Chronic meningitis, hydrocephalus and spinal paraplegia in non-systemic histoplasmosis
Fabiano ReisMarcondes C. FrançaAnamarli NucciLuciano de Souza QueirózFelipe Barjud Pereira do NascimentoAlberto MartínezMarcelo NunesKarla de Oliveira Lucca
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Abstract:
A 27-year-old immunocompetent agricultural worker presented chronic meningitis and hydrocephalus.Despite CSF and systemic investigation no etiology was defined.Spastic paraplegia installed 15 years later.Spinal and brain MRI are displayed in Figures 1 and2.The patient developed intracranial hypertension and died days later.A diagnosis of histoplasmosis was made at autopsy (Figure 3).Histoplamosis as isolated central nervous system disease is rare, being more common in immunosuppressed patients 1,2 .As in this case, it can be a challenging diagnosis, and should be considered in any brain or spinal cord lesion with granulomatous pattern.Keywords:
Paraplegia
Among people with HIV, histoplasmosis represents an important cause of mortality. Previous studies have provided estimates of the disease incidence. Here, we compared those estimates with the results obtained from a screening program implemented in Guatemala, which included histoplasmosis detection for people with HIV. To compare the results of this program, with previous estimations, a literature search was done and reports about histoplasmosis incidence were analyzed. The screening program enrolled 6,366 patients. The overall histoplasmosis incidence in the screening program was 7.4%, which was almost double than those estimated by the previous studies. From 2017 to 2019, the screening program showed an upward trend in histoplasmosis cases from 6.5% to 8.8%. Histoplasmosis overall mortality among those who were newly HIV diagnosed showed a decrease at 180 days from 32.8% in 2017 to 21.2% in 2019. The screening approach using rapid diagnostic assays detects quickly more cases of histoplasmosis, allowing a specific treatment, which decreases the mortality of the disease. Therefore, the use of these new techniques, especially in endemic areas of histoplasmosis, must be implemented.
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Purpose: Histoplasmosis is not endemic in the U.S. northwest, but a type of multifocal choroiditis resembling ocular histoplasmosis occurs there. This study was designed to find a group of affected patients and study their clinical characteristics and immunologic responses to Histoplasma antigens. Method: Ten patients were found in the authors' files whose geographic histories made it unlikely that they had ever been exposed to Histoplasma capsulatum and yet they had features of ocular histoplasmosis. They were recalled for examination and testing by lymphocyte-stimulation assay for previous exposure to histoplasmosis. Results: The clinical features of these patients resembled those of patients with ocular histoplasmosis, but their histories and the results of the assay did not support H. capsulatum as the cause of the ocular disease. Conclusion: This study confirmed that there is a type of choroiditis that resembles ocular histoplasmosis but is due to another agent or agents.
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The diagnosis of Histoplasma capsulatum infection by serologic testing for the presence of antibodies is limited by a high rate of false positive and false negative results and by the requirement that the patient have a normal immune response. We have developed a radioimmunoassay for the detection of H. capsulatum antigen in urine and serum specimens. Antigenuria was noted in 20 of 22 episodes of disseminated histoplasmosis that occurred in 16 patients, in 6 of 32 patients with self-limited infection, in 2 of 32 patients with cavitary histoplasmosis, and in 4 of 8 patients with a sarcoid-like illness caused by H. capsulatum. The detection of antigen in urine was reproducible in 38 of 41 (93 percent) retests of specimens. H. capsulatum antigen was also detected in the serum during 11 of the 22 episodes of disseminated histoplasmosis, in none of the 12 episodes of other types of histoplasmosis in patients with antigenuria, in 1 of the 33 patients with histoplasmosis who lacked the urinary antigen, and in none of the 50 controls. Antigenemia and antigenuria decreased after initiation of antifungal therapy and recurred in patients who had a relapse. We conclude that this radioimmunoassay for H. capsulatum antigen represents a useful new method for the rapid diagnosis of disseminated histoplasmosis.
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Among people with HIV, histoplasmosis represents an important cause of mortality. Previous studies provided estimates of the disease incidence. Here, we compared those estimates with the results obtained from a screening program implemented in Guatemala, which included histoplasmosis detection for people with HIV. To compare the results of this program with previous estimations, a literature search was performed and reports concerning histoplasmosis incidence were analyzed. The screening program enrolled 6366 patients. The overall histoplasmosis incidence in the screening program was 7.4%, which was almost double that estimated in previous studies. From 2017 to 2019, the screening program showed an upward trend in histoplasmosis cases from 6.5% to 8.8%. Histoplasmosis overall mortality among those who were newly HIV diagnosed showed a decrease at 180 days from 32.8% in 2017 to 21.2% in 2019. The screening approach using rapid diagnostic assays detects histoplasmosis cases more quickly, allowing a specific treatment to be administered, which decreases the mortality of the disease. Therefore, the use of these new techniques, especially in endemic areas of histoplasmosis, must be implemented.
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