Thrombocytopenia and disseminated histoplasmosis in immunocompetent adults

Abstract

Key Clinical MessageDisseminated histoplasmosis among immunocompetent patients is rare, but may be associated with clinically significant refractory thrombocytopenia. Platelet counts often return to normal levels following antifungal therapy. Therefore, the most important management of this refractory thrombocytopenia is the recognition and treatment of histoplasmosis infection.

Refractory Thrombocytopenia Associated to Disseminated Histoplasmosis in a Living-Related Renal Transplant Recipient: A Case Report and Review of the Literature

“…Contrary to the aforementioned case, our patient had platelet recuperation 48 hours after the application of the IVIG. The possible mechanisms by which H. capsulatum produces thrombocytopenia have been described: 1) by infiltration of MO affecting platelet production; 2) promoting platelet aggregation; or, 3) inducing ITP [6]. In the MO aspirate of our case, megakaryocytes producers of platelets were reported, and there were no yeasts of H. capsulatum found.…”

“…In 2017, Kutkut I. et al [6], reported a case of severe refractory thrombocytopenia with DH, which, during the course of the illness, required multiple transfusions of platelets and IVIG at a dose of 1g/kg/day for two days without improvement. In this case, after the administration of amphotericin B liposomal at 3 mg/kg/ day for 14 days, followed by itraconazole at 200 mg/day for one year, it favored recuperation and normalization of the platelets, associated with an absence of the urinary antigen of H. capsulatum [6]. Contrary to the aforementioned case, our patient had platelet recuperation 48 hours after the application of the IVIG.…”

“…The IVIG is used to maintain platelet levels, and to favor decreases inthe doses of corticosteroids [12]. Kutkutet al [6], showed recovery of DH at two months from the onset of antifungal treatment, and platelet normalization. On the other hand, Armitage et al [13], reported two cases of DH and thrombocytopenia: the first case without improvement with the use of amphotericin B but with transitory improvement using corticosteroids, and complete recovery after splenectomy.…”

“…The incidence of DH in SOT is less than 1% [2] and can compromise the Medulla Ossium (MO) in up to one third of cases, with anemia and leukopenia as the most common alterations [3]. Thrombocytopenia is also reported in DH [4,5]; however, refractory cases have only been documented in immunocompetent patients [6], and there is no existing information on the immunocompromised. Recuperation of the depletion of cell lines occurs in a few weeks and is associated with the response to antifungal treatment [7,8].…”

Disseminated histoplasmosis with refractory thrombocytopenia in a renal transplant patient

“…9 Several mechanisms by which H. capsulatum produces thrombocytopenia have been described as (1) by infiltration of bone marrow affecting platelet production; (2) by inducing ITP; or (3) by promoting platelet aggregation. 10 The Infectious Disease Society of America (IDSA) recommends itraconazole therapy for 6-12 weeks for patients with mild/moderate disease. 11 For severe disease, the IDSA recommends liposomal amphotericin B for one to 2 weeks, followed by itraconazole for an additional 12 weeks.…”