Histoplasma endocarditis: clinical and mycologic features and outcomes

Bhatti, Sabha; Vilenski, Leonid; Tight, Robert R.; Smego, Raymond A.

doi:10.1016/j.jinf.2004.10.002

Cited by 40 publications

(50 citation statements)

References 37 publications

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“…Histoplasma endocarditis is a rare manifestation of disseminated histoplasmosis. Infection can occur on native valves, prosthetic valves, and even atrial myxomas (3,6,41,107). The patient has symptoms typical of chronic disseminated histoplasmosis and also has cardiac findings and embolic phenomena.…”

Section: Disseminated Histoplasmosismentioning

confidence: 99%

Histoplasmosis: a Clinical and Laboratory Update

2007

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SUMMARY Infection with Histoplasma capsulatum occurs commonly in areas in the Midwestern United States and Central America, but symptomatic disease requiring medical care is manifest in very few patients. The extent of disease depends on the number of conidia inhaled and the function of the host's cellular immune system. Pulmonary infection is the primary manifestation of histoplasmosis, varying from mild pneumonitis to severe acute respiratory distress syndrome. In those with emphysema, a chronic progressive form of histoplasmosis can ensue. Dissemination of H. capsulatum within macrophages is common and becomes symptomatic primarily in patients with defects in cellular immunity. The spectrum of disseminated infection includes acute, severe, life-threatening sepsis and chronic, slowly progressive infection. Diagnostic accuracy has improved greatly with the use of an assay for Histoplasma antigen in the urine; serology remains useful for certain forms of histoplasmosis, and culture is the ultimate confirming diagnostic test. Classically, histoplasmosis has been treated with long courses of amphotericin B. Today, amphotericin B is rarely used except for severe infection and then only for a few weeks, followed by azole therapy. Itraconazole is the azole of choice following initial amphotericin B treatment and for primary treatment of mild to moderate histoplasmosis.

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Section: Disseminated Histoplasmosismentioning

confidence: 99%

Histoplasmosis: a Clinical and Laboratory Update

2007

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“…However, both urine and serum antigen assays in our patient, performed shortly after valve replacement, were negative. Urine Histoplasma antigen has been reported to be positive only for one patient with endocarditis (2). In other published case reports of Histoplasma endocarditis, the antigen assay was not performed or reported.…”

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confidence: 94%

“…Infections have been reported on both native and prosthetic valves. Diagnosis is often delayed because Ͼ80% of cases have negative blood cultures, and the lack of a timely diagnosis and appropriate antifungal therapy leads to high mortality (2).…”

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confidence: 99%

“…On the other hand, infection with H. capsulatum occurs commonly in areas in the Midwestern United States and Central America but rarely manifests as endocarditis. Previously, 44 cases of Histoplasma endocarditis have been reported (2). Most recently, Boland et al reported three cases of prosthetic valve endocarditis due to Histoplasma in their review of all cases of fungal prosthetic valve endocarditis at the Mayo Clinic from 1970 to 2008 (3).…”

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Histoplasma capsulatum Prosthetic Valve Endocarditis with Negative Fungal Blood Cultures and Negative Histoplasma Antigen Assay in an Immunocompetent Patient

Jinno¹,

Gripshover²,

Lemonovich³

et al. 2010

J Clin Microbiol

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We report a case of Histoplasma capsulatum endocarditis in which Histoplasma antigen assay and fungal blood cultures were negative. The diagnosis was made by microscopic examination and culture of the excised valve. Histoplasma capsulatum should be considered in the differential diagnosis of culture-negative endocarditis in regions where it is endemic and in travelers. CASE REPORTThe patient, a 59-year-old female living in northeastern Ohio, with a history significant for coronary artery disease, hypertension, bicuspid aortic valve, and aortic stenosis, had an aortic bioprosthetic valve replacement in 2004. In April 2010, she presented to her primary care physician with fever, chills, dry cough, and shortness of breath persisting for 10 days and was prescribed amoxicillin-clavulanate for presumed bronchitis. Her symptoms continued to worsen, and she presented to the emergency room in our institution. On examination, her vital signs were significant for a temperature of 101°F, respiratory rate of 22 breaths/min, heart rate of 105 beats/min, blood pressure of 129/50 mm Hg, and oxygen saturation of 100% on 2 liters nasal cannula supplemental oxygen. The physical exam was remarkable for oral caries and an aortic systolic ejection murmur. There were no peripheral stigmata of infective endocarditis or signs of heart failure. A complete blood count showed a white blood cell count of 8,400 cells/mm 3 with 82% neutrophils, hemoglobin of 11.2 g/dl, and a platelet count of 206,000/mm 3 . Other investigations were remarkable for an erythrocyte sedimentation rate of 108 mm/h (normal, Ͻ30 mm/h), C-reactive protein level of 5.96 mg/dl (normal, Ͻ0.8 mg/dl), and creatinine level of 1.37 mg/dl. Liver function tests were normal. Chest X ray was normal, but transesophageal echocardiography (TEE) showed a 5-by 6-mm vegetation on the aortic valve with mild aortic regurgitation. Numerous blood cultures, including three fungal cultures using 10-ml Isolator tubes, were negative. The presumptive diagnosis was culture-negative endocarditis associated with recent antibiotic use. Initially, the patient was started on vancomycin, gentamicin, ceftriaxone, and rifampin. Subsequently, ceftriaxone was switched to meropenem due to the concern for drug fever. Despite antibiotic therapy, the patient continued to have persistent fevers and rigors. A magnetic resonance image (MRI) of the brain and a computed tomography (CT) of the abdomen and pelvis did not reveal embolic lesions or abscesses. Fourteen days after the initial TEE, a repeat TEE demonstrated enlargement of the vegetation on the aortic valve with no definite periannular abscess. The patient underwent an aortic valve replacement, during which vegetations were found on all three aortic leaflets. The aortic annulus, left ventricular free wall, and septum were not involved. Direct microscopic examination of the vegetations stained with calcofluor white-KOH disclosed numerous small, oval yeasts. Histopathology of the excised valve showed chronic inflammation consistent with infection of the b...

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“…Fungi are the causative agents in approximately 5 to 7% of all prosthetic valve endocarditis episodes (1). H. capsulatum is rare; in a review of 270 cases of fungal endocarditis, only 6% were attributed to H. capsulatum (2).…”

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confidence: 99%