Two Specific Strains of <Emphasis Type="Italic">Histoplasma capsulatum</Emphasis> causing Mucocutaneous Manifestations of Histoplasmosis: Preliminary Analysis of a Frequent Manifestation of Histoplasmosis in Southern Brazil

Objectives  Skin lesions, uncommon in US cases (<10%), occur in 38–85% of cases reported from Latin America. Although these differences may reflect reporting bias, delayed diagnosis, or differences in host immune response among different ethnic groups, they also could result from genetic differences changing the pathobiology of the organism. It is possible that genetic differences among strains of H. capsulatum may influence the pathogenesis and clinical manifestations of histoplasmosis. Methods  We examined the clinical features of patients with mucocutaneous manifestations of histoplasmosis and performed genetic analysis based on nucleotide sequence variations in the internal transcribed spacer regions of rRNA genes of H. capsulatum isolates of patients. Two pairs of PCR primers were designed to develop and amplify the ITS regions of H. capsulatum, 5′-TACCCGGCCACCCTTGTCTA-3′ and 5′-AGCGGGTGGCAAAGCCC-3′. These primers were based on the ITS sequence of Ajellomyces capsulatus, the ascomycetous teleomorph form of H. capsulatum, deposited in the GenBank (accession number U18363). Eight patients attending a tertiary-care hospital in southern Brazil were enrolled into the study. All case patients had skin cultures growing H. capsulatum at the mycology laboratory. Results  Six of eight (75%) patients were HIV-positive and presented involvement of multiples organs by H. capsulatum. Two HIV-negative patients did not present evidence of involvement of other organs besides mucosa and skin. ITS sequencing of a DNA H. capsulatum fragment of 485-bp from isolates of 8 patients revealed two distinct strains. The 2 distinct fragments (Hc1, Hc2) differed from each other at 7 positions in the ITS regions. They were identical to strains of H. capsulatum isolated in patients from Colombia and Argentina, but different from strains isolated in US. Hc1 and Hc2 were isolated in 5 patients and 3 patients, respectively, with mucocutaneous manifestations of histoplasmosis. Both Hc1 and Hc2 strains were isolated in HIV-infected and non-HIV-infected patients. Conclusions  Mucocutaneous manifestations of histoplasmosis, which are frequently seen in Brazilian patients were caused by 2 specific strains in our institution. Those strains have been isolated in patients with these particular clinical features of histoplasmosis in Latin America. Our study suggests that unique pathogenic characteristics among the Latin American species of H. capsulatum might explain its increased dermatotropism.     

<Emphasis Type="Italic">Histoplasma capsulatum</Emphasis> Sinusitis: Case Report and Review

Histoplasma capsulatum has not typically been associated with sinusitis in either immunocompetent or immunocompromised hosts. We report a case of sinusitis caused by H. capsulatum in a patient with chronic lymphocytic leukemia and discuss the reported cases of this rare clinical manifestation of histoplasmosis in the medical literature.     

A natural focus ofHistoplasma capsulatum var.duboisii is a bat cave

The natural reservoir ofHistoplasma capsulatum var.duboisii, the etiological agent of histoplasmosis duboisii (African histoplasmosis) is not yet known. We report the isolation ofH. capsulatum var.duboisii from soil admixed with bat guano and from the intestinal contents of a bat in a sandstone cave in a rural area, Ogbunike in Anambra State of Nigeria. Eight of 45 samples of soil admixed with bat guano yieldedH. capsulatum var.duboisii. Of the 35 bats belonging to the speciesNycteris hispida andTadirida pumila examined, only one (N. hispida) yielded this fungus from its intestinal contents. Identification of the isolates asHistoplasma was confirmed by exoantigen tests and by mating with tester strains ofH. capsulatum. In vitro conversion to large yeast from suggestive ofH. capsulatum var.duboisii was obtained on brain heart infusion agar supplemented with sheep blood and glutamine or cysteine. Pathogenicity tests with mice for all the isolates confirmed their identity by the demonstration of large yeast forms (8–15 µm in diameter) within giant cells in the infected tissues. Investigations on the possible occurrence of human infections in the area are in progress.A poster based on this work was presented at the 11th ISHAM Congress in Montreal, Canada (22–28 June 1991), La-Hoffman Roche, Basel, Switzerland kindly financed the trip of one of us (H.C.G) for the Congress.     

Gingival histoplasmosis: An atypical presentation of African histoplasmosis in three baboons (Papio spp)

Gingival lesions as the sole manifestation of African histoplasmosis (Histoplasma capsulatum var. duboisii) have never been reported in baboons. Grossly, lesions can be indistinguishable from bacterial ulcerative gingivitis or gingival hyperplasia. Clinical outcomes of primary gingival histoplasmosis in baboons are unknown and may complicate colony management decisions.     

Is Histoplasma capsulatum a native inhabitant of Japan?

Histoplasmosis is an infectious disease caused by inhaling spores of the fungal pathogen H. capsulatum and in Japan is considered an imported mycosis. However, some patients in Japan with histoplasmosis have no history of traveling overseas nor of risk of occupational exposure to Histoplasma. To investigate the possibility of native distribution of Histoplasma in Japan, 187 bat guano samples from 67 bat‐inhabited caves in 17 prefectures were collected. These were examined for H. capsulatum by culture and Histoplasma‐specific PCR in three independent laboratories. No H. capsulatum was detected by either method, therefore H. capsulatum is unlikely to be present in bat guano in Japanese caves.     

Immunocytochemical staining of Histoplasma capsulatum at the electron microscopic level

Summary Rabbits were immunized with histoplasmin emulsified in Freund's complete adjuvant. Antibody raised in these rabbits was exposed to Histoplasma capsulatum yeast cells, either in tissue culture medium, or after in vitro or in vivo phagocytosis by mouse macrophages. The sites of antibody binding were identified using an immunoperoxidase technique. At least two sites of antibody binding were identified, one to the fungal cell wall and the other to the outer cell membrane. Within 6 h after phagocytosis by macrophages, fungal cell walls appeared roughened, with what appeared to be cell wall antigen released into the phagolysosome, appearing associated with the phagolysosome membrane, and possibly adjacent macrophage cytoplasm. Similar staining of fungal antigen was noted in alveolar macrophages which had ingested Histoplasma capsulatum after a respiratory challenge. This method may be useful in detailing the host/pathogen interactions which occur in human pulmonary histoplasmosis.     

Histoplasmosis as cause of penile ulcer in acquired immune deficiency syndrome (AIDS): three case reports

Background Histoplasma capsulatum is the causative agent of American histoplasmosis. The relationship between disseminated histoplasmosis and AIDS has been well established. Widespread hematogenous dissemination of Histoplasma capsulatum in HIV positive patients can cause a plethora of clinical manifestations; virtually any organic system can be affected. However, genital ulceration by H. capsulatum in patients with AIDS is a real challenge during investigation of the infection due to the great variety of differential diagnoses that are involved. Method The diagnosis was performed by histopathologic study; H. capsulatum was detected by silver staining (Grocott staining) and confirmed by immunocytochemistry. Results We report three cases of histoplasmosis in patients with AIDS, in which we observed genital ulcers, an unusual form of presentation of this disease. In one of these cases, the treatment resulted in total cure. Conclusion The cases reported herein are to illustrate the plurality of pathologies and clinical manifestations, which may affect immunocompromised patients. The correct diagnosis of fungal diseases in these patients following well established treatment will improve the prognosis.     

Histoplasma capsulatum Recovery from the Urine and a Short Review of Genitourinary Histoplasmosis

Although virtually any organ can be involved in disseminated histoplasmosis, the recovery of Histoplasma capsulatum from the urine is a rare finding. Here we describe that a renal transplant recipient had H. capsulatum recovered from urinary sediment. The organism was also recovered from urine cultures. The potential implications of this finding are discussed, and the literature on genitourinary histoplasmosis is reviewed.     

Histoplasma capsulatum in the environment of sporadic histoplasmosis cases

Conclusions 1. Acute pulmonary histoplasmosis in adults is demonstrated to be associated with exogenous sources of infection in one-half of a series of cases. 2. No exogenous sources of infection were found in chronic pulmonary histoplasmosis in adults by methods comparable to those used in acute pulmonary histoplasmosis. 3. The significance of these findings for the pathogenesis of the three clinical forms of histoplasmosis is discussed. 4. In acute pulmonary histoplasmosis in adults, the isolation ofH. capsulatum from the environment at sites of exposure aided in specific diagnosis.Two acute pulmonary histoplasmosis cases were reported previously (2–3).     

Histoplasmosis and Thrombocytopenic Purpura: Transmission by Renal Homotransplantation

Two patients with disseminated histoplasmosis are reported. One patient presented with severe thrombocytopenic purpura and splenomegaly. Histoplasmin skin test, blood and bone marrow cultures and smears, sputum cultures, and chest radiographs were negative for Histoplasma capsulatum. She died on the sixth hospital day from a massive intracerebral hemorrhage. Cardiorespiratory function was maintained until one kidney was removed for homotransplantation. The second patient, with chronic glomerulonephritis and uremia, received the renal homograft from the first patient. Initial signs of homograft rejection developed five days postoperatively. Diffuse thrombocytopenic purpura occurred shortly thereafter. Spores of Histoplasma capsulatum were observed in blood smears, in leukocyte concentrates, and in five-day leukocyte cultures from the blood obtained prior to death. Disseminated histoplasmosis was found in both patients at autopsy. The severe platelet deficit in both cases suggests that systemic histoplasmosis should be considered as a cause of thrombocytopenic purpura.To our knowledge, this is the first reported instance of direct transmission of Histoplasma capsulatum, and must be considered a hazard in homotransplantation.In vitro leukocyte cultures as a method for early diagnosis of certain disseminated fungous infections needs further investigation.     

First cases of histoplasmosis diagnosed in recife,Brasil

Summary Three cases of histoplasmosis are described, one also with subcutaneous nodule, the first cases reported from Pernambuco, Brasil.Histoplasma capsulatum was isolated from tissues in two cases and from sputum in two cases, all in pure culture.Docente Livre de Parasitologia, Chefe de Secção de Micologia. Cat. Prof.Alvaro de Figueiredo.Professor, Washington University, formerly Visiting Professor, Cadeira de Parasitologia.Pesquisadora, Cadeira de Parasitologia, Secção de Micologia.     

An unusual presentation of disseminated histoplasmosis in a non-HIV patient from Vietnam

BackgroundHistoplasmosis is a systemic infection caused by the dimorphic fungus Histoplasma capsulatum, naturally found in nitrogen-rich soil, whose main transmission route is the inhalation of conidia. Up to 95% of histoplasmosis cases are asymptomatic or transient, and the remaining 5% of cases have pathological manifestations in the lungs, bone marrow, liver, spleen, intestine, mucous membranes, and rarely on the skin. This mycosis has been reported from many endemic areas, mainly in immunosuppressed patients, such as HIV-positive patients, and its disseminated form is rarely reported.Case reportHistoplama capsulatum was isolated and identified by means of microscopy, culture characteristics and nested PCR from the cutaneous lesions of a non-HIV patient from Vietnam. The patient improved significantly with systemic itraconazole treatment.ConclusionsDisseminated histoplasmosis with cutaneous involvement in non-HIV patients is an extremely unusual presentation.     

Occurrence of histoplasmosis in Asia

The occurrence of histoplasmosis in Asia has been reviewed. Authentic cases of histoplasmosis in man are known from India, Malaysia, Singapore, Indonesia, Thailand, South Vietnam and Japan, but the autochthonous nature of the cases reported has not been established unequivocally. Of the 30 cases of human histoplasmosis recorded from Asia, 15 were confirmed by positive cultures, and their country-wise distribution is as follows: Malaysia — 4, Indonesia — 3, Singapore — 2, Thailand — 2, South Vietnam — 2 and one each from India and Japan. Authentic cases of histoplasmosis in animals are currently unknown from Asia, and likewise there is no information on the natural habitats of the etiologic agentH. capsulatum in this part of the world except for a solitary isolation from soil in bat-infested cave in Malaysia.The available data on the prevalence of cutaneous hypersensitivity to histoplasmin indicates that histoplasmin sensitivity is absent in Israel, Syria, Saudi Arabia, Lebanon and Qatar; sensitivity is negligible or of a very low order in Iran, Iraq, Pakistan and India, and for these countries it has been even suggested that the positive reactors observed may represent cross-sections with some unknown fungus/fungi which may be antigenically related toH. capsulatum. In Japan the frequency of histoplasmin positive reactors has been negligible except in groups of persons working near a U.S. Army base and in factories which used soil and sand imported from overseas including the U.S.A. In Burma and Taiwan the bulk of positive reactions in which the induration did not exceed 8 mm in diameter has been considered probably non-specific. In Indonesia and South Vietnam, on the other hand, where less than 10 per cent of the reactions tended to concentrate around an induration of 16 mm sensitivity to histoplasmin may represent specificH. capsulatum infection in certain cases. Likewisef the requently large reactions reported from the Philippines have also been interpreted to represent specific histoplasmosis infection.The recovery ofH. capsulatum from soil coupled with the finding of well-documented cases of histoplasmosis in Malaysia suggests that the disease is endemic in that country. It is not unlikely that histoplasmosis is endemic in other parts of Asia although this has not been demonstrated so far. Comprehensive mycological, serological and soil studies are indicated in order to investigate the prevalence and incidence of histoplasmosis and to map out the endemic areas of the disease in Asia.Paper read at the Eighth International Congresses for Tropical Medicine and Malaria, September 1968, Teheran (Iran).     

Indigenous Case of Disseminated Histoplasmosis from the <Emphasis Type="Italic">Penicillium marneffei</Emphasis> Endemic Area of China

This is the first indigenous case of disseminated histoplasmosis reported from the Penicillium marneffei endemic area in southern China. It was diagnosed by histopathology of tissue, gross and microscopic morphology of the culture and PCR assay of the isolated fungus. Successful antifungal treatment was with itraconazole 400 mg/day for 5 months. This case suggests that histoplasmosis should be an important differential diagnosis in immunocompromised patients in southern China and South East Asia (the only endemic area for P. marneffei).     

Histoplasmosis in northwestern Argentina II: Prevalence ofHistoplasmosis capsulati and Paracoccidioidomycosis in the population south of Chuscha,Gonzalo and Potrero in the province of Tucuman

The present work was undertaken to obtain epidemiological data on the extent and distribution ofHistoplasma capsulatum var.capsulatum andParacoccidiodes brasiliensis infections south of the Chuscha, Gonzalo and Potrero areas of Argentina. Skin tests surveys of the human population with histoplasmin and paracoccidioidin were carried out in the permanent population of those localities. The infection index of the population showed that the area south of Chuscha has a high-prevalence of histoplasmosis capsulati. The Gonzalo and Potrero areas, according to their rates of infection also can be considered to have a relatively high prevalence of this disease. The frequency of individuals infected withP. brasiliensis suggests that the level of exposure to this fungus is considerable, especially in Gonzalo where the frequency of infection was 9.23%. The endemic areas of both diseases can be superimposed, as occurs in the northeastern part of Argentina.     

Experimental histoplasmosis in the baboon (Papio sp.)

Summary Ten male and female baboons were inoculated with saline suspensions ofHistoplasma capsulatum spores using the intratracheal, intravenous, and intraperitoneal routes. Skin testing, complement fixation, agar-gel diffusion, x-rays, as well as culture and histopathological sections of the internal tissues were used for determining the susceptibility of the baboon to histoplasmosis.No systemic histoplasmosis was established in any of the baboons, but preliminary infection was obtained by the three routes of inoculation. Two baboons inoculated intravenously showed a complete negative response to the pathogen.     

Gastrointestinal Histoplasmosis in a Hepatitis C-Infected Individual

Gastrointestinal histoplasmosis is a rare manifestation of this fungal infection, typically identified in immunocompromised patients, such as those with HIV/AIDS. Here, we report a case of disseminated histoplasmosis with gastrointestinal involvement in a Hepatitis C-infected patient. The fungal agent was confirmed to be Histoplasma capsulatum by a DNA probe assay performed on a bone marrow sample. We propose that this fungal disease should be kept on the differential of patients infected with the Hepatitis C virus, as it has been reported to have numerous damaging effects on the adaptive immune system.     

Perforation of the Nasal Septum as the First Sign of Histoplasmosis Associated with AIDS and Review of Published Literature

Disseminated histoplasmosis in South America is associated with AIDS in 70–90 % of cases. It is visceral and cutaneous, compromising the oral, pharynx, and laryngeal mucous membranes. The involvement of the nasal mucosa is unusual. Two patients with perforation of the nasal septum as the only sign of their disease were clinically and histopathologically diagnosed as leishmaniasis. The revision of the biopsies and the culture of nasal discharge secretions showed that the pathogens seen were not amastigotes but Histoplasma capsulatum. Other mycotic lesions were not detected, nor there was history of cutaneous leishmaniasis. The leishmanin skin test, available only for the male patient, was negative. The PCR and immunofluorescence antibody titers for Leishmania were negative in both patients. They were HIV positive; in the male, his CD4+ T cell count was 60/mm³ and in the female 133/mm³. The nasal ulcer was the only manifestation of histoplasmosis and the first of AIDS in both patients. The male patient recovered with amphotericin B and itraconazole treatment. The female has improved with itraconazole. Both patients received antiretroviral treatment. Nasal mucous membrane ulcers should include histoplasmosis among the differential diagnosis. In conclusion, two patients had perforation of their nasal septum as the only manifestation of histoplasmosis, a diagnosis confirmed by nasal mucosa biopsy and by culture of H. capsulatum, findings which demonstrated that both patients had AIDS.     

Additional studies of histoplasmin formation

Summary Culture filtrates of 20 strains ofHistoplasma capsulatum were studied to determine the effect of certain growth conditions on histoplasmin formation. The presence of histoplasmin was denoted by an antigenic titer of 1:4 or higher with the complement fixation test.The data indicated that, in addition to verifying that the strain used affected histoplasmin formation, the morphological condition of the inoculum was extremely important. It was found that most strains which converted readily to the yeast phase at 37° C produced histoplasmin poorly. Tests with different volumes of media also showed that 500 ml volumes of culture media produced histoplasmin with higher titers than 3 liter volumes when cultured at 25° C for six months.Some additional histoplasmin could be liberated by sonification of the mycelial pad from culture filtrates which contained histoplasmin. A few strains produced high titer histoplasmin by the shake method if incubated for three months, but they had low titers after only six weeks.Complement fixation tests with sera from proven cases of histoplasmosis indicated that histoplasmin from a single strain ofH. capsulatum can give identical results with those obtained with histoplasmin from a pool ofH. capsulatum strains if H and M antigen components are present.     

Histoplasmosis in Africa: Current perspectives,knowledge gaps,and research priorities

BackgroundHistoplasmosis is a chronic granulomatous disease caused by the thermally dimorphic fungus Histoplasma capsulatum. The 2 variants Histoplasma capsulatum var. capsulatum (Hcc) and Histoplasma capsulatum var. duboisii (Hcd) causes infection in humans and commonly termed classical or American histoplasmosis and African histoplasmosis, respectively. Histoplasma capsulatum var. farciminosum (Hcf) affects equines. In recent times, there have been heightened sensitization on fungal infections such as histoplasmosis in Africa, aimed at improving awareness among relevant stakeholders, particularly healthcare workers. This effort is expected to be paralleled with increased detection of both classical and African histoplasmosis, which has remained underdiagnosed over the years. In this narrative review, we describe the current perspectives of histoplasmosis in Africa, identify knowledge gaps, and suggest research priorities.MethodsA PubMed, Google Scholar, and Africa Journal Online (AJOL) literature search was conducted for studies on histoplasmosis in Africa between 2000 and 2020. Histoplasmosis essays in medical mycology textbooks were also consulted. This narrative review was prepared from the data gathered.FindingsIn the past 2 decades, histoplasmosis in general has seen a relative increase in case detection in some Africa countries, probably attributable to the gradually increasing medical mycology advocacy efforts in Africa. Histoplasmosis cases are dominated by African histoplasmosis mostly in Western and Central Africa, while classical histoplasmosis is more common in Southern and Northern Africa. Although both classical and African histoplasmosis are common in Africa, the latter is more restricted to Africa, and cases outside the continent usually have a travel history to the continent. Despite the clinical and laboratory difference between African histoplasmosis and classical histoplasmosis, it is not straightforward to distinguish them. The typical manifestation of African histoplasmosis is the appearance of lesions affecting the skin, bones, and lymph nodes and unusually linked to human immunodeficiency virus (HIV)/AIDS. By contrast, classical histoplasmosis mostly affects the lungs and is often associated with immunosuppression, mainly HIV/AIDS. The present perspectives of histoplasmosis in Africa highlight unclear details on the true burden, strain diversity, infection route and genetic basis of African histoplasmosis, availability of specie-specific diagnostic tools, and compliance with recommended antifungal therapy. These knowledge gaps represent research questions that require scientific exploration.ConclusionsDespite a subtle increase in identifying histoplasmosis cases in Africa, it remains underdiagnosed and neglected in some parts of the continent. Increasing awareness and training among healthcare workers, bridging diagnostic and therapeutic gaps, and encouraging more research in Africa are crucial to improve the current perspectives of histoplasmosis in Africa.