A Large Outbreak of Histoplasmosis Among American Travelers Associated With a Hotel in Acapulco, Mexico, Spring 2001

Abstract

During spring 2001, college students from Pennsylvania reported an acute febrile respiratory illness after returning from spring break vacation in Acapulco, Mexico. Acute pulmonary histoplasmosis was presumptively diagnosed and the cluster of illness was reported to the Centers of Disease Control and Prevention. A large investigation then ensued, which included finding student-travelers for interviews and requesting sera for histoplasmosis testing. We defined a clinical case by fever and at least one of the following: cough, shortness of breath, chest pain, or headache, in an Acapulco traveler during March−May 2001. A laboratory-confirmed case had positive serology. An initial study determined that the likely site of histoplasmosis exposure was Hotel H; we therefore performed a large cohort study among travelers who stayed at Hotel H. Of 757 contacted, 262 (36%) met the clinical case definition. Of 273 serum specimens tested, 148 (54%) were positive. Frequent use of Hotel H's stairwells, where construction was ongoing, was associated with increased risk of illness (relative risk ‫ס‬ 10.5, 95% confidence interval ‫ס‬ 3.7-30.5; P < 0.001). This is the first histoplasmosis outbreak associated with a hotel undergoing construction. Hotels in endemic areas should consider construction precaution measures to prevent histoplasmosis among their guests.

Occupation, Lifestyle, Diet, and Invasive Fungal Infections

“…Because H. capsulatum is found in soil contaminated with bird or bat droppings, farmers, bird handlers, wood cutters, and speleologists are at risk of contracting histoplasmosis [2][3][4][5]. Activities that disrupt the soil during excavation and the construction, demolition, and rehabilitation of buildings generate infected dust; therefore, construction workers in endemic areas should also be considered to be at a high risk of contracting histoplasmosis [6]. For example, researchers reported a cluster of cases of acute histoplasmosis associated with exposure to soil during a golf course renovation [7].…”

Histoplasmosis in Israeli Travelers

“…Often there is a group history of participation in activities that involve heavy exposure to bat or bird droppings, mostly spelunkers 18,19 or volunteers with recent involvement in cleaning tasks or rehabilitation of old buildings, 20 but one large outbreak in travelers returning from Mexico was reported in which the source of infection was a hotel where all the cases had resided during their trip. 5 In our series, there were no groups, making the diagnosis more challenging, but 8 of the 23 cases formed 4 pairs of travel partners. This difference may simply reflect different travel habits, but may also reflect a higher index of suspicion for histoplasmosis in our setting-a specialist clinic for returning travelers and tropical disease whose staff are more likely to consider histoplasmosis even in isolated cases, as opposed to larger groups of returning travelers with a similar clinical syndrome, in whom the diagnosis may be more apparent.…”

“…4 However, other sources of outbreaks may occur as observed with one large outbreak in which the source of infection was apparently a hotel in Acapulco, Mexico. 5 A survey of Spanish travelers returning from Central and South America found that 20% had a positive histoplasmin skin test (versus none of a control group with no history of travel to endemic countries), but only 19% of these had any symptoms. 6 Prolonged travel, sleeping outdoors, and travel to Central (rather than South) America were associated with infection.…”

A Multinational Outbreak of Histoplasmosis Following a Biology Field Trip in the Ugandan Rainforest

“…Similarly, in a large outbreak of APH in American travelers vacationing in Acapulco, Mexico, in 2001, 25% of symptomatic, laboratory-confirmed cases received antifungal treatment and 56% received other antimicrobials. 10 Reporting ''sentinel'' cases on ProMED-mail can alert other physicians to possible outbreaks of pulmonary histoplasmosis, facilitating diagnosis and management.…”