Histoplasmosis in India: truly uncommon or uncommonly recognised?

To study the clinical profile of patients with proven histoplasmosis who had presented to a tertiary care referral centre.

We retrospectively analysed the medical records of 24 patients diagnosed to have histoplasmosis between January 2002 and April 2011. Histoplasmosis was diagnosed when compatible intracellular organisms were seen on biopsy and/or when Histoplasma capsulatum was grown in culture.

Twenty four patients were diagnosed to have histoplasmosis of whom 23 were male. Diabetes and HIV infection was the most common co-morbid conditions. Subacute progressive disseminated histoplasmosis (PDH) (22 patients) was the most common clinical presentation. Ten patients had received 2-3 months of empiric anti-tuberculous therapy (ATT) with no response prior to the diagnosis of histoplasmosis. Fever, weight loss, hepato-splenomegaly, oral ulcers and lymphadenopathy were the most common clinical features. Bilateral adrenal enlargement was detected by imaging in 15 patients and adrenal insufficiency was noted in 4 patients. Itraconazole alone was used for treatment in 20 patients while 3 patients were treated with amphotericin B initially, followed by itraconazole. Response to therapy was excellent in 20 patients.

Histoplasmosis is an under-recognized disease in India and should be considered in the differential diagnosis of male patients with prolonged fever, adrenal enlargement, hepato-splenomegaly, oral ulcers and granulomatous disease on histopathology without response to ATT. When tissue biopsy specimens show granulomas, fungal stains should be routinely performed. Treatment with itraconazole leads to an excellent outcome in most patients.