Histoplasmosis B39.41

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Darling's disease; reticuloendothelial cytomycosis

History
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Darling, 1906

Definition
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Intracellular systemic mycosis with infestation of the immune system and internal organs by the dimorphic fungus Histoplasma capsulatum.

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Pathogen
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Histoplasma capsulatum(dimorphic fungus living as a saprophyte in soil, dust, bird and bat droppings).

Classification
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Clinical course:
  • Benign or asymptomatic form
  • Acute pulmonary histoplasmosis
  • Disseminated form
  • Chronic pulmonary histoplasmosis.

Occurrence/Epidemiology
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Endemic mainly in North America, Latin America and Asia; more rarely in Africa (see below histoplasmosis, African). Common in immunocompromised patients (e.g. HIV infection).

Etiopathogenesis
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Primary infection of the respiratory tract and lungs with Histoplasma capsulatum by inhalation of spore-containing dust.

Clinical features
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Most infections are subclinical or inapparent. When a lung infection manifests itself, it appears as a tuberculosis-like disease, which can heal spontaneously.

Inhalation of a large amount of pathogens can lead to the development of acute pneumonia.

In individual cases, especially in immunocompromised persons, a haematogenic spread can occur with infestation of the lymph nodes, spleen, liver and bone marrow.

Primary infections of the skin (and/or mucous membranes) can lead to chronic ulcers at the inoculation site.

Skin alterations are also observed in hematogenic sowing: disintegrated granulomas in the area of mouth, nose and larynx with later mutilation.

Histology
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Histiocyte proliferation; granuloma formation (indistinguishable from tuberculosis); unspecific granulation tissue.

Diagnosis
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Cultural pathogen detection from sputum, serodiagnosis (CBR) and intradermal tests outside the endemic areas.

Differential diagnosis
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External therapy
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For solitary flocks: surgical removal under amphotericin B protection.

Internal therapy
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Most patients do not need therapy.
  • In immunocompetence: In non-meningeal, non-life-threatening, disseminated forms, antifungal therapy with azole derivatives. Itraconazole (e.g. Sempera Kps.) 200-400 mg/day for 6-9 months has proven to be the preparation with the fewest side effects and good efficacy.
  • For immunosuppression or life-threatening forms: Amphotericin B once/day 0.3-0.8 mg/kg bw i.v. for 6 weeks. Gradual introduction with 0.25 mg/kg bw/day, with good tolerability increase to the above-mentioned dose as a continuous infusion over 4-6 hours. Side effects such as paresis, arachnoiditis or radiculitis can be reduced by pre-injection of glucocorticoids. Subsequent maintenance therapy with itraconazole 200 mg/day p.o. Maintenance therapy is absolutely necessary in immunocompromised patients because of the high relapse rate. Therapy duration depends on the clinic.

Literature
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  1. Buck BE et al (2001) Transmission of histoplasmosis by organ transplantation. N Engl J Med 344: 310
  2. Darling STA (1906) A protozoon general infection producing pseudotubercels in the lungs and focal necroses in the liver, spleen and lymph nodes. JAMA 46: 1283-1285
  3. Jackson A et al (1994) Oral azole drugs as systemic antifungal therapy. N Engl J Med 330: 263-272
  4. Johnson PC et al (2002) Safety and efficacy of liposomal amphotericin B compared with conventional amphotericin B for induction therapy of histoplasmosis in patients with AIDS. Ann Internal Med 137: 105-109
  5. Karimi K et al (2002) Differences in histoplasmosis in patients with acquired immunodeficiency syndrome in the United States and Brazil. J Infect Dis 186: 1655-1660
  6. Lee JH et al (2002) Life-threatening histoplasmosis complicating immunotherapy with tumor necrosis factor alpha antagonists infliximab and etanercept. Arthritis Rheum 46: 2565-2570
  7. LeMonte AM (2000) Amphotericin B combined with itraconazole or fluconazole for treatment of histoplasmosis. J Infect Dis 182: 545-550
  8. Norris S et al (1994) Prevention of relapse of histoplasmosis with fluconazole in patients with the acquired immunodeficiency syndrome. At J Med 96: 504-508
  9. Stevens DA (1994) Management of systemic fungal disease in patients with AIDS. J Am Acad Dermatol 31: 64-67
  10. Wheat J et al (1993) Prevention of relapse of histoplasmosis with itraconazole in patients with the acquired immunodeficiency syndrome. The national institute of allergy and infectious disease clinical trials and mycosis study group collaborators. Ann Inter Med 118: 610-616
  11. Vathesatogkit P et al (2003) A 27-year-old HIV-infected woman with severe sepsis and pulmonary infiltrates. Disseminated histoplasmosis with severe sepsis and acute respiratory failure. Chest 123: 272-273, 274-276
  12. Wood KL et al (2003) Histoplasmosis after treatment with anti-tumor necrosis factor-alpha therapy. At J Respir Crit Care Med 167: 1279-1282

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Last updated on: 29.10.2020