtained from the nasal sinus during the endoscopic surgery, on KOH mount and histopathological study revealed broad septed hyaline hyphae. Growth on the Sabouraud's dextrose agar and potato dextrose agar produced white moulds with microscopic and macroscopic characters of S. commune. Till date there are few reports of S. commune sinusitis in immunocompetent individuals Worldwide. This is the first reported case in India to the best of our knowledge.     

Bacteremia due to Rhodococcus equi in an immunocompetent infant

Rhodococcus equi , previously known as Corynebacterium equi, is one of the most important causes of zoonotic infection in grazing animals. Increased cases of human infection with R. equi have been reported especially in immunocompromised patients. Infection in immunocompetent patients is extremely rare. We report a case of R. equi bacteremia in a 26-day-old immunocompetent infant with recurrent swellings on different parts of the body. To the best of our knowledge, this is the first ever report of R. equi bacteremia from an immunocompetent patient from Northern India.     

African histoplasmosis in a Guinea Bissau patient with HIV-2: Case report and review

African histoplasmosis is the relatively unknown infection by Histoplasma capsulatum var. duboisii. It is endemic to Central and West Africa, generally involving the skin with potential for systemic dissemination, and has been described mainly in immunocompetent hosts. We present the case of a 30-year-old Bissau-Guinean man with HIV-2 infection known for 16 years, irregularly treated, admitted with two weeks of fever, diarrhoea and cutaneous lesions. Examination revealed multiple subcutaneous nodes, Molluscum contagiosum-like lesions, generalized lymphadenopathy and painful palpation of the left iliac fossa. Laboratory tests showed severe nonhaemolytic anaemia and CD4+ count of 9/mm3, with normal creatinine and hepatic enzymes. Chest roentgenogram was unremarkable and a research for Mycobacterium tuberculosis by GeneXpert® was negative. Nonetheless, given the lack of further diagnostic tools, a presumptive diagnosis of disseminated tuberculosis was made, and the patient was started on tuberculostatic and antiretroviral drugs. Despite initial improvement, a national shortage of antiretrovirals precluded further treatment, with worsening of the clinical picture, namely an increase in the number and dimensions of the skin lesions. An excisional biopsy of a subcutaneous nodule revealed Histoplasma capsulatum var. duboisii. Unfortunately, due to the unavailability of antifungals, the patient died one week later. To our best knowledge, this is the first confirmed case of an HIV infected patient with African histoplasmosis in Guinea-Bissau.     

Disseminated histoplasmosis in an immunocompetent individual--a case report

We report a rare case of disseminated histoplasmosis in a immunocompetent young adult person involving bone marrow, liver, spleen and oral cavity. He presented with oral ulcers, weight loss and pancytopenia. His bone marrow aspiration examination revealed Histoplasma capsulatum.     

Cutaneous histoplasmosis in AIDS

A patient with human immunodeficiency virus (HIV) infection presented with multiple cutaneous lesions on upper extremities, trunk, face and with ulcers involving oral mucosa. Histoplasma capsulatum was isolated in culture from scrapings from both cutaneous as well as oral mucosal lesions. The patient responded well initially to the treatment with Amphotericin B followed by itraconazole; however, lesions recurred after three months with the further deterioration of immune status of the patient indicated by decline in CD4 counts. The same treatment was restarted and the patient is still being followed-up.     

Disseminated varicella with multiorgan failure in an immunocompetent adult

A case of fulminant disseminated varicella is reported in a 28‐year‐old immunocompetent man. He developed hepatitis, severe pneumonia, rhabdomyolysis and disseminated intravascular coagulation, followed by encephalopathy and multiorgan failure despite acyclovir therapy. He spent a total of 3.5 months in intensive care and rehabilitation units. Real‐time PCR yielded a rapid diagnosis of varicella‐zoster virus (VZV) infection and was used to monitor plasma viral load for 56 days. Plasma viral load peaked at 7.1 log₁₀/ml on day 4 after symptom onset, then gradually declined and became undetectable after between 1 and 2 months; viral load in lung fluid followed a similar pattern. The glycoprotein E variant associated with increased VZV virulence was not detected, and the VZV thymidine kinase gene bore no major mutations associated with acyclovir resistance. This case serves as a reminder that varicella can be life‐threatening in adults and that vaccination of individuals at risk remains essential. J. Med. Virol. 81:747–749, 2009 © 2009 Wiley‐Liss, Inc.     

Cytomegalovirus-associated acute transverse myelitis in immunocompetent adults

We report a case of transverse myelitis as a complication of acute cytomegalovirus (CMV) infection in immunocompetent patients; and review the literature on the entity. Primary CMV infection was documented by CMV antigenemia and high serum titers of CMV IgM and IgG antibodies. Cerebrospinal fluid (CSF) pleocytosis indicated central nervous system inflammation; CSF polymerase chain reaction (PCR) for CMV, however, was negative. The results of magnetic resonance imaging of the myelon were normal. Although CMV-associated transverse myelitis has been well described in HIV-positive individuals, but is very rare in immunocompetent individuals. It remains unclear whether the neuronal damage is immune mediated or due to a cytotoxic effect of viral infection. The outcome is mainly favorable.     

Fatal disseminated aspergillosis in an immunocompetent patient with COVID-19 due to Aspergillus ochraceus

Aspergillus infection is a well-known complication of severe influenza and severe acute respiratory syndrome coronavirus (SARS-CoV), and these infections have been related with significant morbidity and mortality even when appropriately diagnosed and treated. Recent studies have indicated that SARS-CoV-2 might increase the risk of invasive pulmonary aspergillosis (IPA). Here, we report the first case of Aspergillus ochraceus in a SARS-CoV-2 positive immunocompetent patient, which is complicated by pulmonary and brain infections. Proven IPA is supported by the positive Galactomannan test, culture-positive, and histopathological evidence. The patient did not respond to voriconazole, and liposomal amphotericin B was added to his anti-fungal regimen. Further studies are needed to evaluate the prevalence of IPA in immunocompetent patients infected with SARS-CoV-2. Consequently, testing for the incidence of Aspergillus species in lower respiratory secretions and Galactomannan test of COVID-19 patients with appropriate therapy and targeted anti-fungal therapy based on the primary clinical suspicion of IPA are highly recommended.     

Pyosalpinx: not always a sexual transmitted disease? Pyosalpinx caused by Plesiomonas shigelloides in an immunocompetent host

Plesiomonas shigelloides are ubiquitous Gram-negative bacteria that are found in fresh or marine water, particularly in tropical or warm climates; they were recently implicated in diarrhoeal disease. Patients usually present with a history of recent travel to tropical regions or consumption of uncooked seafood. Extraintestinal disease has rarely been reported, occurring generally in neonates or immunocompromised patients, and is often fatal. We report a case of right pyosalpinx due to P. shigelloides acquired by swimming in contaminated water. Laparoscopic salpingectomy led to a good outcome.     

Caecal perforation in a renal transplant patient with disseminated histoplasmosis.

A renal transplant patient developed a fatal caecal perforation after Histoplasma capsulatum infection acquired abroad. Disseminated histoplasmosis is an uncommon fungal infection, usually seen in patients with impaired immunity. The diagnosis should be considered in immunosuppressed patients who develop prolonged fever or whose health deteriorates unexpectedly after travelling overseas. The infection is endemic in parts of the United States of America but occurs all over the world. Rapid diagnosis is often possible by histological examination of infected tissues. Treatment if started early may lead to recovery, but if it is not treated it is usually fatal.