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Progressive disseminated histoplasmosis: The experience in one non-endemic medical center
Lucy X Li1, Shakila Tenkayala Abdul Rajack1, Darin Ostrander1
1Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.
Abstract:
Histoplasmosis, the most common endemic mycosis in North America, presents in a myriad of ways, spanning the spectrum from self-limiting pneumonia to progressive disseminated histoplasmosis (PDH). Toward better describing contemporary histoplasmosis syndromes, risks, and outcomes, this single-center retrospective cohort study was performed (2009-2019). The population who developed PDH was similar to that with other forms of histoplasmosis (OFH) except for higher rates of preexisting immunocompromising conditions (91.3% vs. 40%, P < .001) and a trend toward receiving more chronic immunosuppression (65.2% vs. 33.3%, P = .054) compared to those with OFH. Diagnosis was most frequently achieved by urinary or serum antigen positivity. People with PDH more frequently tested positive compared to those with OFH, but negative tests did not rule out histoplasmosis. Median time to diagnosis was prolonged among people with both PDH and OFH (32 vs. 31 days, respectively). Following diagnosis, people with PDH received more liposomal amphotericin (78.3% vs. 20%, P < .001). Subsequent survival at 90 and 365 days and treatment response were similar in both groups. Patients with PDH were more often hospitalized (95.7% vs. 60%, P = .006); however, once admitted, there were no differences in hospital length of stay or intensive care unit admission rate. The challenges of diagnosing histoplasmosis based on clinical presentation alone highlight the need for heightened awareness of these entities especially given the recent reports on expanded endemicity and delays in diagnosis.
Insights
Progressive disseminated histoplasmosis (PDH) primarily affects immunocompromised individuals and often requires antigen testing for diagnosis. Despite treatment differences, outcomes for PDH and other histoplasmosis forms are similar.
Area of Science:
- Mycology
- Infectious Diseases
- Epidemiology
Background:
- Histoplasmosis is a common North American endemic mycosis with varied presentations, from mild pneumonia to severe progressive disseminated histoplasmosis (PDH).
- Contemporary understanding of histoplasmosis syndromes, risks, and outcomes requires updated data.
- Identifying risk factors and diagnostic challenges is crucial for effective management.
Purpose of the Study:
- To describe contemporary histoplasmosis syndromes, associated risks, and patient outcomes.
- To compare characteristics and outcomes of progressive disseminated histoplasmosis (PDH) with other forms of histoplasmosis (OFH).
- To evaluate diagnostic methods and time to diagnosis for histoplasmosis.
Main Methods:
- Single-center retrospective cohort study.
- Inclusion of patients diagnosed with histoplasmosis between 2009 and 2019.
- Comparison of patient demographics, clinical presentation, diagnostic methods (antigen testing), treatment, and outcomes between PDH and OFH groups.
Main Results:
- Patients with PDH had higher rates of pre-existing immunocompromising conditions (91.3%) compared to OFH (40%).
- Urinary or serum antigen positivity was the most frequent diagnostic method; PDH patients were more likely to test positive.
- Despite differences in treatment (liposomal amphotericin more common in PDH) and hospitalization rates, 90-day and 365-day survival and treatment response were similar between PDH and OFH groups.
Conclusions:
- Histoplasmosis diagnosis remains challenging, underscoring the need for increased clinical awareness, especially with expanding endemicity.
- Antigen testing is valuable, but negative results do not exclude histoplasmosis.
- Prompt diagnosis and management are essential, although outcomes for PDH and OFH are comparable when treated appropriately.
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