Expanding the horizons of histoplasmosis: disseminated histoplasmosis in a renal transplant patient after a trip to Bangladesh

U. Rappo, J.R. Beitler, J.R. Faulhaber, B. Firoz, J.S. Henning, K.M. Thomas, M. Maslow, D.S. Goldfarb, H.W. Horowitz. Expanding the horizons of histoplasmosis: disseminated histoplasmosis in a renal transplant patient after a trip to Bangladesh.
Transpl Infect Dis 2010: 12: 155–160. All rights reserved Abstract: Histoplasmosis is recognized to occur in the Ohio and Mississippi River Valleys of the United States, but less widely appreciated is its worldwide distribution. We report a case of disseminated histoplasmosis with disease involving skin, lungs, and epiglottis in a renal transplant patient 6 months after a trip to Bangladesh, to highlight the potential risk of acquisition of this infection in the Indian subcontinent.     

A multicenter study of histoplasmosis and blastomycosis after solid organ transplantation

S.A. Grim, L. Proia, R. Miller, M. Alhyraba, A. Costas‐Chavarri, J. Oberholzer, N.M. Clark. A multicenter study of histoplasmosis and blastomycosis after solid organ transplantation.
Transpl Infect Dis 2011. All rights reserved Aim. A review of the clinical presentation, diagnosis, treatment and outcomes of 30 solid organ transplant recipients (SOTRs) with histoplasmosis or blastomycosis from 3 Midwestern academic medical centers. Background. The endemic fungal pathogens, Histoplasma capsulatum and Blastomyces dermatitidis, may cause severe infection in SOTRs. In this report, we describe the clinical presentation, diagnosis, treatment, and outcomes of these endemic fungal infections (EFIs) among SOTRs at 3 academic transplant centers. Methods. A retrospective review was conducted of SOTRs with histoplasmosis or blastomycosis from 3 Midwestern medical centers in the United States. Data collected included demographics, immunosuppression, clinical presentation, method of diagnosis, antifungal treatment, response to therapy, and patient and graft survival. Results. Between 1996 and 2008, 30 transplant recipients with histoplasmosis or blastomycosis were identified, giving a cumulative incidence of infection of 0.50% (30/5989); 73% of the study patients were renal transplant recipients, and the median time to disease onset after transplantation was 10.5 months. The lungs were the most common site of infection (83%), and 60% had disseminated disease. Urine antigen testing was positive in all patients in whom it was performed (23/23). Initial antifungal therapy consisted of amphotericin B in 70%, and 87% received azoles, typically itraconazole (83%). Two patients developed relapsed infection and 7 patients had graft failure after EFI. Overall mortality was 30%, with an attributable mortality of 13%. Conclusions. As in several previous single‐center studies, the incidence of post‐transplant histoplasmosis and blastomycosis was <1%, but often resulted in disseminated infection. In this cohort, EFI was associated with a high rate of allograft loss and overall mortality.     

Disseminated histoplasmosis in allogeneic bone marrow transplant: a diagnosis not to be missed

Immunosuppressed patients are at highest risk for disseminated histoplasmosis, but only a few cases have been reported in hematopoietic stem cell transplant recipients. We report a case of disseminated histoplasmosis in an allogeneic bone marrow transplant recipient residing in a non‐endemic area. Diagnosis was first suspected based on a peripheral blood smear.     

Epididymal and prostatic histoplasmosis in a renal transplant recipient from southern India

An unusual case of epididymal and prostatic histoplasmosis is reported from Karnataka State of southern India, in a 37-year-old male renal transplant recipient, who had presented with gastrointestinal histoplasmosis a year before the second presentation and had responded successfully to 9 months' treatment with itraconazole. The patient presented a second time with high-grade fever and pain in the scrotum and the lower abdomen. Ultrasound of the abdomen revealed a retrotrigonal abscess, which was confirmed on computed tomography scan of the pelvis. Pus was drained via transrectal route and biopsy specimens were taken from the epididymis and the prostate. Histopathology revealed the picture suggestive of histoplasmosis, and the pus on culture confirmed the infection with Histoplasma capsulatum. To our knowledge, only 5 cases of epididymal histoplasmosis have been reported in the literature, our case being the second report from India and sixth in the world; prostatic histoplasmosis is also a rare occurrence.     

播散型组织胞浆菌病四例

我科近年来收治播散型组织胞浆菌病（PDH）4例,其中1例误诊为黑热病死亡,3例用H性霉素B治愈。现报道如下。临床资料1．一般资料：男性3例,女性1例,年龄25～46岁,平均年龄30．75岁。持续发热l～6个月（平均5个月）入院。五例曾有HBV感染史5年,1例病后2个月并发2型糖尿病。     

Progressive histoplasmosis with hemophagocytic lymphohistiocytosis and epithelioid cell granulomatosis: A case report and review of the literature

Histoplasmosis in central Europe is a rare fungal disease with diverse clinical presentations. Apart from acute pulmonary histoplasmosis and involvement of the central nervous system, the most serious clinical presentation is progressive disseminated histoplasmosis which is generally associated with severe immunodeficiency and, in particular, advanced human immunodeficiency virus infection. Here, we report on an immunocompetent female residing in a non‐endemic area, presenting with progressive disseminated histoplasmosis after a remote travel history to Thailand and Costa Rica. Diagnosis was delayed by several months due to misinterpretation of epithelioid cell granulomatosis of the intestine as Crohn's disease and of similar lung lesions as acute sarcoidosis. Prompted by clinical deterioration with signs and symptoms consistent with hemophagocytic lymphohistiocytosis, a bone marrow aspiration was performed that documented hemophagocytosis and intracellular organisms interpreted as Leishmania sp., but later identified by molecular methods as Histoplasma capsulatum. Treatment with liposomal amphotericin B followed by posaconazole led to prompt clinical improvement and ultimately cure.     

Disseminated toxoplasmosis presenting as septic shock five weeks after renal transplantation

We discuss a case of acute disseminated toxoplasmosis in a renal transplant recipient presenting with septic shock. Our literature review of disseminated toxoplasmosis presenting as septic shock reveals a disease process that is rapid and almost uniformly fatal. This unusual presentation warrants a high index of suspicion in transplant recipients with immediate administration of appropriate empiric antimicrobials.     

Gastrointestinal histoplasmosis in a patient after autologous stem cell transplant for multiple myeloma

A 59‐year‐old patient with multiple myeloma on maintenance chemotherapy presented with fever, weight loss, and night sweats. An F‐18 fluorodeoxyglucose (FDG) positron emission tomography (PET) computed tomography (CT) showed intra‐abdominal lymphadenopathy with a mesenteric mass that led to further workup and diagnosis of histoplamosis. The patient was treated with amphotericin B and subsequently switched to itraconazole. This exemplifies the usefulness of FDG PET CT in diagnosis of infectious complications.     

A case of successful renal transplantation for hydatid disease after surgical treatment of disseminated cysts

Hydatid disease is a systemic disorder affecting especially the liver and lungs. Although it is not endemic in Europe, it can be seen sporadically, particularly because of travel and immigration. Severe, multiple organ involvement is quite rare. A 39‐year‐old Kurdish male patient presented with the previous diagnosis of hydatid disease and disseminated cysts in the liver, lung, and left kidney, leading to renal failure and the need for hemodialysis. Following multiple operations, complete eradication of infectious cysts was achieved, and kidney transplantation was performed. After 4 years of follow‐up, the patient is in good condition, especially with normal renal function and no sign of recurrent hydatid disease.     

A case of disseminated histoplasmosis following autologous stem cell transplantation for Hodgkin's lymphoma: an initial misdiagnosis with a false-positive serum galactomannan assay

Abstract: Systemic histoplasmosis is uncommonly reported in patients who have undergone bone marrow or solid organ transplantation. Diagnosis of systemic histoplasmosis in recipients of transplants may be hampered by lack of consideration of this infection in the differential diagnosis and may be confounded by conflicting information from other testing performed to evaluate for opportunistic infections in this population. We report successful treatment of a case of disseminated histoplasmosis in a patient with Hodgkin's lymphoma who had undergone autologous stem cell transplantation. The diagnosis was delayed by the finding of a positive serum galactomannan assay.     

Airway complication contributing to disseminated fusariosis after lung transplantation

Fungal infections are common after lung transplantation. However, disseminated fusariosis is rare and we report the first case of airway complications associated with this infectious process. A 77‐year‐old Caucasian woman, who was status post left single‐lung transplant for emphysema, presented to clinic 8 months after lung transplantation with pleurisy, shortness of breath, and declining lung function. Bronchoscopy showed narrowing of the left anastomotic site with dynamic compression during exhalation. An AERO stent was deployed successfully, but 3 weeks later, her symptoms recurred. Bronchoscopy showed total stent occlusion with thick tenacious mucus. Fusarium solani was isolated from cultures, and a new 1.5 cm skin nodule was found on the anteromedial midportion of the patient's left lower leg. Voriconazole and anidulafungin were started. No evidence of mucus accumulation was seen during a follow‐up bronchoscopy. It is likely that Fusarium infection contributed to the initial anastomotic complication as well as to obstruction of the stent. Furthermore, the stent may have contributed to establishment and development of disseminated fusariosis. With antifungal therapy, stent patency was maintained and the patient improved clinically.     

Pseudotumoral presentation of fungating mycetoma caused by Phaeoacremonium fuscum in a renal transplant patient

Eumycetoma is an unusual infection in immunocompromised patients outside the tropics, caused by a variety of fungal pathogens. We describe the case of a 51‐year‐old renal transplant recipient who presented with a large pseudotumoral foot lesion necessitating complete surgical excision of the lesion. Cultures and molecular diagnosis confirmed Phaeoacremonium fuscum. This is the first case, to our knowledge, of fungating mycetoma caused by this fungal species in a solid organ transplant recipient.     

A case of Pneumocystis pneumonia,with a granulomatous response and vitamin D‐mediated hypercalcemia,presenting 13 years after renal transplantation

Vitamin D‐mediated hypercalcemia is an uncommon complication of Pneumocystis infection. A granulomatous response resulting from Pneumocystis infection is also atypical. In this report, we describe an exceptional case of granulomatous Pneumocystis pneumonia associated with vitamin D‐mediated hypercalcemia, in a patient who presented unusually late after renal transplantation. The patient's hypercalcemia resolved with treatment of the infection.     

Very late‐onset cytomegalovirus disease with ganciclovir resistance >15 years following renal transplantation

Cytomegalovirus (CMV) infection is a significant cause of morbidity and mortality after solid organ transplantation. There has been a significant shift in disease epidemiology with the introduction of antiviral prophylaxis, with CMV disease occurring later and clinical presentations more atypical. We describe two cases of very late‐onset CMV disease where first disease occurred 15 and 18 years post–renal transplantation, with both cases complicated by antiviral drug resistance. We subsequently review the published cases and literature of very late‐onset CMV disease (onset > 10 years post–solid organ transplantation) as an increasingly recognized phenomenon which is emerging as an important aspect in improving long‐term patient outcomes in the current era of renal transplantation.     

Clinical and laboratory features of disseminated histoplasmosis in HIV patients from Brazil

OBJECTIVES: To identify the main clinical and laboratory features of disseminated histoplasmosis (DH) in human immunodeficiency virus (HIV) patients and compare them with those of HIV patients with other opportunistic diseases. METHODS: Retrospective study of HIV patients comparing the clinical and laboratory data of patients with and without DH. Univariate and multivariate analyses were performed to verify the risk factors related to DH. RESULTS: In total, 378 HIV patients were included, 164 with DH and 214 with other opportunistic diseases. Acute renal failure, respiratory insufficiency and septic shock were more frequent in DH patients, who also had a higher mortality (32%vs. 14%, P < 0.001). Independent risk factors for DH were: acute renal failure [odds ratio (OR) 5.2; 95% confidence interval (CI) 3.2-8.5; P < 0.001], splenomegaly (OR 3.4; 95% CI 1.19-9.9; P < 0.001), respiratory insufficiency (OR 2.7 95% CI 1.5-5.0; P < 0.001), proteinuria (OR 2.7; 95% CI 1.3-5.2; P = 0.03), hypotension (OR 2.5; 95% CI 1.2-5.0; P = 0.008), hepatomegaly (OR 2.4; 95% CI 1.2-4.8; P = 0.01), cutaneous lesions (OR, 1.9; 95% CI 1.0-3.3; P = 0.02) and weight loss (OR 1.8; 95% CI 1.0-3.1; P = 0.03). CONCLUSION: Our results suggest that DH is a severe opportunistic disease with high mortality rate, which should be promptly recognized in order to provide early specific treatment.     

Cerebral coccidioidomycosis after renal transplantation in a non‐endemic area

C. Carvalho, I. Ferreira, S. Gaião, S. Guimarães, R. Costa, J. Santos, S. Sampaio, M. Bustorff, G. Oliveira, M. Pestana. Cerebral coccidioidomycosis after renal transplantation in a non‐endemic area.
Transpl Infect Dis 2010: 12: 151–154. All rights reserved Abstract: Coccidioidomycosis is a fungal infection caused by Coccidioides species endemic to the desert south western United States. In healthy people, manifestations range mainly from asymptomatic to mild influenza‐like syndrome. In immunosuppressed patients, extrapulmonary dissemination is common. We report the case of a patient with a parenchymal central nervous system lesion. This presentation is considered very rare. The highest risk of infection after solid organ transplantation occurs during the first year. Risk factors include treatment of acute rejection. In the reported case, the infection was probably donor‐derived, as our patient had no history of traveling to endemic areas. Mortality is high among transplanted recipients with coccidioidomycosis, particularly those with disseminated infection.