Sarcoidlike manifestations of histoplasmosis

We have evaluated 11 patients with sarcoidosis accompanied by laboratory evidence for histoplasmosis. Clinical findings were typical of those described in sarcoidosis. Eight patients were treated with corticosteroids and responded promptly without progression of histoplasmosis. One patient received a 35 mg/kg course of amphotericin B without clinical improvement, but responded appropriately to corticosteroid therapy. Another patient had positive sputum cultures for Histoplasma capsulatum 5 years after initial diagnosis of sarcoidosis, but showed no improvement in the pulmonary infiltrate after treatment with amphotericin B. Although histoplasmosis and sarcoidosis may be interrelated in several ways, we postulate that H capsulatum may have triggered a chronic inflammatory disease recognized as sarcoidosis in some of these patients, a hypothesis yet to be tested. Alternative explanations for the association of histoplasmosis and sarcoidosis include the coincidental occurrence of two separate illnesses in a "hyperendemic" area for histoplasmosis and false-positive serologic test results caused by the heightened humoral immune response observed in sarcoidosis.     

Factors associated with persistent airflow limitation in severe asthma.

Persistent airflow limitation can develop in nonsmoking patients with asthma. However, the prevalence and risk factors for airways obstruction with incomplete reversibility in asthma are unknown. We assessed the prevalence of persistent airflow limitation (defined as postbronchodilator FEV(1) or FEV(1)/VC < 75% predicted) in 132 nonsmoking outpatients with severe asthma visiting chest physicians in general hospitals in The Netherlands. They had used inhaled corticosteroids (> or = 1,600 microg/d) and/or daily oral prednisone and long-acting bronchodilators for > 1 yr. In addition, we examined whether persistent airways obstruction in these patients was associated with specific clinical characteristics (age at onset, smoking history, atopic status, bronchodilator reversibility, provocative concentration of histamine causing a 20% decrease in FEV(1) [PC(20)histamine]) or markers of inflammation (exhaled nitric oxide [NO], blood eosinophils, total IgE; and eosinophilia or neutrophilia in induced sputum). Multiple logistic regression analyses were used to calculate adjusted odds ratios (OR). Persistent airflow limitation was observed in 49% of the patients in the study, and apart from older age and longer asthma duration, was strongly associated with a sputum eosinophils percent > or = 2% (OR = 7.7; confidence interval [CI]: 2.4 to 25), PC(20)histamine < or = 1.0 mg/ml (OR = 3.9; CI: 1.2 to 13), and adult onset (> or = 18 yr) of asthma (OR = 3.3; CI: 1.2 to 9). Only sputum eosinophilia appeared to be independently associated with persistent airflow limitation (OR = 8.9; CI: 1.3 to 59). In conclusion, persistent airflow limitation is common in adult patients with severe asthma, and is associated with adult onset of the disease, airway hyperresponsiveness, and most importantly, sputum eosinophilia. These findings suggest that eosinophilic airway inflammation contributes to persistent airflow limitation in severe asthma. Whether reduction of sputum eosinophils with more vigorous treatment leads to a better prognosis in severe asthma is still an open question.     

Disseminated histoplasmosis in a Danish patient with AIDS

We present the first case of disseminated histoplasmosis in an AIDS patient in Europe, a 33-year-old Danish homosexual man, and recommend a detailed travel history in HIV-positive patients presenting with fever, weight loss and organomegaly. In Scandinavia disseminated histoplasmosis is rare but should be kept in mind as the disease is a major opportunistic infection in patients with AIDS. Treatment with amphotericin B followed by fluconazole was effective.     

Disseminated histoplasmosis and AIDS in an Argentine hospital: clinical manifestations, diagnosis and treatment

We describe 16 HIV-infected patients with disseminated histoplasmosis (14 men, mean age 28 +/- 7.84 years), diagnosed at Hospital Eva Perón in Argentina during the period of October 1993 to July 2000. Disseminated histoplasmosis occurred in 5.3% of HIV-infected patients over the study period. The main symptoms included fever, weight loss and hepatosplenomegaly in 93.8%. Other relevant findings were respiratory compromise (56.3%), digestive symptoms (43.8%), mucocutaneous lesions (75%) and multiple lymphadenopathy (69%). Treatment consisted of amphotericin B 1 mg/kg/day up to a total dose of 1 g, followed by 400 mg/day of oral itraconazole. Mortality in the acute phase was 19% and 37.5% of patients relapsed.     

Endocrine manifestations of AIDS.

The endocrine manifestations of AIDS are now appreciated to involve virtually any of the endocrine organs. Some of these manifestations are subtle and clinically not apparent. Others, like adrenal involvement, can eventuate, although rarely, into frank glandular insufficiency. This Endocrine Rounds case illustrates a number of endocrine manifestations of AIDS and discusses their involvement from clinical and pathophysiologic aspects.     

Gastrointestinal histoplasmosis in patients with AIDS: case report and review.

Histoplasmosis is the most common endemic mycosis in individuals with AIDS, occurring in 2%-5% of this population. Infection is more likely to be disseminated than in immunocompetent individuals and generally presents insidiously with nonspecific symptoms. The gastrointestinal tract is involved in 70%-90% of cases of disseminated histoplasmosis, yet gastrointestinal histoplasmosis per se is infrequently encountered in patients with AIDS. The diagnosis of gastrointestinal histoplasmosis is often not suspected, particularly in areas of nonendemicity, and a delay in diagnosis may lead to increased morbidity and risk of death. Since antifungal therapy improves outcome for >80% of AIDS patients with histoplasmosis, it is essential that caregivers be aware of the varied presentations of gastrointestinal histoplasmosis in order to diagnose and to treat this potentially life-threatening infection effectively.     

Rheumatologic manifestations of histoplasmosis: a review

Histoplasmosis is an important cause of morbidity in endemic areas of the USA. Infection is often asymptomatic but can cause a broad spectrum of pathology. Less commonly, histoplasmosis can present with a wide-range of rheumatologic manifestations. The aim of this review is to provide a synopsis of the rheumatologic manifestations of this endemic mycosis in addition to emphasizing the high degree of histoplasmosis infection in persons with rheumatologic disease.     

Ileal perforation secondary to histoplasmosis in AIDS

Our patient presented with abdominal pain, weight loss, and fever with evidence of oral thrush and pelvic inflammatory disease on exam. Radiographs demonstrated a small bowel obstruction with free air. An exploratory laparotomy demonstrated 2 perforations of the distal ileum. Pathologic exam revealed features consistent with histoplasmosis. We discuss gastrointestinal involvement of histoplasmosis in AIDS and its treatment.     

Rheumatologic manifestations of histoplasmosis in the recent Indianapolis epidemic

Rheumatologic manifestations were noted in 24 (6.3%) of 381 patients with symptomatic histoplasmosis who were seen during a recent epidemic in Indianapolis. Typically, these patients had rapidly additive, rather than migratory, arthritis or arthralgia, which was symmetric in 50%. Ten patients had oligo- or monarticular disease. Knees, ankles, wrists, and small joints of the hand were the most common sites affected. Eleven patients had erythema nodosum. The rheumatologic manifestations were usually mild and, in all but 2 patients, resolved without treatment or with a brief course of nonsteroidal antiinflammatory drugs. The joint disease in patients with erythema nodosum was essentially the same as that seen in patients who did not develop skin lesions. However, those without erythema nodosum more frequently exhibited systemic features, e.g., chills, fever, anemia, and elevated erythrocyte sedimentation rates. Rheumatologic complaints led 16 of the patients in this series (67%) to seek medical attention, and in 3 patients they constituted the sole presenting complaint.