A rare presentation of progressive disseminated histoplasmosis in an immunocompetent patient from a non-endemic region

Abstract

Histoplasmosis is an important systemic fungal infection in endemic areas. In India, the disease has been reported from several parts of the country, most cases being from eastern India considered to be endemic for the disease. There have been very few cases reported from the state of Andhra Pradesh, in the southern part of India. We report a case of progressive disseminated histoplasmosis presenting with bleeding manifestations in an immune competent patient from the state of Andhra Pradesh.

Thrombocytopenia and disseminated histoplasmosis in immunocompetent adults

“…Finally, with disseminated infection, abnormal activation of the coagulation system, as in disseminated intravascular coagulation, may lead to consumption of platelets. In our patient, as well as two other reported cases , thrombocytopenia improved dramatically following successful treatment of histoplasmosis. Although our patient had evidence of H. capsulatum in the bone marrow, megakaryocytes were present, suggesting that infiltration of the bone marrow alone was likely not a sufficient mechanism to cause such severe thrombocytopenia.…”

“…The 13 articles fulfilling inclusion criteria are summarized in Table 1. In total, 45 cases of histoplasmosis and thrombocytopenia have been reported in immunocompetent adults since 1950, including 21 from Vanderbilt University Medical Center [5], 10 from the Christian Medical College in India [7], four from the National Institutes of Health Clinical Center [8], and 10 reports of individual cases [3,4,6,[9][10][11][12][13][14][15]. Among these reports, demographics and case details were provided for 14 patients; ages ranged from 20 to 77 years (mean of 52), 11 patients (79%) were male, nine (64%) had splenomegaly, and four (29%) died from active histoplasmosis.…”

“…Among 61 cases of histoplasmosis in India, 10 cases were immunocompetent adults with pancytopenia Subbalaxmi et al [4] Medical Mycology Case Reports A 56-year-old male farmer from southern India with disseminated histoplasmosis, refractory thrombocytopenia, and bleeding manifestations Kashif et al [12] Case Reports Critical Care A 34-year-old man with sickle-cell disease who developed Histoplasma duboisii infection and did not respond to amphotericin B. He progressed to develop hemophagocytic lymphocytosis, disseminated intravascular coagulation, and cardiorespiratory arrest Gajendra et al [14] Turkish Journal of Haematology…”

Current Concepts in the Epidemiology, Diagnosis, and Management of Histoplasmosis Syndromes

“…However, PDH has been described in immunocompetent patients, presumably due to exposure to large inocula. 104 Histoplasmosis in the setting of solid-organ transplantation is rare (<1%) even in endemic areas and most cases occur within 1 to 2 years of transplantation. 105 Donor-derived infection has been described but occurs only in 1:10,000 transplants.…”

Endemic Fungi Presenting as Community-Acquired Pneumonia: A Review

“…[47][48][49][50][51] PDH has been described in presumably immunocompetent patients following infection with a large fungal inoculum. 52 PDH is a progressive illness characterized by fever, constitutional symptoms such as fatigue, night sweats, and weight loss, and predominantly respiratory symptoms of dyspnea, cough, and hypoxia. The illness can progress to multiorgan system failure with ARDS, shock, and coagulopathy if diagnosis and treatment are delayed.…”