Granulomatous Inflammation Presenting as a Pulmonary Artery Mass.

Granulomatous fungal infections are common worldwide, and they can result in mediastinal lymphadenopathy. However, infectious pulmonary artery masses are rare and have only been associated with tuberculosis or mucormycosis. Here, we present a case of histoplasmosis resulting in a pulmonary artery mass, which was treated with debulking and reconstruction of pulmonary vasculature.

Histoplasmosis Infection of Aortobifemoral Graft Treated with a Neoaortoiliac System.

Aortic graft infections are a feared complication of aortic bypass operations and impart significant morbidity and mortality when they occur. The most common etiology is bacterial, with a presentation ranging from subclinical to acutely symptomatic depending on the organism. Fungal infections of prosthetic grafts are rare, especially in immunocompetent patients. Graft infections remain a clinical diagnosis. We report a rare case of an aortobifemoral graft infection with Histoplasma capsulatum that was diagnosed on surgical pathology, as the preoperative infectious evaluation was negative. The neoaortoiliac system operation was successfully used to solve this patient's highly morbid condition.

Histoplasmosis mimicking metastatic spinal tumour.

Histoplasmosis is an infection caused by a fungus called Histoplasma. Diagnosis of histoplasmosis is based on the culture of biological samples and detection of fungus in tissues. Histoplasmosis can mimic malignant lesions. We report a 65-year-old, immunocompetent, male patient with back pain. We describe the main clinical and radiological characteristics in our patient who had vertebral histoplasmosis that mimicked cancer. A computed tomography scan showed lytic lesions of the right side of T4, T5, and T6 vertebral bodies. Magnetic resonance imaging displayed abnormal marrow signals in T4, T5, and T6 vertebral bodies (low signal on T1, high on T2 and short time inversion recovery (STIR)). Which was mimicking malignancy, such as haematological malignancy and metastatic bone cancer. Therefore, thoracic spinal surgery using the anterior approach was performed. An intraoperative frozen section examination and routine postoperative pathology showed thoracic histoplasmosis infection. Treatment of histoplasmosis was performed with oral itraconazole. The lesions did not progress and the patient symptomatically improved at a follow-up of 26 months.

Chronic bronchitis with fungal infection presenting with marked elevation of serum carbohydrate antigen 19-9: a case report.

Carbohydrate antigen 19-9 (CA19-9) is the most frequently applied serum tumor marker for diagnosis of cancers in the digestive organs. However, some patients with benign diseases can have elevated serum levels of CA19-9 as well. The current study presents a 55-year-old female who was admitted to our hospital for further evaluation of a nodular cavity shadow in the right lower lobe and clarification of the cause of the marked elevation of serum CA19-9 levels. Abdominal MRI and gastrointestinal endoscopy did not find any malignancy. As lung cancer cannot be excluded in this patient, a video-assisted thoracoscopic surgery was carried, intraoperative and postoperative biopsy analysis both suggested chronic bronchitis with fungal infection (due to Histoplasma capsulatum or Penicillium marneffei) and organization. Immunohistochemistry showed marked positive staining for CA19-9 in the damaged lung tissue. The CA19-9 levels quickly returned to the normal range following lobe resection. Therefore, the marked elevation of serum CA19-9 levels, in this case, may have resulted from the chronic bronchitis with fungal infection.

Thoracoscopic pneumonectomy in management of histoplasmosis and fibrosing mediastinitis.

Pulmonary histoplasmosis is generally a self-limited respiratory illness in endemic areas. Fibrosing mediastinitis is a severe chronic complication of pulmonary histoplasmosis in which pulmonary vessels and airways can be compressed with the potential for life-threatening implications. We present a 50-year-old male patient who presented with a total occlusion of the left pulmonary artery due to fibrosing mediastinitis.

Histoplasmosis mimicking adrenal carcinoma.

OBJECTIVES: The incidence of unilateral adrenal histoplasmosis in nonendemic areas is rare. This is even rarer if the host is immunocompetent. METHODS: We report a patient who was referred for unexplained weight loss who underwent a computed tomography scan of abdomen revealing a large unilateral adrenal nodule measuring 7.6 cm in size. RESULTS: Hormonal workup was negative including urine 24-hour free metanephrines, and the patient underwent unilateral adrenalectomy. The pathology showed budding yeast that stained with Gomori's methenamine silver (GMS) revealed the diagnosis of adrenal histoplasmosis. CONCLUSION: We encourage clinicians to include infection by Histoplasma capsulatum as well as other granulomatous diseases and tumors in the differential diagnosis of unilateral adrenal enlargement even in immunocompetent hosts living in nonendemic areas.

A case in Europe of feline histoplasmosis apparently limited to the skin.

BACKGROUND: Histoplasma capsulatum has a worldwide distribution, but reports in Europe remain rare. We present the second report of histoplasmosis in a cat in Europe and, to the best of our knowledge, the first case of feline histoplasmosis infection apparently limited to the skin. CASE REPORT: A 6-year-old male castrated outdoor cat was presented to the dermatology service with a history of skin lesions evolving over 1 month and consisting of multiple papules and nodules on the head and neck. General examination was unremarkable. Cytological examination of the ulcerated nodules revealed a pyogranulomatous infiltrate, with numerous macrophages containing oval yeast-like cells, 2-5 µm in size, with a central, lightly basophilic core surrounded by a clear halo. A tentative diagnosis of fungal infection was made, and skin biopsy specimens were taken. Histological examination confirmed the cytology findings, and Grocott staining showed numerous organisms suggestive of Histoplasma within macrophages. Thoracic radiographs, abdominal ultrasound and routine laboratory testing were unremarkable. Fungal culture of a nodule was negative. PCR of total DNA extracted from the infected tissue and subsequent sequencing confirmed the diagnosis of H. capsulatum var. capsulatum. Surgical excision of the other nodules was performed, and the cat was treated with oral itraconazole 5 mg/kg once daily; 12 weeks after initial consultation, no lesions were visible. No recurrence was observed during an 8 month follow-up period. CONCLUSIONS AND CLINICAL IMPORTANCE: Histoplasmosis should be included in the differential diagnosis of nodular diseases of cats worldwide.

Surgery for other pulmonary fungal infections, Actinomyces, and Nocardia.

Surgical participation in the management of fungal infections has changed since the advent of effective antimicrobials. Even so, a surgeon may be called on for a variety of reasons, depending on the specific fungal infection and the evolution of thoracic disease. Specific fungal infections are enumerated. Each organism, its clinical picture, and method of diagnosis are briefly described and the medical and surgical management of thoracic disease are discussed.

Anterior mediastinal mass secondary to histoplasmosis.

Histoplasmosis in the mediastinum is an uncommon diagnosis that presents similarly to other benign and neoplastic conditions encountered in the chest. Here we describe a 36-year-old woman who presented with dyspnea secondary to a large anterior mediastinal mass that was biopsy and culture negative for neoplasm or infection. Video-assisted thoracoscopic surgery biopsy confirmed a large anterior mediastinal mass adherent to the aorta, which contained foci of histoplasmosis species. She is currently undergoing a long postoperative course of itraconozole and an empiric course of oral steroids to prevent development of fibrosing mediastinitis.

Neuroendoscopic diagnosis of central nervous system histoplasmosis with basilar arachnoiditis.

OBJECTIVE: Histoplasmosis of the central nervous system (CNS) is seen in 10% to 20% of patients with disseminated histoplasmosis and/or in association with immunocompromised patients. Meningitis, arachnoiditis, and hydrocephalus are the most common clinical manifestations of CNS histoplasmosis. Patients with CNS histoplasmosis present similarly to other infectious etiologies, and confirmatory diagnosis is important in the management of these patients. However, diagnosis of CNS histoplasmosis can be difficult, and sometimes performing a parenchymal biopsy is necessary to confirm the diagnosis. METHODS AND RESULTS: We describe the case of a 41-year-old man with HIV/AIDS who presented with the signs, symptoms, and radiologic evidence of basal meningitis and hydrocephalus. Cerebrospinal fluid (CSF) analysis from multiple lumbar punctures was negative. The patient underwent a neuroendoscopic procedure with diagnostic and therapeutic goals. Internal CSF diversion (endoscopic third ventriculostomy) and biopsy of the floor of the third ventricle and subarachnoid space were performed; surgical biopsies identified noncaseating granulomas, and ventricular CSF was positive for Histoplasmosis antibodies. The patient was treated with liposomal amphotericin B and itraconazole. The patient had resolution of his symptoms immediately after surgery, and 1-month follow-up computed tomography of the head demonstrated resolution of the hydrocephalus. At the last follow-up 12 months postoperatively, the patient has not required insertion of a ventriculoperitoneal shunt. CONCLUSION: Clinicians should maintain a high index of suspicion for fungal basal meningitis in patients with AIDS and hydrocephalus. With nondiagnostic lumbar CSF sampling, neuroendoscopy can be considered as an alternative for diagnosis and treatment of basal meningitis and hydrocephalus.

Retroperitoneal pyogranulomatous and fibrosing inflammation secondary to fungal infections in two dogs.

CASE DESCRIPTIONS: A 4-year-old spayed female Golden Retriever (dog 1) was examined because of acute edema and erythema in the left hind limb and an inguinal mass, and a 5-year-old female Jack Russell Terrier (dog 2) was examined because of a recurring retro-peritoneal mass. CLINICAL FINDINGS: Dog 1 had an edematous, hyperemic left hind limb with a fixed inguinal mass. Monocytic neutrophilic leukocytosis and hypoalbuminemia were detected. Diagnostic imaging revealed abnormal tissue surrounding the larger vessels and ureters and complete occlusion of the left limb veins. Surgery resulted in incomplete removal of the mass. Histologic examination revealed fibrosing pyogranulomatous inflammation. Results of a Histoplasma antigen test were positive, and reanalysis of the tissues revealed yeast cells indicative of Histoplasma capsulatum. Dog 2 had incomplete removal of a retroperitoneal mass. Histologic examination revealed fibrosing pyogranulomatous inflammation. The mass recurred 8 months later in dog 2; exploratory abdominal surgery at that time resulted in substantial hemorrhage from the adhered caudal aorta. Histologic examination of tissue sections from the second surgery revealed yeast cells consistent with Blastomyces dermatitidis. TREATMENT AND OUTCOME: Both dogs had temporary improvement after surgery. Full clinical resolution required treatment for fungal disease. Dog 1 was treated with itraconazole, then fluconazole (total treatment time, 23 weeks). Dog 2 was treated with fluconazole for 36 weeks. CLINICAL RELEVANCE: Retroperitoneal pyogranulomatous fibrosis caused by fungal infections has not been reported in veterinary medicine. There was substantial morbidity, but the prognosis can be good when this abnormality is recognized and antifungal medications are administered.

Massive bilateral chylothoraces complicating mediastinal granulomatous disease.

Mediastinal granulomatous disease with resulting fibrosis is known to cause several serious complications, including pulmonary artery occlusion, bronchial stenosis, superior vena cava syndrome, and constrictive pericarditis. This process is typically the result of an excessive fibrogenic response to the antigen of the fungus Histoplasma capsulatum. We present a case of a 20-year-old man who had massive bilateral chylothoraxes develop as a complication of mediastinal granulomatous disease. Aggressive surgical therapy was necessary to treat this potentially life-threatening condition with an excellent result.

Surgical management of pulmonary and mediastinal sequelae of histoplasmosis: a challenging spectrum.

BACKGROUND: Histoplasmosis may result in a spectrum of complications that require thoracic surgical intervention. We reviewed our 17-year experience in the management of histoplasmosis to determine outcomes as well as gain insight into the distribution of complications requiring surgical intervention. METHODS: The hospital records of patients who underwent surgical treatment for complications related to histoplasmosis from 1991 to 2008 were reviewed. Based on the predominant presentation, patients were categorized with complications secondary to broncholithiasis, granulomatous disease, or fibrosing mediastinitis. Patients who underwent diagnostic surgery and were found to have histoplasmosis were excluded. RESULTS: Of the 49 patients who underwent surgery for histoplasmosis-related complications, 27 (55%) had granulomatous disease, 13 (27%) had broncholithiasis, and 9 (18%) had fibrosing mediastinitis. The most common clinical presentations were recurrent pneumonia (n = 16) and hemoptysis (n = 13); less common presentations included dysphagia (n = 3) and superior vena cava syndrome (n = 1). Two patients required cardiopulmonary bypass for resection; 1 of these died postoperatively (series mortality 2%). Seven patients (14%) had complications. Relief of symptoms was achieved in all surviving patients. CONCLUSIONS: Complications of histoplasmosis requiring thoracic surgical intervention are diverse with pulmonary complications predominating. Although surgically challenging, excellent short- and long-term outcomes may be expected.

Risk factors for rhegmatogenous retinal detachment in the submacular surgery trials: SST report No. 22.

OBJECTIVE: To identify risk factors associated with the development of rhegmatogenous retinal detachment (RRD) in patients enrolled in the Submacular Surgery Trials. METHODS: One thousand fifteen patients with eligible subfoveal neovascular lesions in the study eye were assigned randomly to observation or to surgery. Eyes were examined at 3 months, 6 months, 12 months, and 24 months after enrollment to assess study outcomes and adverse events, including RRDs. Adverse events also were reported at other times as clinical personnel became aware of them. Potential risk factors for the development of RRD in study eyes were evaluated using recursive partitioning and logistic regression analysis. RESULTS: Among 506 eyes assigned to surgery, RRD developed in 44 (8.7%) compared with 4 (0.8%) of 509 eyes assigned to observation. Of the 44 eyes in which RRD developed, 27 had age-related macular degeneration (AMD) and large (>3.5 MPS disk areas) hemorrhagic subfoveal neovascular lesions at baseline and represented 16.1% of all eyes with such lesions assigned to surgery. Eyes with AMD and larger hemorrhagic lesions (>16 MPS disk areas) together with relatively poor visual acuity (best-corrected visual acuity < or =20/1280) had a higher risk of RRD (odds ratio = 6.2, 95% confidence interval: 2.2-16.7) compared with those with smaller lesions and better visual acuity at baseline. CONCLUSION: Poor visual acuity and very large, predominantly hemorrhagic subfoveal neovascular AMD lesion type were the greatest risk factors for RRD after submacular surgery. Submacular surgery should be undertaken in such eyes with full awareness of the risk of RRD during subsequent follow-up.