Post kidney transplant histoplasmosis: An under‐recognized diagnosis in India

Abstract

The availability of better and more potent immunosuppressive drugs have significantly reduced the risk of acute rejections (AR), while increasing the risk of other complications, especially infections in kidney transplant recipients. 1 Infections remain the second most common cause of death and the most common cause of hospitalization in solid organ transplant (SOT) recipients. 2 Histoplasmosis is a systemic fungal infection caused by the dimorphic fungus Histoplasma capsulatum. In India the disease is endemic in the northeast region. 3 Histoplasmosis in immunocompromised can present with varied clinical manifestations and it should be diagnosed and treated promptly with antifungal drugs otherwise it can be fatal. 4,5 Many symptoms of histoplasmosis mimic tuberculosis which is endemic in India, and sometimes empiric antitubercular treatment is started, which can have devastating consequences and lead to mortality in many patients. 6 There are only a handful of case reports of histoplasmosis in SOT recipients from India, hence it is often overlooked as a cause of pyrexia of unknown origin (PUO), chest infection, and cutaneous lesions in non-endemic regions. Hereby, we present five cases of histoplasmosis in kidney transplant recipients with varied clinical presentations and outcomes, highlighting both diagnostic approach in such cases and the importance of keeping histoplasmosis in the differential diagnosis in transplant recipients with similar presentations.

Clinical Characteristics and Outcomes of Endemic Mycoses After Solid Organ Transplantation: A Comprehensive Review

“…Half of recipients (74 of 144 [51.4%]) were on MMF [ 73 , 74 , 80 , 83–86 , 92–94 , 96 , 98 , 101–104 , 107–109 , 113–116 , 118–120 , 122 , 126 , 130 , 132–135 , 140 , 143 , 145 , 148–150 , 152 , 153 , 155 , 156 , 159 , 161–165 , 172–174 , 177 , 179 , 181 , 194 , 196 , 197 , 204 ]. T-cell–depleting induction was reported in 23 cases [ 78 , 104 , 107 , 108 , 110 , 113–115 , 118 , 125 , 133 , 146 , 154 , 163 ] while acute rejection occurred in 30 recipients within 1–3 months before symptom onset [ 72 , 73 , 76 , 78 , 90 , 103 , 108 , 114 , 115 , 118 , 124 , 128 , 129 , 135 ...…”

South Asian Transplant Infectious Disease Guidelines for Solid Organ Transplant Candidates, Recipients, and Donors

“…Histoplasma capsulatum infection is endemic in the northeast region and the Gangetic belt of India and is increasingly reported from other parts of SA. [70][71][72] Histoplasma thrives in a warm and humid environment such as soil enriched with nitrogenous compounds and phosphates derived from avian excreta and bat guano. 70 The infection is usually acquired through the inhalation of microconidia.…”

“…The presentation is nonspecific with fever, lymphadenopathy, and nodules/infiltrate on chest imaging and can mimic TB. [70][71][72][73] Diagnosis requires demonstration of the fungus in blood, fluid, or tissue specimens obtained by bronchoscopy or FNAC/biopsy. [71][72][73] In patients with disseminated infection, blood cultures using a lysis centrifugation system and Histoplasma antigen in urine and body fluids (BAL, cerebrospinal fluid [CSF]) can help in early diagnosis.…”

“…[70][71][72][73] Diagnosis requires demonstration of the fungus in blood, fluid, or tissue specimens obtained by bronchoscopy or FNAC/biopsy. [71][72][73] In patients with disseminated infection, blood cultures using a lysis centrifugation system and Histoplasma antigen in urine and body fluids (BAL, cerebrospinal fluid [CSF]) can help in early diagnosis. 8,73 Serology is not very useful for diagnosis in immunocompromised patients.…”

“…73 The median duration of presentation from the time of transplant in 1 series from India was 5 y (range, 1.5–5 y). 71 Most infections in western data occurred within 1 to 2 y posttransplant.…”