Histoplasmosis en pacientes con infección por VIH en Paraguay: Casuística del Laboratorio Central del Ministerio de Salud Pública en el período 1993-2017

Resumen Introducción: La histoplasmosis es una micosis sistémica en pacientes inmunodeprimidos y su epidemiología es desconocida en el país. Objetivo: Describir los datos demográficos y clínicos de pacientes con infección por VIH (IpVIH) e histoplasmosis diagnosticadas en el Laboratorio Central de Salud Pública, Asunción-Paraguay. Pacientes yMétodos: Estudio retrospectivo y transversal de pacientes con muestras positivas a Histoplasma capsulatum diagnosticados en el período 1993-2017. Resultados: Fueron diagnosticados 162 pacientes con IpVIH e histoplasmosis. El origen de los pacientes en orden de prevalencia fue: la capital Asunción, Central, Cordillera y San Pedro. La relación hombre/mujer fue 4:1 y la edad media 34,1 ± 7,7 años con un rango de 18 a 61 años. La fiebre, las lesiones en piel y las úlceras en mucosa fueron los síntomas y manifestaciones más frecuentes. Los métodos para diagnósticos más utilizados fueron las escarificaciones de piel, úlceras muco-cutáneas y las punciones de médula ósea. Conclusión: Por ser el primer reporte nacional de histoplasmosis en pacientes con IpVIH, consideramos este trabajo relevante para la base de otros estudios de micosis profunda.

Abstract Background: Histoplasmosis is a systemic mycosis in immunosuppressed patients and its epidemiology is unknown in the country. Aim: To describe the demographic and clinical data of patients with HIV infection and histoplasmosis diagnosed in the Central Public Health Laboratory, Asunción-Paraguay. Methods: Retrospective and cross-sectional study of patients with Histoplasma capsulatum positive samples diagnosed in the period 1993-2017. Results: 162 patients with HIV infection were diagnosed as histoplasmosis. The origin of the patients in order of prevalence were the capital Asunción, Central, Cordillera and San Pedro departments. The male/female ratio was 4: 1 and the mean age was 34.1 ± 7.7 years with a range of18 to 61 years. Fever, skin lesions and mucosal ulcers were the most frequent symptoms and manifestations. The most widely used diagnostic methods were scarification of skin, mucocutaneous ulcers and bone marrow punctures. Conclusion: As it is the first national report of histoplasmosis in patients with HIV infection, we consider this work relevant for the basis of other studies of deep mycosis.

Histoplasmosis diseminada en una mujer con artritis seronegativa / Disseminated histoplasmosis in a woman with seronegative arthritis

Resumen Histoplasma capsulatum es un hongo ambiental que se encuentra distribuido comúnmente en los valles de los ríos Ohio y Mississippi, América Central, Sudamérica y Asia. Las zonas más afectadas en Argentina son las cuencas de los ríos Paraná y de La Plata. Los pacientes con histoplasmosis tienen una amplia variedad de manifestaciones clínicas. La mayoría son asintomáticos, mientras que aquellos con com promiso de la inmunidad celular tienen un riesgo aumentado de padecer la forma diseminada. Presentamos el caso de una mujer adulta, en tratamiento con metotrexato por una artritis seronegativa, que desarrolló la forma diseminada de la enfermedad, y que representó un desafío diagnóstico debido a la dificultad para identificar el agente etiológico.

Abstract Histoplasma capsulatum is an environmental fungus commonly found in the Ohio and Mississippi River valleys, Central and South America, and Asia. The most affected areas in Argentina are the Paraná and de La Plata river basins. Patients with histoplasmosis can have a wide range of clinical presentations. Most of them are asymptomatic, while those with compromised cellular immunity are at increased risk for the disseminated form. We present the case of a patient undergoing treatment with methotrexate for seronegative arthritis who developed the disseminated form of the disease, and who represented a diagnostic challenge due to the difficulty in identifying the etiologic agent.

Histoplasmosis diseminada. A propósito de un caso / Disseminated Histoplasmosis. About a case

RESUMEN La histoplasmosis es una micosis profunda causada por el hongo dimorfo Histoplasma capsulatum (H. capsulatum). Ingresa al organismo principalmente por la vía inhalatoria en forma de microconidias, las cuales se transforman en elementos levaduriformes intracelulares, y luego se diseminan por vía hemática. La primoinfección en pacientes inmunocompetentes suele ser asintomática y de resolución espontánea, pero los pacientes inmunodeprimidos generalmente pueden presentar una enfermedad diseminada con compromiso mucocutáneo con pápulas, nódulos, gomas, úlceras de fondo granulomatoso serosanguinolento y costras. Se presenta un caso clínico de un paciente diabético inmunodeprimido con infección por H. capsulatum, en el cual se realiza diagnóstico a partir de las lesiones cutáneas.

SUMMARY Histoplasmosis is a deep mycosis caused by the dimorfo fungus Histoplasma capsulatum (H. capsulatum). Which enters the body mainly through the inhalation route in the form of microconidia which are transformed into intracellular levaduriform elements, and then disseminated by blood. The primary infection in immunocompetent patients is usually asymptomatic and spontaneously resolved, but immunocompromised patients can usually present with a disseminated disease with mucocutaneous involvement, with papules, nodules, gums, granulomatous serosanguinolent fundus ulcers and scabs. A clinical case of an immunocompromised diabetic patient with H. capsulatum infection is presented, in which diagnosis is made from the skin lesions.

A Case Report on Biochemical Aberrations in Disseminated Histoplasmosis: The Clues Toward Addison’s Disease

@#The incidence of Addison’s disease (AD) is rare. One of the most common causes of AD in developed countries is autoimmune. On the other hand, in developing countries, infective causes still predominate. The symptoms are mostly insidious in onset and non-specific, making it challenging to diagnose AD. The delay in starting the right treatment predisposes to high mortality due to Addison’s crisis. Hence, biochemical parameters play a vital role in diagnosing AD since they usually will present with prominent hyponatraemia, hyperkalaemia and hypoglycaemia. Here, we report a case of a 66-year-old man with multiple co-morbidities and disseminated histoplasmosis who presented with asymptomatic hyponatraemia and hyperkalaemia and was eventually diagnosed with Addison’s disease. Although the non-specific symptoms from his multiple co-morbidities obscured the diagnosis of AD, comprehensive biochemical tests have helped in establishing the diagnosis.

Disseminated histoplasmosis mimicking an acute appendicitis

@#Introduction: Histoplasmosis can present in a myriad of clinical manifestations, which often makes its diagnosis difficult and occasionally, deceptive. Case Report: We describe a case of a 33 years old gentleman who was clinically diagnosed as acute appendicitis at initial presentation in view of a one-week history of fever, right lower quadrant abdominal pain- and guarding at right iliac fossa. He had thrombocytopenia and lymphopenia on presentation. Mesenteric lymphadenitis and small bowel lesion were found intraoperatively, which was respectively biopsied and resected. Histopathological result confirms disseminated histoplasmosis. Retroviral screen was positive. He was treated with amphotericin B for one week, subsequently switched to oral itraconazole, followed by initiation of highly active antiretroviral therapy (HAART). Discussion: This case illustrates the various nature of histoplasmosis presentation. A high index of suspicion is needed to clinch the diagnosis and subsequently institute prompt treatment as disseminated disease can be fatal if left untreated in an immunosuppressed host.

Histoplasmosis diseminada. Una infección oportunista en pacientes con infección por VIH. Experiencia en el Hospital Nacional Prof. A. Posadas, 2011-2017 / Disseminated histoplasmosis. An oportunistic infection in HIV positive patients Experience in the Hospital Nacional Prof. A. Posadas, 2011-2017

Resumen La histoplasmosis diseminada es una micosis sistémica endémica, causada por el hongo dimórfico Histoplasma capsulatum. Las manifestaciones clínicas dependen de la carga fúngica inhalada, del estado inmunológico del paciente y de la virulencia de la cepa infectante. La variante diseminada es más frecuente en inmunocomprometidos, registrándose 90% de los casos en pacientes con serología positiva para VIH. En esta serie se evaluaron 37 pacientes con diagnóstico de infección por VIH e histoplasmosis diseminada. El 43,2% de los pacientes no sabía su serología en forma previa a la consulta por histoplasmosis. Las principales manifestaciones clínicas fueron síndrome de impregnación (67,6%), fiebre (64,9%), síntomas respiratorios (62,2%) y manifestaciones muco-cutáneas (67,6%), entre otras. El 94,6% de los pacientes presentó anemia, 75,7% tenía bicitopenia y 32,4% pancitopenia. La sensibilidad de los hemocultivos fue de 70,4%. El 86,5% no tuvo otra infección oportunista concomitante al momento del diagnóstico. En 83,8% de los pacientes la histoplasmosis diseminada fue la primera enfermedad marcadora de SIDA. Se registró una mortalidad de 14,7%.

Disseminated histoplasmosis is an endemic systemic mycosis, caused by the dimorphic fungus Histoplasma capsulatum. The clinical manifestations depend on the inhaled fungal load, the immunological state of the patient and the virulence of the infecting fungal strain. The disseminated variant is most frequent in immunocompromised patients, with 90% of cases in patients with positive serology for HIV, In this series, 37 patients with diagnosis of HIV and disseminated histoplasmosis were evaluated. The 43.2% of the patients did not know their serology prior to the consultation due to histoplasmosis. The main clinical causes were impregnation syndrome (67.6%), fever (64.9%), respiratory symptoms (62.2%) and mucocutaneous manifestations (67.6%), among others. The 94.6% of the patients presented anemia, 75.7% had bicytopenia and 32.4% pancytopenia. The sensitivity of the blood cultures was 70.4%. The 86.5% of the patients did not have another opportunistic infection concomitant at the time of diagnosis. In 83.8% of patients, disseminated histoplasmosis was the first AIDS disease. A mortality of 14.7% was recorded.

Progressive disseminated histoplasmosis: a systematic review on the performance of non-culture-based diagnostic tests

Abstract The diagnosis of progressive disseminated histoplasmosis is often a challenge to clinicians, especially due to the low sensitivity and long turnaround time of the classic diagnostic methods. In recent years, studies involving a variety of non-culture-based diagnostic tests have been published in the literature. We performed a systematic review by selecting studies evaluating non-culture-based diagnostic methods for progressive disseminated histoplasmosis. We searched for articles evaluating detection of antibody, antigens, as well as DNA-based diagnostic methods. A comprehensive PUBMED, Web of Science, and Cochrane Library search was performed between the years 1956 and 2016. Case reports, review articles, non-human models and series involving less than 10 patients were excluded. We found 278 articles and after initial review 18 articles were included: (12) involved antigen detection methods, (4) molecular methods, and (2) antibody detection methods. Here we demonstrate that the pursuit of new technologies is ultimately required for the early and accurate diagnosis of disseminated histoplasmosis. In particular, urinary antigen detection was the most accurate tool when compared with other diagnostic techniques.

Disseminated Histoplasmosis in an Immunocompetent Patient from a Non Endemic Region, North India: Pointers to Potential Endemicity.

Progressive Disseminated Histoplasmosis (PDH) reported worldwide is yet a rare entity in India. Although, usually associated with an underlying immunocompromised state but few reports of this disease in non- immunocompetent individuals have been surfacing in last decade. We report PDH from Himalayan state of Uttarakhand North India in an agriculturist, non immunocompromised who responded well to treatment with no evidence of recurrence of the disease. Of late a number of cases are being reported from this region, an indication that this might be a hot spot of Histoplasma capsulatum.

Progressive disseminated histoplasmosis presenting like chronic parenchymal liver disease with ascites: a rare case report and discussion.

A 82 year old diabetic and hypertensive Muslim man presented with ascites along with features of portal hypertension. Though it initially seemed to be a primary case of chronic parenchymal liver disease, investigations revealed it to be a case of Progressive Disseminated Histoplasmosis (PDH) with bilateral adrenomegaly, hepatosplenomegaly and ascites. The ascites was high SAAG in nature and no evidence of malignancy or tuberculosis could be found. The patient was treated with liposomal amphotericin B and was subsequently discharged on oral itraconazole therapy. On follow-up he was found to be significantly better at 3 months.

Histoplasmose disseminada aguda como primeira manifestação da síndrome da imunodeficiência adquirida / Acute disseminated histoplasmosis as first clinical manifestation of acquired immune deficiency syndrome

Justificativa e objetivos: Histoplasmose disseminada aguda (HDA) é considerada uma doença definidora da síndrome da imunodeficiência adquirida (Aids). Este relato se destina a demonstrar um caso de HDA associado à Aids, sua dificuldade diagnóstica e alta letalidade. Relato do caso: Paciente do sexo masculino, 26 anos, sem patologias prévias, iniciou quadro agudo de febre diária associado à afecção pulmonar e do trato gastrointestinal. Foi realizado anti-HIV, que detectou positividade. Durante a internação apresentou piora clínica, sendo então tratado empiricamente para as principais doenças oportunistas desta imunodeficiência, porém sem resposta eficaz. Evoluiu para o óbito, sendo obtido tardiamente o diagnóstico de HDA através da necrópsia. Conclusão: HDA deve ser aventada em todo e qualquer portador de HIV com síndrome febril e CD4 baixo, independente de sua procedência, ocupação ou história epidemiológica de exposição ao Histoplasma capsulatum. A associação da Aids e HDA pode ter um curso rápido e fatal...

Histoplasmosis diseminada con manifestaciones cutáneas en un paciente con SIDA / Disseminated histoplasmosis with cutaneous manifestations in a patient with AIDS

La histoplasmosis, es una micosis oportunista frecuente en pacientes con HIV/SIDA, en quienes suele presentarse con su variante diseminada progresiva. Las manifestaciones cutáneas son heterogéneas y a menudo, se acompañan de síntomas constitucionales inespecíficos. Los fármacos de elección para el tratamiento incluyen: la anfotericina-B y los compuestos azólicos como el itraconazol. Presentamos el caso de un hombre con SIDA, quien desarrolló una histoplasmosis diseminada subaguda, con manifestaciones cutáneo-mucosas.

Histoplasmosis is a frequent opportunistic fungal infection in patients with HIV/AIDS, who often present with the progressive disseminated variant. Cutaneous manifestations are heterogeneous and often they are accompanied by nonspecific constitutional symptoms. Amphotericin B and azolic compounds such as itraconazole are the drugs of choice in the treatment of the disease. We report the case of a man with AIDS who developed a subacute disseminated histoplasmosis with mucocutaneous manifestations.

Úlceras gastroduodenais como manifestação clínica de histoplasmose disseminada em paciente com vírus da imunodeficiência humana positivo: relato de caso / Progressive disseminated histoplasmosis presenting as gastroduodenal ulcers in a human immunodeficiency virus patient: case report

JUSTIFICATIVA E OBJETIVOS: A histoplasmose é uma doença fúngica causada pelo Histoplasma capsulatum. É rara em imunocompetentes;no entanto, em pacientes imunossuprimidos, a infecção ocorre de forma disseminada e grave, podendo acometer vários órgãos, incluindo o trato gastrintestinal. O objetivo deste estudo foi relatar o caso de uma apresentação incomum de infecção pelo H. capsulatum, alertando os clínicos quanto à inclusão da histoplasmose no diagnóstico diferencial de úlceras gastrintestinais, principalmente no paciente imunocomprometido. RELATO DO CASO: Paciente do sexo masculino, 45 anos,portador de síndrome da imunodeficiência adquirida (SIDA),com perda de peso, febre, sudorese noturna, adenomegalias cervicais e sangramento gastrintestinal. A radiografia de tórax mostrou infiltrado intersticial bilateral difuso, e a tomografia computadorizada (TC) de abdômen mostrou hepatomegalia e adenomegalias intra-abdominais. Na endoscopia digestiva alta foram encontradas úlceras no estômago e duodeno. O exame anatomopatológico das lesões foi compatível com histoplasmose do trato gastrintestinal. CONCLUSÃO: É de extrema importância o diagnóstico diferencial de úlceras gastrintestinais, principalmente em pacientes imunossuprimidos, uma vez que diversas doenças que assim se manifestam se não tratadas adequadamente, têm evolução fatal.

BACKGROUND AND OBJECTIVES: Histoplasmosis is afungal disease caused by Histoplasma capsulatum. It rarely occurs in immunocompetent individuals; however, in immunocompromised patients, the infection is usually severe and disseminated. Many organs can be affected, including the gastrointestinal tract.The objective of this study is to report an uncommon presentation of histoplasmosis, showing that the differential diagnosis of gastrointestinal ulcers is of great importance, particularly in the immunocompromised patient. CASE REPORT: Male patient, 45-year-old, immunodeficiency virus human-positive, was admitted to the hospital presenting with weight loss, night sweats, fever, cervical adenomegalies and gastrointestinal bleeding. Chest radiography showed diffuse interstitial pulmonary infiltrates bilaterally; computerized tomography of the abdomen showed hepatomegaly and intraabdominal adenomegalies. Upper gastrointestinal endoscopy revealed gastric and duodenal ulcers. The pathologic examination of the ulcerswas consistent with gastrointestinal histoplasmosis. CONCLUSION: Reassures the need for the differential diagnosis of gastrointestinal ulcers, particularly in immunosuppressed patients, since many diseases that present this way, have fatal outcomeif not treated properly.

Histoplasmosis diseminada progresiva en una cohorte de pacientes coinfectados con el VIH / Progressive disseminated histoplasmosis in a cohort of patients with HIV coinfection

Objetivo: identificar manifestaciones clínicas y métodos de laboratorio conducentes al diagnóstico de histoplasmosis diseminada progresiva (HDP), en una cohorte de pacientes coinfectados con el VIH. Diseño: análisis retrospectivo de historias clínicas. No intervención adicional. Pacientes: cuarenta pacientes con HDP e infección por VIH del Hospital La María, enero de 1992 a diciembre de 2008. Mediciones: datos demográficos, signos, síntomas y exámenes de laboratorio que permitieron el diagnóstico de HDP. Resultados: cuarenta pacientes, 34 hombres (85%), y seis mujeres (15%), con edades promedio de 33.4 y 27 años, respectivamente. En éstos predominaron: tos (77.5%), fiebre (90%) y anorexia con pérdida de peso en 92.5% y 77.4%, respectivamente. Lesiones en piel en 55% y en mucosa en 50%, crecimiento ganglionar en 62.5% y hepatomegalia en 52.5%. Menos frecuentes fueron disnea, esplenomegalia, vómito, diarrea y cefalea. Presentaron anemia el 85%, leucopenia el 52.5% y trombocitopenia el 30% de los pacientes. Exámenes micológicos: directo positivo en 21 muestras, de lavado broncoalveolar siete, piel seis, ganglio 12, biopsia transbronquial una y lesión de mucosa una. Se aisló H. capsulatum en todos los pacientes a partir de muestras de piel 10, ganglio 18, sangre tres, médula ósea una, lavado broncoalveolar (LBA) 10, y mucosa tres. Además, en siete pacientes, el hongo se aisló de más de un sitio anatómico. La serología realizada en 13 pacientes, se mostró reactiva en la inmunodifusión en gel de agar (IDGA) en 11 y en la fijación del complemento (FC) en 10. Conclusión: ante un cuadro clínico compatible con HDP en paciente con infección por VIH que presenta fiebre, pérdida del estado general, crecimiento ganglionar, compromiso medular y piel y mucosas, el laboratorio permitirá confirmar fácilmente el diagnóstico de la sospecha clínica de la entidad (Acta Med Colomb 2011; 36: 63-67).

Objective: to identify the clinical manifestations and laboratory methods leading to the diagnosis of progressive disseminated histoplasmosis (PDH) in a cohort of patients co-infected with HIV. Design: retrospective analysis of case histories. No further intervention. Patients: forty patients with PDH and HIV infection from Hospital La María. January 1992 to December 2008. Measurements: demographic data, signs and symptoms, and laboratory tests leading to the diagnosis of PDH. Results: 40 patients, 34 males (85%) and 6 females (15%), with mean ages of 33.4 and 27 years, respectively. The dominant symptoms were: cough (77.5%), fever (90%), and anorexia with weight loss in 92.5% and 77.4%, respectively. Skin lesions in 55% and mucosal lesions in 50%, enlargement of lymph nodes in 62.5%, and hepatomegaly in 52.5%. Less frequent manifestations were dyspnea, splenomegaly, vomiting, diarrhea, and headache. Anemia was found in 85%, leucopenia in 52.5%, and thrombocytopenia in 30% of the patients. Mycological tests: directly positive in 21 samples: bronchoalveolar lavage (7), skin (6), lymph node (12), transbronchial biopsy (1), and mucosal lesion (1). H. capsulatum was isolated in all patients from samples of: skin (10), lymph node (18), blood (3), bone marrow (1), bronchoalveolar lavage fluid (10), and mucosa (3). Moreover, the fungus was isolated in more than one anatomical site in 7 patients. Serology carried out in 13 patients was reactive on agar gel immunodifusion test in 11 cases and on complement fixation in 10 cases. Conclusion: in the face of a clinical picture consistent with PDH in a patient with HIV who presents with fever, constitutional symptoms, enlargement of lymph nodes, and involvement of the bone marrow, skin, and mucous membranes, laboratory testing allows easy confirmation of the clinically suspected condition (Acta Med Colomb 2011; 36: 63-67).

Características clínico-evolutivas de 134 pacientes com histoplasmose disseminada associada a SIDA no Estado do Ceará / Clinical and evolutionary characteristics of 134 patients with disseminated histoplasmosis associated with AIDS in the State of Ceará

INTRODUÇÃO: Desde o início da epidemia de HIV no Ceará, histoplasmose disseminada tem sido detectada com frequência em pacientes com aids. MÉTODOS: De modo a conhecer características clínico-laboratoriais, evolução e sobrevida da co-infecção HD/AIDS, analisou-se retrospectivamente 134 prontuários casos de HD internados de 1999 a 2005 no hospital referência para HIV no Ceará. RESULTADOS: Pacientes com HD apresentaram maior frequência de febre diária, tosse, perda de peso, hepatoesplenomegalia e insuficiência renal aguda. Diagnóstico foi dado por pesquisa e/ou cultura. À admissão, foram fatores de risco relacionados ao óbito de pacientes com HD: vômitos, dispnéia, insuficiência respiratória e IRA, hemoglobina<8g/L, uréia>40mg/dL e creatinina >1,5mg/dL. CONCLUSÕES: pacientes com HD apresentaram caracteristicamente febre mais elevada, internamentos anteriores por infecção respiratória, mais complicações clínicas e como fatores independentes para óbito, anemia importante e elevação de uréia.

INTRODUCTION: Since the beginning of the HIV epidemic in Ceará, disseminated histoplasmosis (DH) has often been detected among AIDS patients. METHODS: In order to investigate the clinical and laboratory characteristics, evolution and survival of cases of DH/AIDS coinfection, the medical records on 134 cases of DH admitted to a reference hospital in Ceará between 1999 and 2005 were analyzed. RESULTS: Patients with DH presented higher frequency of daily fever, coughing, weight loss, enlarged liver and spleen and acute kidney failure. The diagnosis was made using investigation and/or cultures. At admission, the following were risk factors for death among DH patients: vomiting, dyspnea, respiratory failure, acute kidney failure, hemoglobin < 8g/l, urea > 40mg/dl and creatinine >1.5 mg/dl. CONCLUSIONS: Patients with DH characteristically presented higher fever, previous hospitalization due to respiratory infection and more clinical complications. Significant anemia and elevated urea were independent risk factors for death among DH patients.

Úlcera de lengua como presentación del Histoplasma capsulatum / Tongue ulceration as a presentation of Histoplasma capsulatum infection

La histoplasmosis diseminada progresiva es una enfermedad que se manifiesta como reactivación de una infección latente en pacientes inmunodeprimidos, especialmente en personas con déficit en la inmunidad celular. Existen formas agudas, subagudas y crónicas. Las lesiones focales, en especial úlceras mucocutáneas, predominan en la forma diseminada crónica. Reportamos el caso de una paciente con artritis reumatoidea, que controlaba su patología con fármacos antirreumáticos modificadores de la enfermedad (DMARD), la que consultó por úlcera de lengua como única manifestación de una histoplasmosis diseminada crónica. La histopatología fue compatible y el cultivo positivo para Histoplasma capsulatum. La serología para el HIV fue negativa. Existen pocos casos publicados de pacientes con esta localización atípica en forma aislada, en particular aquellos HIV negativos. El itraconazol y la anfotericina B son las dos drogas más utilizadas para tratar esta enfermedad. Los datos clínicos sobre los nuevos azoles, voriconazol y posaconazol son limitados.

The progressive disseminated histoplasmosis is a disease produced by reactivation of latent infection in immunocompromised host, specially in persons with defective cell-mediated immunity. There are acute, subacute and chronic forms in the progressive illness. Focal lesions, specially mucocutaneous ulcers, are most frequent in the chronic disseminated forms. We reported a patient with rheumatoid arthritis treated with disease modifying antirheumatic drug (DMARD), with an ulcer of the tongue as only clinical manifestation of a chronic disseminated histoplasmosis. The histopathology was compatible, and the culture was positive for Histoplasma capsulatum. The serology for the HIV was negative. There are few published cases of this isolated form, particularly in patients with HIV negative serological test. Itraconazole and amphotericin B are the most frequently drugs used for the treatment in this disease. Clinical data on the new azoles, voriconazole and posaconazole, are limited.

Histoplasmosis diseminada y VIH: correlación clínico-diagnóstica de cinco casos / Disseminated Histoplasmosis and VIH: diagnostic-clinical correlation of five cases

Reportamos los casos de cinco pacientes (VIH positivo), quienes ingresaron al hospital de Infectología “Dr. José Rodríguez Maridueña” de Guayaquil. La histoplasmosis diseminada ocurre usualmente en personas con conteos de linfocitos T CD4: <150/mm3; su presentación clínica habitual asociada a pacientes con VIH es la de una enfermedad multiorgánica con síntomas constitucionales. La correlación clínica-epidemiológica del paciente constituye un factor preponderante en la toma inicial de decisiones ante un posible cuadro de histoplasmosis diseminada; la necesidad de encontrar un método de diagnóstico rápido y eficaz llega a ser imperativo, debido al dramático incremento en la incidencia de infecciones micóticas en pacientes VIH.

This is a report of five cases (HIV positive), admitted to the Hospital of Infectious Diseases “Dr. José Rodríguez Maridueña” in Guayaquil. Disseminated Histoplasmosis usually occurs in people with a lymphocytes counting <150/mm3; its usual clinical presentation associated to patients with HIV is that of a multiorganic illness with constitutional symptoms. Clinical-epidemiologic correlation of a patient is a predominant factor in the initial decision making facing a possible medical profile of Disseminated Histoplasmosis. It is imperative to find a fast and effective diagnosis method because of the dramatic increase in the incidence of mycotic infections in HIV patients.

Características histopatológicas e imunohistoquímicas das lesoes cutâneas e da mucosa oral na histoplasmose disseminada de portadores da síndrome da imunodeficiência adquirida (AIDS) / Histopathological and immunohistochemical characteristics of cutaneous and oral mucosa lesions in disseminated histoplasmosis associated with acquired immunodeficiency syndrome (AIDS)

Biopsy specimens of the skin and oral mucosa from twenty-five patients bearing the disseminated form of histoplasmosis (H. capsulatum) associated with AIDS (acquired immunodeficiency syndrome) were studied by histologic and immunohistochemistry techniques. Histologically, the skin lesions showed four different patterns: diffuse macrophage, granulomatous, vasculitic with leukocytoclastic and scarce inflammatory reaction. The cell markers for macrophages, lymphocytes B and T and H. capsulatum revealed CD68, UCHL-1 and L26 associated with variable amounts of fungi.

A análise histopatológica e imunohistoquímica de 25 biópsias cutâneas e da mucosa oral de portadores da associação AIDS e histoplasmose mostrou o seguinte: 1) em 18 casos as lesões cutâneas eram múltiplas e se apresentavam sob a forma de pápulas (eritematosas, violáceas ou acastanhadas), úlceras, vesículo-pústulas e eram distribuídas por todo tegumento cutâneo; Em sete casos as lesões se localizavam na mucosa da língua, palato, úvula e eram do tipo ulcerado ou moruliforme; 2) histologicamente as lesões apresentavam quatro aspectos distintos: macrofágico difuso; granulomatoso; vasculítico com leucocitoclasia; e com escassa reação inflamatória; 3) a tipagem dos linfócitos T e B e dos macrófagos através dos anticorpos monoclonais mostrou que a resposta imunológica ao Histoplasma capsulatum é predominantemente do tipo celular nos quatro tipos histológicos; 4) o teste imunohistoquímico para o fungo nas lesões confirmou o diagnóstico morfológico de H. capsulatum.