Oral manifestations of systemic fungal infections: 25-year experience in an endemic region

Some mycoses are endemic. They develop through hematogenous spread, causing a generalized infection, usually with secondary mucosal involvement.The aim of this observational and retrospective study was to report the prevalence and characteristics of oral lesions in patients diagnosed with systemic fungal infections (SFI) over a 25-year period in southern Brazil. Demographic (age, sex, ethnicity, occupation) and clinical (anatomical location, symptoms,histopathological diagnosis and management) data from the medical records of patients with SFI were collected from 1995 to 2019. 34 cases of SFI were found, of which 31 (91.18%) were diagnosed as paracoccidioidomycosis (PCM) and 3 (8.82%) as histoplasmosis. Men were much more affected (n = 31; 91.18%), with an average age of 46.9 years. Most patients (n = 18; 58.06%) were Caucasian; 48% (n = 15) were farm/rural workers and the most affected region was the jugal mucosa (n = 13; 25.49%) followed by the alveolar ridge (n = 12; 23.52%). All patients with histoplasmosis were immunocompetent men (mean age: 52.67 years), and the palate was the most affected. All patients underwent incisional biopsy and were referred to an infectologist. The dentist has an essential role in the recognition of SFI, whose oral manifestations may be the first sign. SFI should be included in differential diagnosis in patients from endemic areas. In addition, the inevitable human mobility and globalization make knowledge of these mycosesnecessary worldwide, especially since advanced cases in immunocompromised patients can be fatal.

Oral ulcerative lesions in a post-liver-transplantation patient

Oral involvement is rarely found in histoplasmosis, except in its disseminated form, which is mostly observed in the severely immunocompromised host. Herein, we presented the case of a 36-year-old female with a previous history of liver transplant, who was hospitalized due to fever, chills, night sweats, diarrhea, and painful oral lesions over the last 3 days. The oral examination revealed the presence of painful shallow ulcers lined by a pseudomembrane in the gingiva and the soft and hard palate. The initial working diagnosis comprised cytomegalovirus reactivation or herpes simplex virus infection. The diagnostic work-up included incisional biopsies of the gingiva and the sigmoid colon. Both biopsies confirmed the diagnosis of histoplasmosis. Intravenous itraconazole was administered with significant improvement after 7 days. Although oral involvement is rare, histoplasmosis should be included in the differential diagnosis of oral lesions, particularly when the patient is immunosuppressed. This study reports a rare presentation of histoplasmosis involving the mucosa of the oral cavity and the colon.

Histoplasma panniculitis in a patient with systemic lupus erythematosus

Abstract: Histoplasmosis usually presents primarily as lung infection. Occasionally, mainly in immunocompromised hosts, it can spread and cause systemic manifestations. Skin lesions have been reported in 10 to 15 percent of cases of disseminated histoplasmosis, and panniculitis has been described as an unusual form of presentation in affected patients. We present the case of a patient with systemic lupus erythematosus who presented cellulitis due to disseminated histoplasmosis.

Pulmonary histoplasmoma: a disguised malady

Histoplasmosis is a mycosis caused by the dimorphic fungus, Histoplasma capsulatum, which is transmitted via dust and aerosols. Lung involvement is the most common, with a varied clinical presentation. Although it is not the only source of infection, H. capsulatum is frequently found in bat guano, which is the reason why it is highly prevalent among caving practitioners. The solitary histoplasmoma of the lung is an unusual and chronic manifestation of this entity, which mimics, or at least is frequently misconstrued, as a malignancy. Almost invariably, the diagnosis of this type of histoplasmosis presentation is achieved after lung biopsy. The authors present the case of a young woman who sought medical care because of chest pain. The diagnostic work-up revealed the presence of a pulmonary nodule. She was submitted to a thoracotomy and wedge pulmonary resection. The histologic analysis rendered the diagnosis of histoplasmoma. Thisreport aims to call attention to this diagnosis as the differential diagnosis of a pulmonary nodule.

Lesiones cutáneas como manifestación de una histoplasmosis diseminada en un hospital del Perú / Skin lesions of a disseminated histoplasmosis in Peru

The dermatological manifestations of disseminated histoplasmosis present in about 17% of the cases, is a challenge for its diagnosis. We report the case of a patient from the northern coast of Peru, who presented diffuse dermal lesions, erythema-violaceous nodules, and ulcers histopathologically compatible with the infection of the genus Histoplasma var. capsulatum

Síntomas faríngeos como primera manifestación clínica en un paciente con Histoplasmosis generalizada / Pharyngeal symptoms as first clinical manifestation in a patient with Generalized Histoplasmosis

Introducción: La Histoplasmosis es una enfermedad endémica, que presenta un comportamiento oportunista cuyo germen causal es el Histoplasma capsulatum (HC), considerado un hongo dimórfico. Objetivo: Presentar un caso con el diagnóstico de Histoplasmosis generalizada, cuyas manifestaciones faríngeas fueron el inicio de la enfermedad. Presentación del caso: Se presenta el caso de un paciente, con los síntomas faríngeos que fueron la primera manifestación de la enfermedad, en el que la biopsia permitió llegar al diagnóstico nosológico. Posteriormente presentó otras manifestaciones con aspectos clínicos-microbiológicos de diseminación progresiva. Conclusiones: La Histoplasmosis faríngea es una micosis sistémica infrecuente y de difícil diagnóstico, es preciso un buen interrogatorio y examen físico, en aquellos pacientes con factores de riesgo de enfermedades infecciosas sin diagnóstico aparente y deterioro progresivo de su estado general(AU)

Introduction: The Histoplasmosis is an endemic illness that presents an opportunist behavior in which causal germ is the Histoplasma capsulatum (HC), considered a dimorphic mushroom. Objective: To present a case with the diagnosis of Generalized Histoplasmosis in which pharyngeal manifestations were the beginning of the illness. Presentation of the case: The case of a patient is presented with the pharyngeal symptoms that were the first manifestation of the illness, in which the biopsy allowed to arrive to the diagnostic. Later the patient presented other manifestations with clinical-microbiologic aspects of progressive dissemination. Conclusions: The pharyngeal Histoplasmosis is an uncommon systemic mycosis and with a difficult diagnostic, it is necessary a good interrogation and physical exam, in those patients with factors of risk of infectious illnesses without apparent diagnosis and progressive deterioration of their general state(AU)

Oral manifestation of histoplasmosis on the palate

Abstract This case report describes an uncommon manifestation of histoplasmosis on the soft palate. The importance of appropriate treatment and follow-up in complex cases is emphasized, especially in patients with chronic diseases. Oral lesions may occur as multiple, granular and painful ulcers, as well as verrucous growths. Lesions may also be deep, with infiltrative edges and erythematous or with white areas, accompanied by local lymphadenopathy, resembling a carcinoma on clinical examination. In this sense, a fast and accurate diagnosis is essential to the success of treatment of oral histoplasmosis.

Histoplasmosis diseminada en pacientes HIV/SIDA: Buenos Aires, 2009-2014 / Disseminated histoplasmosis in patients with AIDS. Buenos Aires, 2009-2014

Durante 2009-2014, en nuestro hospital fueron diagnosticados 171 casos de histoplasmosis en pacientes con HIV/sida: 64 en 2009-2011, y 107 en 2012-2014. El mayor número de casos durante el segundo trienio no tuvo relación con la infección por HIV, cuya tasa de diagnóstico permaneció estable. La relación hombre/mujer fue 3.7:1 y la edad media 37.4 años. Al diagnóstico, solo 54/171 (31.6%) recibían TARGA y el recuento de linfocitos T CD4+ varió entre 4 y 264 células/μl. El 64.3% (n = 110) presentó lesiones cutáneas (pápulas ulceradas o "moluscoides") positivas para Histoplasma capsulatum al examen microscópico con tinción Giemsa. Siguieron en frecuencia las manifestaciones respiratorias y el lavado broncoalveolar fue positivo en 41/171 (24.0%) pacientes. Las imágenes radiológicas más frecuentes en orden decreciente fueron patrón miliar, infiltrados intersticiales y condensaciones focales. Se aisló H. capsulatum en 82 (58.2%) de los 141 hemocultivos realizados. No hubo diferencia significativa entre el rendimiento diagnóstico del hemocultivo y el de las escarificaciones cutáneas (p = 0.6164). Otras infecciones oportunistas previas o concomitantes con la histoplasmosis se observaron en 70/171 (40.9%). Se registró asociación con tuberculosis en 16/171 (9.4%) y un aislamiento de Mycobacterium tuberculosis resultó multirresistente. La gravedad del caso determinó el tratamiento con anfotericina B desoxicolato en 115 (67.3%), con itraconazol en 43 (25.1%), y con terapias combinadas en 14 (8.2%). La letalidad fue 19.9% (34/171). La mayor prevalencia en el segundo trienio debe alertar a la comunidad médica a considerar el diagnóstico de la histoplasmosis en pacientes con HIV/sida para disminuir la mortalidad.

A retrospective study was carried out on 171 cases of disseminated histoplasmosis diagnosed in HIV/AIDS patients during the period 2009-2014. Although HIV diagnosis rates remained stable over the study period, a sensible increase in the number of histoplasmosis cases was observed in the last three years. Disseminated histoplasmosis was prevalent in males with an average age of 37.8 years. At diagnosis, only 54/171 (31.6%) were receiving HAART, and CD4+ T-lymphocyte counts ranged from 4 to 264 cells/μl. Cutaneous lesions, including ulcerated papules or molluscoid plaques, were present in 110/171 (64.3%), with Histoplasma capsulatum being observed in all skin scraping specimens upon Giemsa staining. Respiratory manifestations were second in frequency with bronchoalveolar lavage showing a high diagnostic performance. Radiological findings included milliary patterns, interstitial infiltrates, and focalized condensations. Out of 141 blood cultures performed, H. capsulatum was isolated in 82 (58.2%). No significant difference in diagnostic performance was found between blood cultures and skin scraping (p = 0.6164). Other opportunistic infections were observed in 70/171 (40.9%) prior to or concomitantly with histoplasmosis. Association with Mycobacterium tuberculosis was recorded in 16/171 (9.4%) and one had a multi-drug resistant isolate. The severity of histoplasmosis determined the monotherapy with amphotericin B deoxycholate in 115 (67.3%), itraconazole in 42 (24.5%), and combined therapies in 14 (8.2%). Mortality was 19.9% (34/171). Finally, we emphasize that the higher prevalence in the last three years of the study should prompt the medical community to consider the diagnosis of histoplasmosis to reduce mortality of AIDS patients.

Cutaneous histoplasmosis as a complication after anti-TNF use - Case report

Anti-TNF agents are effective in the treatment of psoriasis. However, they render individuals more susceptible to infections. We report an atypical case of histoplasmosis in an immunosuppressed patient due to anti- TNF therapy. A patient who used anti-TNF for the treatment of psoriasis had had a lesion on the right eyebrow since discontinuation of the medication. The diagnostic hypothesis was basal cell carcinoma, but the histopathological examination was compatible with histoplasmosis.

Atypical presentation of histoplasmosis in an immunocompromised patient

We present a case of disseminated cutaneous histoplasmosis in a male patient, rural worker, HIV positive for 20 years, with a history of irregular use of antiretroviral therapy, T cell counts below 50 cells/mm3 and with good response to treatment with Itraconazole. We highlight importance of skin lesions in clarifying early diagnosis, since this co-infection often leads patients to death.

Primary cutaneous histoplasmosis developed in the penis of an immunocompetent patient

A 70-year-old male presenting a 3-month history of genital painless erythematous nodules in the balanopreputial sulcus was referred to our service. Histopathological exam presented a chronic dermatitis with epithelioid granulomas and Grocott staining revealed numerous fungal structures with a suggestive morphology of Histoplasma sp. Cultures evidenced Histoplasma capsulatum var. capsulatum. Treatment with oral itraconazole led to complete remission of lesions.

Manejo de criptococosis meníngea refractaria: a propósito de un caso / Management of refractory cryptococcal meningitis: report of a case

La criptococosis es una de las infecciones oportunistas más frecuentes en pacientes con infección por HIV. La toxicidad de la anfotericina B y el aislamiento de un número creciente de cepas resistentes a fluconazol determinan la necesidad de tratamientos alternativos y estrategias novedosas. Este artículo presenta un paciente HIV positivo con criptococosis meníngea sin negativización de los aislamientos de Cryptococcus neoformans con el tratamiento convencional de inducción con anfotericina B más fluconazol, y respuesta favorable al sustituir este último antifúngico por voriconazol...

Cryptococcosis is one of the most common opportunistic infections in patientes with HIV infection. The toxicity of amphotericin B and isolation of an increasing number of strains resistant to fluconazole dictate the need for alternative treatments and novel strategies. This paper presents an HIV positive patient with cryptococcal meningitis without negativisation Cryptococcus neoformans isolates with conventional induction therapy with amphotericin B plus fluconazole, and favorable to the latter replaced by voriconazole antifungal response...

Histoplasmose pulmonar canina no estado de Pernambuco, Brasil: relato de caso / Canine pulmonary histoplasmosis in Pernambuco State, Brazil: case report

A histoplasmose é uma das principais doenças micóticas que acometem o trato respiratório inferior de pequenos animais, sendo ocasionada pelo Histoplasma capsulatum, fungo encontrado em solos ricos em compostos nitrogenados, derivados de matéria orgânica em decomposição. Descreve-se um caso de histoplasmose pulmonar em um canino da raça Boxer, domiciliado no estado de Pernambuco, Brasil, o qual apresentava uma síndrome respiratória com evolução clínica de aproximadamente seis meses. Na análise citopatológica do lavado broncoalveolar, foram visualizadas estruturas leveduriformes de aproximadamente dois micrômetros de diâmetro, características de H. capsulatum, sendo, então, indicada a terapia com itraconazol. O exame citopatológico do lavado broncoalveolar é uma ferramenta diagnóstica importante na identificação do agente, e o tratamento com itraconazol é eficiente, levando à remissão completa dos sinais clínicos.

Histoplasmosis is a main fungal diseases that affect the lower respiratory tract of small animals, being caused by Histoplasma capsulatum, a fungus found in soil rich in nitrogen compounds, derived from decaying organic matter. It is described a case of pulmonary histoplasmosis in a dog of Boxer breed, domiciled in the state of Pernambuco, Brazil, which had a respiratory syndrome with clinical course of about six months. On cytopathological examination of bronchoalveolar lavage were visualized yeast structures of approximately two micrometers in diameter, characteristics of H. capsulatum, and then was indicated therapy with itraconazole. The cytopathological examination of bronchoalveolar lavage is an important diagnostic tool in the identification of the agent and the treatment with itraconazole is efficient, leading to complete remission of clinical signs.

Histoplasmose simulando neoplasia primária de pulmão ou metástases pulmonares / Histoplasmosis mimicking primary lung cancer or pulmonary metastases

OBJETIVO: Descrever as principais características clínico-radiológicas de pacientes com histoplasmose simulando câncer de pulmão. MÉTODOS: Estudo descritivo e retrospectivo baseado na análise dos prontuários médicos de 294 pacientes diagnosticados com histoplasmose no Laboratório de Micologia da Irmandade Santa Casa de Misericórdia de Porto Alegre, em Porto Alegre (RS), entre 1977 e 2011. O diagnóstico de histoplasmose foi estabelecido por cultura, exame histopatológico ou identificação de bandas M ou H por imunodifusão. Após identificar os pacientes com lesões macroscópicas e com achados compatíveis de malignidade em radiografia ou TC de tórax, os pacientes foram divididos em dois grupos: pacientes com história de câncer e lesões simulando metástases (grupo HC) e pacientes sem história de câncer com lesão simulando neoplasia primária (SHC). RESULTADOS: Dos 294 pacientes com histoplasmose, 15 apresentaram lesões simulando neoplasia primária ou metástases (9 e 6 nos grupos HC e SHC, respectivamente). A idade dos pacientes variou de 13 a 67 anos (mediana, 44 anos) Dos 15 pacientes, 14 (93%) apresentaram lesões pulmonares no momento da internação. CONCLUSÕES: A síndrome clínica e radiológica da doença neoplásica não se limita a malignidade, e, portanto, as doenças infecciosas granulomatosas devem ser consideradas no diagnóstico diferencial.

OBJECTIVE: To describe the main clinical and radiological characteristics of patients with histoplasmosis mimicking lung cancer. METHODS: This was a retrospective descriptive study based on the analysis of the medical records of the 294 patients diagnosed with histoplasmosis between 1977 and 2011 at the Mycology Laboratory of the Santa Casa Sisters of Mercy Hospital of Porto Alegre in the city of Porto Alegre, Brazil. The diagnosis of histoplasmosis was established by culture, histopathological examination, or immunodiffusion testing (identification of M or H precipitation bands). After identifying the patients with macroscopic lesions, as well as radiological and CT findings consistent with malignancy, we divided the patients into two groups: those with a history of cancer and presenting with lesions mimicking metastases (HC group); and those with no such history but also presenting with lesions mimicking metastases (NHC group). RESULTS: Of the 294 patients diagnosed with histoplasmosis, 15 had presented with lesions mimicking primary neoplasia or metastases (9 and 6 in the HC and NHC groups, respectively). The age of the patients ranged from 13 to 67 years (median, 44 years). Of the 15 patients, 14 (93%) presented with pulmonary lesions at the time of hospitalization. CONCLUSIONS: The clinical and radiological syndrome of neoplastic disease is not confined to malignancy, and granulomatous infectious diseases must therefore be considered in the differential diagnosis.

Posaconazole as rescue therapy in African histoplasmosis

Posaconazole Histoplasmosis Salvage therapy African histoplasmosis is a granulomatous mycosis caused by Histoplasma capsulatum var. duboisii. Treatment is usually extrapolated from guidelines for classical histoplasmosis, and includes 2-4 weeks of amphotericin B followed by a step-down maintenance therapy with itraconazole. Pediatric usage of posaconazole, an oral second-generation azole, remains off-label, but recent surveys show that it is safe and well tolerated in children. We report a case of disseminated African histoplasmosis in a 12-year-old boy from Guinea-Bissau. Therapy with amphotericin B and itraconazole led to a progressive clinical deterioration. A dramatic and lasting improvement was observed using posaconazole. He completed 12 months of therapy. No relapse was noted during or 3 months after treatment. We report that posaconazole may be a safe and efficacious drug in the salvage management of disseminated AH, either in patients with disease refractory to conventional anti-fungal therapy, or in patients whose serious adverse effects of first-line drugs preclude its use.

Borderline tuberculoid leprosy associated with primary cutaneous histoplasmosis / Hanseníase dimorfa tuberculoide associada à histoplasmose cutânea primária

We describe a case of borderline tuberculoid leprosy associated with primary cutaneous histoplasmosis in a patient who presented at our hospital with skin lesions and joint complaints.

Descrevemos um caso de hanseníase dimorfa tuberculoide associada à histoplasmose cutânea primária em um paciente que procurou nosso hospital com lesões dermatológicas e queixas articulares.

HIV-associated tuberculous lymphadenitis: the importance of polymerase chain reaction (PCR) as a complementary tool for the diagnosis of tuberculosis - a study of 104 patients / Linfadenite tuberculosa associada ao HIV: a importância da reação em cadeia de polimerase (PCR) como ferramenta complementar para o diagnóstico da tuberculose - estudo de 104 pacientes

BACKGROUND: Lymphadenitis is common in HIV-positive patients. Diagnosis of the infections associated with this condition is complex, particularly in the case of tuberculosis. Rapid and specific detection of Mycobacterium tuberculosis (M. tuberculosis) is fundamental in ensuring adequate treatment. In addition, frequent causes of lymphadenitis such as those associated with lymphoma and histoplasmosis, among others, must be eliminated as possible causes. OBJECTIVES: To evaluate the accuracy of polymerase chain reaction as a tool for the diagnosis of lymphadenitis resulting from M. tuberculosis. METHODS: In this study, a protocol was developed using the following procedures: direct microscopy using Ziehl-Neelsen staining, culture in Lowenstein-Jensen medium, histology and polymerase chain reaction. RESULTS: A total of 104 patients were included in the study. According to histopathology, 38 patients (36 percent) were found to have nonspecific chronic lymphadenitis, 27 (26 percent) had tuberculous lymphadenitis, 11 patients (10.5 percent) had lymphoma and 9 (8.7 percent) had histoplasmosis. When Lowenstein-Jensen culture was performed, positive tests for tuberculous lymphadenitis increased by 30 percent. With polymerase chain reaction, M. tuberculosis DNA was detected in 6 out of 38 samples of non-specific chronic lymphadenitis. Three of these patients were followed up, developed symptoms of tuberculosis and were cured following specific treatment. CONCLUSION: The data obtained in this study suggest that all cases of lymphadenopathies should be submitted to histopathology, Lowenstein-Jensen or Ogawa culture and polymerase chain reaction. Polymerase chain reaction may prove to be useful in providing an early and accurate detection of cases of extrapulmonary tuberculosis in HIV-positive patients with lymphadenopathies, avoiding empirical treatment and the possible development of resistant strains.

FUNDAMENTOS: A linfadenite é comum em pacientes HIV-positivos. O diagnóstico das infecções associadas a essa condição é complexo, especialmente em relação à tuberculose. A detecção rápida e específica do Mycobacterium tuberculosis (M. tuberculosis) é essencial para o tratamento adequado. Além disso, frequentes causas de linfadenites tais como as relacionadas a linfoma, histoplasmose, e outras, devem ser afastadas. OBJETIVOS: Avaliar a importância da biópsia cirúrgica excisional das linfadenites e realização dos exames histopatológicos, exames baciloscópicos (Ziehl-Neelsen), cultura (Lowenstein-Jensen) e reação em cadeia da polimerase (PCR) com finalidade diagnostica MÉTODOS: Desenvolveu-se um protocolo para biópsias excisionais de linfonodos, adotando-se os seguintes procedimentos: exame direto de esfregaços corados pelo método de Ziehl-Neelsen, cultura em meio de Lowenstein-Jensen, exame anátomo-patológico e PCR. RESULTADOS: Ao todo foram incluídos 104 pacientes, e o exame histopatológico evidenciou 36 por cento (n = 38 pacientes) de casos de linfadenite crônica inespecífica, 26 por cento (n = 27) de linfadenite tuberculosa, 10,5 por cento (n =11) de linfoma e 8,7 por cento (n = 9) de histoplasmose. Através da cultura no meio de Lowenstein-Jensen, os casos positivos para linfadenite tuberculosa aumentaram para 30 por cento. A PCR detectou M. tuberculosis em 6 das 38 amostras de linfadenite crônica inespecífica. Três desses pacientes foram acompanhados, exibiram sintomas de tuberculose e foram curados após tratamento específico. CONCLUSÃO: Os dados obtidos neste trabalho sugerem que em todos os casos de linfadenopatia deve-se realizar exame histopatológico, cultura em Lowenstein-Jensen ou Ogawa e reação em cadeia da polimerase. A reação em cadeia da polimerase pode ser útil na detecção precoce e acurada de casos de TB extrapulmonar nos pacientes HIV-positivos com linfadenopatias, evitando-se o uso de tratamentos empíricos e o eventual desenvolvimento de cepas resistentes.

Coinfecção histoplasmose e Aids / Histoplasmosis and AIDS co-infection

Apresenta-se um caso de coinfecção histoplasmose e Aids, com lesões cutâneas predominantemente papulosas e comprometimento sistêmico. O exame histopatológico e micológico de lesão cutânea confirmou o diagnóstico. Em doentes com Aids, a histoplasmose surge, principalmente, quando a contagem de células T-CD4-positivas é inferior a 50 células/mm³. Nesses casos, a histoplasmose pode ser grave e, se não tratada adequadamente, levar ao êxito letal, como no paciente relatado.

This report concerns an AIDS patient presenting systemic and cutaneous manifestations of histoplasmosis. A histopathological and mycological examination of the skin lesion confirmed the diagnosis. In AIDS patients histoplasmosis arises mainly when the T-CD4+ cell count is less than 50 cells/mm3. In such cases, histoplasmosis can be severe and if left untreated can lead to death, as occurred with this patient.