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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 6  |  Page : 1115-1117
Infection with Histoplasma capsulatum in a renal transplant recipient


1 Department of Surgery, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra University, Porur, Chennai, India
2 Department of Microbiology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra University, Porur, Chennai, India
3 Department of Nephrology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra University, Porur, Chennai, India

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Date of Web Publication4-Nov-2010
 

   Abstract 

With the advent of potent immunosuppressive therapies in solid organ trans­plantation, patients are more susceptible to a variety of infections with atypical pathogens and presentations. We report a renal transplant recipient with atypical presentation of histoplasmosis.

How to cite this article:
Rekha A, Kindo AJ, Sounderarajan P, Ravi A. Infection with Histoplasma capsulatum in a renal transplant recipient. Saudi J Kidney Dis Transpl 2010;21:1115-7

How to cite this URL:
Rekha A, Kindo AJ, Sounderarajan P, Ravi A. Infection with Histoplasma capsulatum in a renal transplant recipient. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Aug 19];21:1115-7. Available from: http://www.sjkdt.org/text.asp?2010/21/6/1115/72301

   Introduction Top


Histoplasmosis is a fungal infection caused by the dimorphic saprophytic fungus Histoplasma capsulatum, which is endemic in the Central United States, South America, the Caribbean, Africa, and Asia. However, microfoci are be­lieved to occur anywhere with warm humid soil. [1] In patients on immunosuppression, prog­ressive disseminated disease has a high morta­lity rate of 7-23%. [2] Clinical manifestations vary (depending on host's immunity and size of inoculum) from a mild transient flu-like illness to rapidly progressive, often fatal, disseminated disease. [1] An awareness of this uncommon pa­thogen is necessary for the clinician to diag­nose this disease, utilize the investigative mo­dalities and initiate appropriate treatment.


   Case Report Top


A 47- year- old man from Burma came to our hospital in South India with a complaint of fe­ver for 1 month. He had type 2 diabetes mellitus (11 years duration) and undergone renal trans­plant 3 years prior to his current complaint and had been on immunosuppressant therapy with cyclosporine, azathioprine and steroids.

Physical examination disclosed normal blood pressure, but detected a swelling (3 × 4 cms) in the medial aspect of his right arm 5 cm proxi­mal to the cubital fossa and also another swelling (5 × 6 cms) over the dorsum of the right wrist joint [Figure 1]. It was not warm or tender and consistency was variable (soft, fluctuant in some areas, firm in others).There were no palpable lymph nodes and there was no fixation to un­derlying muscles, bone or overlying skin.
Figure 1 :shows mass lesion over the dorsum of the wrist with the inset showing the lesion on the arm.

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The laboratory investigations revealed hemo­globin (HB) 11.7 g/dL, leukocyte count 9800/ mm 3 , urea 75 mg/dL, creatinine 1.8 mg/dL, cal­cium 8.5 mg/dL, phosphate 3.7 mg/dL, alkaline phosphatase 70 IU, bilirubin 0.7 mg/dL, normal liver enzymes (SGOT 33 IU and SGPT 26 IU), and normal sugar levels. Computerized tomo­graphy (CT) scan of the chest was normal cytomegalovirus titers were negative.

A fine needle aspiration count (FNAC) of the swelling was inconclusive and an excision biopsy of the right arm swelling was done. Gomori's Methanamine silver stain (GMS) of the biopsy specimen showed plenty of oval, narrow based budding intracellular yeast cells suggestive of Histoplasma capsulatum [Figure 2]. The diagnosis was confirmed by culture in Sabouraud's dextrose agar and brain heart in­fusion agar. The tubes showed a white compact growth after 3 weeks of incubation at 25ºC. Lactophenol cotton blue mount showed narrow septate hyphae with typical spikes on the wall of the conidia [Figure 3]. Urease test differen­tiated between H. capsulatum and H. dubiosii, and dimorphism was demonstrated by conver­ting the H. capsulatum into yeast forms at 37ºC in brain heart infusion agar.
Figure 2 :showing macroconidia with turbinatesinset shows culture in Sabouraud's dextrose agar.

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The patient was started on amphotericin B 50 mg i.v. for 24 days and T. itraconazole 100 mg orally. Four weeks later, there was no residual lesion left on the upper limb.


   Discussion Top


The vast majority of primary infection with Histoplasma capsulatum (> 90%) causes sub­clinical disease. Central nervous system in­volvement is rare and is seen in transplant patients. When chest infection is present, chest radiographic findings include diffuse, nodular, patchy, or military infiltrates; hilar adenopathy is uncommon. [3],[4] The elderly, those younger than 2 years of age, and individuals whose im­mune system are compromised are more likely to develop a progressive and disseminated di­sease.

Primary infection is acquired by inhalation of infectious microconidia, by direct inoculation into skin, or via an infected allograft. [5] Once the microconidia is lodged in the alveolar and interstitial spaces, it becomes a yeast, multi­plies intracellularly and disseminates until cell mediated immunity develops (2-10 weeks). [6]

Disseminated disease is marked by fever, weight loss, weakness, fatigue and mild respiratory symptoms. The most common symp­tom of infection is fever, and often associated with cutaneous and subcutaneous lesions as shown in [Figure 3].
Figure 3 :Shows intracellularoval yeast cells.

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Cutaneous lesions in disseminated histoplas­mosis include papules, nodules, plaques, ery­thema multiforme-like lesions, and exfoliative dermatitis. [7] Erythema nodosum, a hypersensi­tivity mediated panniculitis in which the orga­nisms are not present has also been described. [8] Gomori's methanamine silver stain is the best stain for H. capsulatum. The organisms are seen as numerous, small (2-4 μm), oval yeast like fungi within the cytoplasm of macrophages in the dermis and subcutaneous tissue.

Definite diagnosis is made by a combination of culture of the organism, detection of it in tissues, measurement of antibodies, or antigen detection. [3] Disseminated histoplasmosis is a life threatening illness if not diagnosed and appro­priately treated.

Amphotericin B is the drug of choice for in­duction therapy. Liposomal amphotericin does not have renal toxicity. However, as it is very costly, we administered conventional ampho­tericin B to our patient without any problems. The recommended dose of conventional am­photericin B is 0.7-1 mg/day with a cumulative dose of approximately 35 mg/kg. [9] This treat­ment must be followed with itraconazole (200 mg/day for 1 year or more) maintenance the­rapy to reduce relapse rate.

In conclusion, cutaneous lesions may be the only sign of serious systemic disease in post transplant immunosuppressed patients, as seen in our case. Transplant physicians need to be aware of this presentation, as appropriate timely investigations and optimal treatment are asso­ciated with good outcome.

 
   References Top

1.Deepe GS Jr. Histoplasma capsulatum in Mandall Douglas and Bennetts' Principals and Practice of Infectious Disease. (6 th Edition) Elsevier Church Hill Livingstone 2005;vol 2: 3012-21.  Back to cited text no. 1
    
2.Daman LA, Hashimoto K, Kaplan RJ, Trent WG. Disseminated histoplasmosis in an immuno­suppressed patient. South Med J 1977;70:353-­6.  Back to cited text no. 2
    
3.Kauffman CA. Histoplasmosis: A clinical and laboratory update. Clin Microbiol Rev 2007; 20:115-32.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Hadley S, Karchmer AW. Fungal infections in solid organ transplant recipients. Infect Dis Clin 1995;19:1045-4.  Back to cited text no. 4
    
5.Wong SY, Allen DM. Transmission of Histo­plasma capsulatum via cadaveric renal trans­plant case report. Clin Infect Dis 1992;14:232-4.  Back to cited text no. 5
[PUBMED]    
6.Farr B, Beachem BE, Aruk NO. Cutaneous histoplasmosis after renal transplantation. South Med J 1981;74:635-7.  Back to cited text no. 6
    
7.Newman SL. Cell mediated immunity to Histoplasma capsulatum. Semin Respir Infect 2001;16:102-8.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Ramdial PK, Mosam A, Dlova NC, Satar NB, Aboobakar J, Singh SM. Disseminated histo­plasmosis in patients infected with human immunodeficiency virus. J Cutan Pathol 2002; 29:215-25.  Back to cited text no. 8
    
9.Wheat J, Sarosi G, McKinsey D, et al. Practice guidelines for the management of patients with histoplasmosis. Clin Infect Dis 2000;30:688-95.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Arcot Rekha
Department of Surgery, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra University, Porur, Chennai
India
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PMID: 21060183

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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    Abstract
    Introduction
    Case Report
    Discussion
    References
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