Bilateral adrenal histoplasmosis in a Malaysian tertiary hospital:Report of four cases

Rationale:Adrenal histoplasmosis can present as bilateral adrenal enlargement with constitutional symptoms and/or adrenal insufficiency.Often these patients are initially investigated as secondary adrenal metastases before eventually their diagnosis established by histopathological examination of the adrenal tissues.Patients concerns:We report 4 cases of patients aged 55-78 who presented with hypocortisolism and bilateral adrenal masses.Diagnoses:Bilateral adrenal histoplasmosis.Interventions:Three patients received antifungal treatment for at least one year while 1 patient passed away before the initiation of antifungal treatment.Outcomes:Two patients’adrenal function recovered not requiring any steroid replacement,while 1 patient still requires long-term steroid replacement.Lessons:Adrenal histoplasmosis should be excluded in patients from endemic areas presenting with bilateral adrenal masses and adrenal insufficiency.Usually patients have an exposure to bird droppings,bat guano or soil contaminated with histoplasmosis fungi.Histopathological examination of biopsied adrenal tissues is still the gold standard investigation as serology and molecular diagnostic methods are still not widely available in most centers in Malaysia.

Differential Diagnosis Value of lSF-FDG Imaging in Lung Histoplasmosis and Lung Cancer

In order to confirm the accuracy of ECT （emission computed tomography） scanning imaging in the diagnosis of lung histoplasmosis is higher than CT （computed tomography） scan. We retrospect a lung histoplasmosis patient, he was examined by the CT scan and ECT scanning, respectively. Results showed that lung cancer for CT diagnosis and large benign lesions for 18F-FDG （18F-fluorodeoxyglucose） ECT diagnosis. This indicated that the ECT diagnosis for benign lesions in the lung maybe have higher accuracy than CT scan.

Disseminated histoplasmosis in a 17-year-old Nigerian male patient:A case report

Rationale:Disseminated histoplasmosis is the most severe form of histoplasmosis and often associated with fatal outcomes.Both pulmonary and disseminated forms mimics tuberculosis(TB)and may be misdiagnosed.Patient concerns:A 17-year-old male patient compliant with anti-tuberculosis therapy with complaints of fever,cough productive of thick yellowish sputum,fast breathing,abdominal pain,swelling and jaundice.HIV status was negative.Diagnosis:Disseminated histoplasmosis.Interventions:Antimicrobials including anti-TB therapy,ceftriaxone,gentamicin,azithromycin and ciprofloxacin.Outcomes:He was responding to anti-TB drugs until about 4 and a half months on treatment when he fell ill.Peripheral blood film done 2 days prior to his demise revealed florid yeast like organisms in monocytes with eccentric chromatin suggestive of Histoplasma capsulatum.Lessons:Histoplasmosis can both mimic and coexist with TB and so a high index of suspicion is needed for its diagnosis.

Fatal gastrointestinal histoplasmosis 15 years after orthotopic liver transplantation

We report a case of ileo-colonic Histoplasmosis without apparent respiratory involvement in a patient who had previously undergone an orthotopic liver transplant(OLT) for primary biliary cholangitis 15 years earlier. The recipient lived in the United Kingdom,a non-endemic region for Histoplasmosis. However,she had previously lived in rural southern Africa prior to her OLT. The patient presented with iron deficiency anaemia,diarrhoea,abdominal pain and progressive weight loss. She reported no previous foreign travel,however,it later became known that following her OLT she had been on holiday to rural southern Africa. On investigation,a mild granulomatous colitis primarily affecting the right colon was identified,that initially improved with mesalazine. Her symptoms worsened after 18 mo with progressive ulceration of her distal small bowel and right colon. Mycobacterial,Yersinia,cytomegalovirus and human immunodeficiency virus infections were excluded and the patient was treated with prednisolone for a working diagnosis of Crohn's disease. Despite some early symptom improvement following steroids,there was subsequent deterioration with the patient developing gram-negative sepsis and multi-organ failure,leading to her death. Post-mortem examination revealed that her ileo-colonic inflammation was caused by Histoplasmosis.

Oozing sub-cutaneous masses due to histoplasmosis in a patient from Mali

We presented the case of a 64 year old from Mali who was admitted to the hospital for "oozing sub-cutaneous masses".The diagnosis of African histoplasmosis was established by serology. Several courses of amphotericin B resulted in a cure with sequellae.

Intestinal histoplasmosis in immunocompetent adults

AIM: To present a retrospective analysis of clinical and endoscopic features of 4 cases of immunocompetent hosts with intestinal histoplasmosis(IH).METHODS: Four immunocompetent adults were diagnosed with IH between October 2005 and March 2015 at West China Hospital of Sichuan University. Clinical and endoscopic characteristics were summarized and analyzed retrospectively. GMS(Gomori methenamine silver), PAS(periodic acid-Schiff) and Giemsa staining technique were used to confirm Histoplasma capsulatum(H. capsulatum). The symptoms, signs, endoscopic presentations, radiographic imaging, pathological stain results and follow-up are presented as tables and illustrations.RESULTS: The cases were male patients, ranging from 33 to 61 years old, and primarily presented with nonspecific symptoms such as irregular fever, weight loss, abdominal pain and distention. Hepatosplenomegaly and lymphadenopathy were the most common signs. Endoscopic manifestations were localized or diffuse congestion, edema, ulcers, and polypoid nodules with central erosion involving the terminal ileum, ascendingcolon, transverse colon, descending colon, sigmoid colon and rectum, similar to intestinal tuberculosis, tumor, and inflammatory bowel disease. Numerous yeast-like pathogens testing positive for PAS and GMS stains but negative for Giemsa were detected in the cytoplasm of the histiocytes, which were highly suggestive of H. capsulatum.CONCLUSION: Immunocompetent individuals suffering from histoplasmosis are rarely reported. It is necessary that gastroenterologists and endoscopists consider histoplasmosis as a differential diagnosis, even in immunocompetent patients.

Clinical,biochemical and imaging characteristics of adrenal histoplasmosis in immunocompetent patients in a non-endemic area:A case series

Objective:To document the clinical,biochemical and imaging phenotypes of immunocompetent patients with adrenal histoplasmosis.Methods:The clinical,biochemical and radiologic data of 18 immunocompetent patients[age:45.00(39.25,56.25)years,median(IQR),m/f(16/2)]with adrenal histoplasmosis presenting in the Department of Endocrinology,BSMMU between 2014 and 2020 were retrospectively analyzed.Results:All patients were seronegative for HIV infection,and 27.8%(5/18)had well controlled diabetes mellitus.The median duration of the symptoms was 6.00(IQR:4.00,11.25)months.All had significant weight loss,anorexia and weakness.Fever was present in 61.1%(11/18)patients and night sweat was present in 27.8%(5/18)cases.Hypotension and hyperpigmentation were present in 55.6%(10/18)and 66.7%(12/18)cases,respectively.Three of 18 patients presented with adrenal crisis.Hyponatremia occurred in 55.6%(10/18)cases,but none had hyperkalemia.Thirteen of 18 patients had adrenal insufficiency whereas 83.3%(15/18)had high adrenocorticotropic hormone.CT scan revealed bilateral adrenal enlargement in all cases with oval shape and regular margin.All were hypodense having radiodensity 21-90 hounsfield unit,and 11.1%(2/18)were heterogeneous in contrast enhancement.None had noticeable calcification whereas 1.1%(2/18)cases had central necrosis with peripheral rim enhancement.Hepatomegaly was present in 6 cases,splenomegaly in 3 cases and 5 patients had abdominal lymphadenopathy.Histoplasmosis were confirmed by positive fine needle aspiration cytology of adrenal tissue.Conclusions:Adrenal histoplasmosis should be considered in the list of differentials of bilateral adrenomegaly in immunocompetent individuals even living in non-endemic areas.

Gastrointestinal histoplasmosis complicating pediatric Crohn disease:A case report and review of literature

BACKGROUND Infection with Histoplasma capsulatum(H.capsulatum)can lead to disseminated disease involving the gastrointestinal tract presenting as diffuse abdominal pain and diarrhea which may mimic inflammatory bowel disease(IBD).CASE SUMMARY We report a case of 12-year-old boy with presumptive diagnosis of Crohn disease(CD)that presented with several months of abdominal pain,weight loss and bloody diarrhea.Colonoscopy showed patchy moderate inflammation characterized by erythema and numerous pseudopolyps involving the terminal ileum,cecum,and ascending colon.Histologic sections from the colon biopsy revealed diffuse cellular infiltrate within the lamina propria with scattered histiocytic aggregates,and occasional non-necrotizing granulomas.Grocott-Gomori’s Methenamine Silver staining confirmed the presence of numerous yeast forms suggestive of Histoplasma spp.,further confirmed with positive urine Histoplasma antigen(6.58 ng/mL,range 0.2-20 ng/mL)and serum immunoglobulin G antibodies to Histoplasma(35.9 EU,range 10.0-80.0 EU).Intravenous amphotericin was administered then transitioned to oral itraconazole.Follow-up computed tomography imaging showed a left lower lung nodule and mesenteric lymphadenopathy consistent with disseminated histoplasmosis infection.CONCLUSION Gastrointestinal involvement with H.capsulatum with no accompanying respiratory symptoms is exceedingly rare and recognition is often delayed due to the overlapping clinical manifestations of IBD.This case illustrates the importance of excluding infectious etiologies in patients with“biopsy-proven”CD prior to initiating immunosuppressive therapies.Communication between clinicians and pathologists is crucial as blood cultures and antigen testing are key studies that should be performed in all suspected cases of histoplasmosis to avoid misdiagnosis and inappropriate treatment.

Histoplasmosis and inflammatory bowel disease: A case report

BACKGROUND Infection with Histoplasma capsulatum can lead to a disseminated disease involving the gastrointestinal tract presenting as diffuse abdominal pain and inflammatory diarrhea which may mimic inflammatory bowel disease(IBD).CASE SUMMARY In the current report,we discuss the case of a 41-year old male who presented to the emergency department with complaints of high-grade intermittent fevers and severe abdominal pain with associated diarrhea and hematochezia.Laboratory results demonstrated transaminitis and elevated erythrocyte sedimentation rate,C-reactive protein and ferritin levels.The patient’s presentation was thought to be an exacerbation of his underlying IBD,but further investigations revealed a positive Histoplasma antigen in the urine.The patient was offered a colonoscopy and biopsy to confirm the diagnosis;however,he refused.He was treated with itraconazole and showed significant improvement of his symptoms,thereby confirming the diagnosis of gastrointestinal histoplasmosis.CONCLUSION Here within,we provide a review of IBD,evaluation of chronic diarrhea,and gastrointestinal histoplasmosis.

Disseminated histoplasmosis in primary Sjogren syndrome:A case report

BACKGROUND Sj?gren syndrome(SS)is a chronic and systemic autoimmune disease characterized by lymphocytic infiltration of the exocrine glands.And histoplasmosis is an invasive mycosis caused by the saprophytic dimorphic fungus H.capsulatum.In patients with primary SS(PSS),disseminated histoplasmosis(DH)is extremely rare.CASE SUMMARY We report a 37-year-old female patient admitted to our hospital with exacerbating fatigue,somnolence,and pancytopenia as the main symptoms.She was eventually diagnosed with DH based on pancytopenia,splenomegaly,and findings of bone marrow smears.The atypical clinical symptoms made the diagnosis process more tortuous.Unfortunately,she died of respiratory failure on the day the diagnosis was confirmed.CONCLUSION We present a rare and interesting case of DH in a PSS patient.This case updates the geographic distribution of histoplasmosis in China,and expands the clinical manifestations of DH in PSS,highlighting the significance of constantly improving the understanding of PSS with DH.

Peritoneal Histoplasmosis about a Case and Literature Review

Histoplasmosis is an opportunistic granulomatous fungal infection. Peritoneal histoplasmosis (PH) is a rare form. The first case of PH was described in 1970 but this is the first case reported in Mauritania. We report the case of a 60-year-old male patient with a history of pulmonary tuberculosis, treated and declared cured, and partial epileptic seizures treated with Carbamazepine. Contrast computed tomography of the abdomen showed a large mass with a large intraperitoneal fluid component with a finely calcified wall in places, for which laparoscopy and biopsy were performed, identifying Histoplasma capsulatum infection. The subject received treatment with amphotericin B deoxycholate with good evolution, and outpatient management with itraconazole. PH is a rare entity that requires high clinical suspicion, especially in immunocompetent patients. The patient was informed that non-identifying information from the case would be submitted for publication, and he provided consent.

Primary Histoplasmosis of Larynx: A Case Series and Review of Literature

Objective: Aim of the study was to analyze 10 managed cases of Primary Histoplasmosis of Larynx, over a period of 10 years. Design: Retrospective, non-randomized, interventional case series. Patients and Method: This study was conducted in the Department of Otorhinolaryngology S.M.S Medical College from 2002 to 2011. The study consisted of evaluation of self-reported and referred patients who presented to ENT OPD and emergency. In all the cases a detailed history and clinical examination was done. All the patients underwent fiber optic laryngoscopy and subsequent direct laryngoscopy and biopsy. CT Scans were obtained for few cases. The study was a retrospective analysis of 10 treated cases. Main Outcome and Measures: Success of the treatment was defined as resolution of symptoms, differ-entiation from malignancy, no recurrence and regular follow up. Result: A total of 10 cases were managed between 2002 and 2011 and were reviewed. The main presentation was hoarseness of voice, with lesion simulating malignancy. Most common site of involvement was false cord and aryepiglottic fold (6 cases). Primary laryngeal Histoplasmosis was essentially a disease of adult males in all 10 cases. Treatment was exclusively medical with use of Itraconazole as drug of choice in 7 cases. Conclusion: Isolated laryngeal Histoplasmosis is a rare entity. Because of its simulation with malignancy it needs to be included in the differential diagnosis of neoplasm both benign and malignant. Our study clearly limits this kind of disease to adult males most commonly involving false cord and aryepiglottic fold in an endophytic pattern. Though it looks like cancer;biopsy confirms the diagnosis. The treatment is mainly medical with Itraconazole being the drug of choice.

洞穴探险与洞穴病-组织胞浆菌病

文章介绍了一种与洞穴探险关系密切的深部真菌感染性疾病-组织胞浆菌病,回顾了组织胞浆菌病及其病原真菌,荚膜组织胞浆菌的发现、洞穴病的提出、洞穴中感染源和传播途径的研究历程。结合世界及我国洞穴中组织胞浆菌病爆发的实例,介绍了预防组织胞浆菌病的相关知识,并为安全地开展洞穴探险提供了建议。

结肠及淋巴结组织胞浆菌病一例

组织胞浆菌是一种致病真菌,免疫功能正常及低下患者均可罹患该菌感染。其临床表现复杂多样,常与其他疾病混淆。本文复习相关文献报道一例我院最近诊治的结肠及淋巴结组织胞浆菌病,以提高临床及病理医师对该病的认识,减少其漏诊及误诊的发生。

组织胞浆菌病7例分析及文献复习

目的分析组织胞浆菌病的临床特点、治疗和转归,加深对该病的认识。方法回顾性分析2001—2014年上海华山医院收治的7例组织胞浆菌病,并总结中国大陆同期发表的组织胞浆菌病文献共549例病例资料。结果播散型组织胞浆菌病的主要表现包括发热、肝脾肿大、浅表及深部淋巴结肿大、血细胞减少等,伴HIV/AIDS者血细胞减少及皮肤黏膜表现突出。局灶性感染者缺乏系统性受累的症状或体征。组织学检查可见巨噬细胞内吞噬的荚膜组织胞浆菌。治疗多用两性霉素B,轻症患者予以伊曲康唑。结论组织胞浆菌病是由荚膜组织胞浆菌引起的深部真菌感染,病原菌培养阳性是诊断的金标准,需及时送检标本;治疗以两性霉素B为主,可辅以伊曲康唑。

组织胞浆菌病的诊断和治疗进展

组织胞浆菌病是由双相型组织胞浆菌所引起的广泛分布于全球的真菌病,我国大陆相关报道近期呈上升趋势。本病的病原菌包括荚膜组织胞浆菌、荚膜组织胞浆菌杜氏变种及马皮疽荚膜组织胞浆菌。临床病例依据其各自的临床表现及严重程度,诊断和治疗手段亦有所不同。本文简要综述各类型组织胞浆菌病的临床诊断及治疗进展。

肺型与进展播散型组织胞浆菌病的临床对比分析

目的:比较肺型与进展播散型组织胞浆菌病的临床特点、诊断及预后差异。方法:回顾性分析中南大学湘雅医院2009年2月至2015年10月期间收治的组织胞浆菌病住院患者12例,其中肺型4例,进展播散型8例。从临床表现、影像学、确诊途径及预后等方面分析两者之间的差异性。结果:肺型组织胞浆菌病临床表现轻微,干咳多见。进展播散型患者全身症状明显,极易出现反复高热、全身浅表淋巴结肿大、肝脾肿大,可合并咳嗽、腹痛、关节痛、皮肤改变等。实验室检查示全血细胞减少、肝功能异常、凝血功能异常等。1例肺型患者给予了左下肺切除术,其余3例肺型及6例进展播散型患者分别给予两性霉素B脱氧胆酸盐、伊曲康唑、伏立康唑或氟康唑抗真菌感染治疗,好转出院,1例播散型确诊后暂未治疗即出院,1例播散型因合并重症肺炎及活动性肺结核治疗无效死亡。结论:组织胞浆菌病临床少见,极易漏诊或误诊,依靠骨髓涂片、病理组织切片特殊染色明确病原学是目前确诊的主要依据,推荐两性霉素B脂质体、两性霉素B脱氧胆酸盐及伊曲康唑抗感染治疗。

肠道荚膜组织胞浆菌病2例临床病理观察

目的探讨肠道荚膜组织胞浆菌病的临床病理特征、诊断与鉴别诊断。方法对2例发生于肠道的组织胞浆菌病进行临床病理学、特殊染色和电镜观察,并复习相关文献。结果 2例患者均为男性,年龄为47岁和68岁。病变部位均为回肠黏膜固有层和黏膜下层;组织细胞内外可以见到组织胞浆菌孢子,PAM和PSA染色均为(+);电镜下组织胞浆菌有分层的荚膜和高电子密度的染色质。2例经抗组织胞浆菌治疗后好转出院。结论肠道组织胞浆菌病多由播散性组织胞浆菌病累及所致,好发于淋巴组织丰富的回肠。病理诊断主要靠光镜检查见真菌孢子,PAM和PAS染色均(+)。电镜检查也有诊断价值。大部分患者可以治愈,少数免疫缺陷患者可导致死亡。

内脏利什曼病、播散型组织胞浆菌病及马内菲青霉菌病的诊断和鉴别

内脏利什曼病(visceral leishmaniasis,VL)、播散型组织胞浆菌病(progressive disseminated histoplasmosis,PDH)和马内菲青霉菌病(penicilliosis marneffei,PMAR)均为人兽共患的感染性疾病,其临床表现以及骨髓或淋巴结等穿刺物涂片镜检的病原体形态相似,故易造成误诊,并常导致严重后果。为此,本文对上述3种疾病的流行病学、临床表现、鉴别诊断及其处理原则等进行简要介绍。

播散型组织胞浆菌病临床特点与药物治疗

目的分析总结组织胞浆菌病例的临床特点,以提高对该病的诊疗水平。方法收集8例确诊并资料完整的病例,进行回顾性分析总结。结果组织胞浆菌病特点如下:患者长期发热,多系统损害,消化、血液和呼吸系统常受累,出现相应的症状和贫血貌、消瘦、皮肤出血点和肝脾肿大等体征;轻度贫血,外周血白细胞总数不增高或偏低,中性粒细胞比例<0.73,杆状核粒细胞偏高,淋巴细胞减少或正常,单核细胞比例偏高,C-反应蛋白增高程度明显高于血沉,血IgG升高,血浆清蛋白/球蛋白(A/G)比值降低;特殊检查以肝脾和腹腔淋巴结肿大为主,肝CT密度值下降疑似脂肪肝。结论具有上述临床特征的患者应进行油镜下骨髓细胞学检查,在巨噬细胞内发现组织胞浆菌,并经骨髓真菌培养,见双相生长的真菌而确诊。治疗用两性霉素B,总剂量约350 mg,疗效极佳。