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Suggest Treatment For Progressive Disseminated Histoplasmosis
Question: My 77 year old father was in ICU for 6 weeks due to ARDS and multiple distributive shock episodes only seeming to respond to steroids. He initially presented with severe upper abd pain and N&V, and fever began 2 days later. He had some transient hepatosplenomegaly and then new finding of bulky, then diffuse thickening of both adrenal glands and a questionable small nodule. He also had oral lesions and then bradycardia, and profound pancytopenia throughout. Ferritin level was extremely high, but TTP and HLH were ruled out. During the investigations, MDS (RAEB1) was discovered. He then developed a serpiginous rash with nodules and plaques on his thorax which spontaneously disappeared after 3 wks. I have always wondered about histoplasmosis because of his immunosuppression and clinical course and requested histoplasmosis antigen testing - but they only did complement fixation and immunodiffusion which came back negative. However, I understand one can't rely on antibodies when they are immunosuppressed. Fungal blood culture and bone biopsy returned negative. I am still concerned he has histoplasmosis because of continued weight loss and nausea (he has been treated for recurrent c diff). What are the chances he may have histoplasmosis? His family doctor refuses to do antigen testing.
Brief Answer:
Histoplasmosis in immuno-suppressed individuals
Detailed Answer:
Hi,
Thank you for your query. I can understand your concerns.
Progressive disseminated histoplasmosis (PDH) is typically seen in immunocompromised individuals, who account for ~70% of cases. Common risk factors include extremes of age(70 years age of your father) and the use of immunosuppressive medications such as chemotherapy with Vidaza (Azacitidine),a nucleoside metabolic inhibitor.
Fungal culture remains the gold standard diagnostic test for histoplasmosis.
In PDH, the culture yield is highest for BAL(bronchoalveolar lavage) fluid, bone marrow aspirate, and blood.
The detection of Histoplasma antigen in body fluids is extremely useful in the diagnosis of PDH and acute diffuse pulmonary histoplasmosis. The sensitivity of this technique is >95% in patients with PDH and ~80% in patients with acute pulmonary histoplasmosis if both urine and serum are tested.
Serologic tests, including immunodiffusion and complement fixation, are especially useful for the diagnosis of self-limited pulmonary histoplasmosis; however, at least 1 month is required for the production of antibodies after acute infection. A fourfold rise in antibody titer may be seen in patients with acute histoplasmosis and is diagnostic.
In view of persistent concern for histoplasmosis (ARDS /pulmonary episode)episode,one can go for antigen testing or repeat serological test to see if there is any rise in titre.
Regards
Dr. T.K. Biswas M.D. XXXXXXX
Histoplasmosis in immuno-suppressed individuals
Detailed Answer:
Hi,
Thank you for your query. I can understand your concerns.
Progressive disseminated histoplasmosis (PDH) is typically seen in immunocompromised individuals, who account for ~70% of cases. Common risk factors include extremes of age(70 years age of your father) and the use of immunosuppressive medications such as chemotherapy with Vidaza (Azacitidine),a nucleoside metabolic inhibitor.
Fungal culture remains the gold standard diagnostic test for histoplasmosis.
In PDH, the culture yield is highest for BAL(bronchoalveolar lavage) fluid, bone marrow aspirate, and blood.
The detection of Histoplasma antigen in body fluids is extremely useful in the diagnosis of PDH and acute diffuse pulmonary histoplasmosis. The sensitivity of this technique is >95% in patients with PDH and ~80% in patients with acute pulmonary histoplasmosis if both urine and serum are tested.
Serologic tests, including immunodiffusion and complement fixation, are especially useful for the diagnosis of self-limited pulmonary histoplasmosis; however, at least 1 month is required for the production of antibodies after acute infection. A fourfold rise in antibody titer may be seen in patients with acute histoplasmosis and is diagnostic.
In view of persistent concern for histoplasmosis (ARDS /pulmonary episode)episode,one can go for antigen testing or repeat serological test to see if there is any rise in titre.
Regards
Dr. T.K. Biswas M.D. XXXXXXX
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Above answer was peer-reviewed by :
Dr. Yogesh D
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