Progressive disseminated histoplasmosis in idiopathic CD4 lymphocytopenia an underdiagnosed combination - a case report

Abstract

Progressive disseminated histoplasmosis (PDH) usually presents as fever, anemia, leukopenia, hepatosplenomegaly, lymphadenopathy and pulmonary symptoms. There are few reports showed the association of Idiopathic CD4 lymphocytopenia (ICL) with histoplasmosis. We describe a 65-year-old female presented with history of fever, papulo-nodular rash and significant weight loss and diagnosed as progressive disseminated histoplasmosis. All immunocompromised conditions were ruled out. In addition, her 2 consecutive CD4 counts were below 300. The patient was diagnosed with PDH associated with ICL. Patient showed significant improvement with liposomal amphotericin B and itraconazole. Absolute CD4 counts should be done in all cases of progressive disseminated histoplasmosis even in HIV negative individuals to rule out associated ICL.

A Rare Case of Coccidioidomycosis Meningitis

“…Histoplasmosis, a dimorphic fungus, was a differential that was considered. Commonly found in soils and yeast forms, its portal of entry is through inhalation [ 18 ]. Patient was tested for histoplasmosis through urine studies and was found to be negative.…”

“…Before the highly active antiretroviral therapy (HAART) medication becoming an effective medication of HIV/AIDs, Coccidioides was a significant opportunistic infection for patients with HIV living in endemic regions as their immune responses were unable to control the viral replication and immune reconstitution without the use of HAART [ 18 ]. It is suggested in data that a peripheral CD4 count ≥ 250/µL can maintain an immune response against any coccidioidal manifestations [ 2 ].…”

Insights on Covid‐19 with superimposed pulmonary histoplasmosis: The possible nexus

“…For example, depletion of CD4 T cells during primary fungal infections promotes survival, whereas depletion of CD8 T cells attenuates fungal clearance in the primary infection. Remarkably, Vβ4+ T cells which are CD8 T cell subtypes are preferentially activated during pulmonary histoplasmosis, and contribute to the generation of protective immunity by recognizing HSP60 from H. capsulatum , and the elimination of these immune cells prevents the resolution of this infection in mice 38,39 . Progressive disseminated pulmonary histoplasmosis is most commonly recognized in AIDS patients, idiopathic lymphocytopenia, and common variable immunodeficiency 39 .…”

“…Progressive disseminated pulmonary histoplasmosis is most commonly recognized in AIDS patients, idiopathic lymphocytopenia, and common variable immunodeficiency 39 . An observational study illustrated that pulmonary histoplasmosis was common in patients with lymphoma and leukemia treated with bendamustine chemotherapy 38 . Over‐activation of Th17 and reduction of regulatory T cells (Treg) are associated with the acceleration and clearance of fungal infections, including H. capsulatum 40 .…”

“…In addition, T cell dysfunction promotes the pathophysiology of SARS‐CoV‐2 infection through prolonged antigen presentation to the auto‐reactive T cells with subsequent development of post‐Covid‐19 syndrome 86 . Besides, disseminated pulmonary histoplasmosis is commonly developed in patients with idiopathic CD4 lymphocytopenia 38 . Notably, defective cell‐mediated immunity is linked with the propagation of disseminated pulmonary histoplasmosis in AIDS patients, immunosuppressive agents, and chronic granulomatous diseases 87 .…”