Journal of Cytology
Home About us Ahead of print Instructions Submission Subscribe Advertise Contact e-Alerts Login 
Users Online:4421
  Print this page  Email this page Small font sizeDefault font sizeIncrease font size


 
 Table of Contents    
CASE REPORT  
Year : 2015  |  Volume : 32  |  Issue : 2  |  Page : 142-144
Disseminated histoplasmosis in an immunocompetent haweli dweller: A diagnosis and follow-up by endoscopic ultrasound-guided fine-needle aspiration


1 Department of Cytopathology, Jaswant Rai Speciality Hospital, Saket, Meerut, Uttar Pradesh, India
2 Department of Gastroenterology, Jaswant Rai Speciality Hospital, Saket, Meerut, Uttar Pradesh, India
3 Department of Medicine, Jaswant Rai Speciality Hospital, Saket, Meerut, Uttar Pradesh, India

Click here for correspondence address and email

Date of Web Publication10-Jul-2015
 

   Abstract 

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is nowadays widespread minimally invasive procedure for diagnosing a large number of benign as well as malignant lesions. We report a case of a 62-year-old immunocompetent elderly male, who presented with high-grade fever, hepatosplenomegaly and mediastinal and intra-abdominal lymph nodes. He was residing in an old haweli with bats infestation. EUS-FNA of the subcarinal and the preaortic lymph node clinched the diagnosis. A rapid on-site evaluation of the cytology material revealed organisms conforming to the morphology of Histoplasma capsulatum. The patient was immediately started on amphotericin B and itraconazole and responded well. In this case, we found the role of EUS-FNA not only in diagnosis, but also in the follow-up of the patient.

Keywords: Disseminated histoplasmosis; endoscopic ultrasound-guided fine needle aspiration; haweli resident, immunocompetent lymph node

How to cite this article:
Ecka RS, Sharma M, Tomar V. Disseminated histoplasmosis in an immunocompetent haweli dweller: A diagnosis and follow-up by endoscopic ultrasound-guided fine-needle aspiration. J Cytol 2015;32:142-4

How to cite this URL:
Ecka RS, Sharma M, Tomar V. Disseminated histoplasmosis in an immunocompetent haweli dweller: A diagnosis and follow-up by endoscopic ultrasound-guided fine-needle aspiration. J Cytol [serial online] 2015 [cited 2019 Nov 19];32:142-4. Available from: http://www.jcytol.org/text.asp?2015/32/2/142/160597



   Introduction Top


Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is nowadays widespread minimally invasive procedure for sampling organs in proximity to the gastro-intestinal tract and to obtain samples for cytology as well as core biopsies. It serves many functions, that is, from diagnosing benign conditions to malignant conditions. [1] Benign conditions include a range of noninfective to infective pathology with most common being tuberculosis in India. Histoplasmosis is a disease of worldwide occurrence caused by dimorphic fungus Histoplasma capsulatum. In India, till now only sporadic cases are reported. Disseminated histoplasmosis is defined as a clinical condition where fungus is present in more than one location [2] and is a less common manifestation of the disease, mainly infecting immunodeficient (transplanted or AIDS) patients, as well as the very young or very old. The clinical presentation varies from the acute disseminated form, which is uncommon in immunocompetent individuals to chronic progressive course typically seen in nonimmunocompromised middle-aged to older adults. [3],[4] We report the case of an immunocompetent patient who presented with the disease, probably as a result of prolonged exposure and delayed diagnosis.


   Case Report Top


A 62-year-old male patient presented with complaints of fever and dry cough since 1½ months duration. Fever was of high grade with chills, rigor, and sweating episodes. On general examination, the positive findings were fever, pallor, and mild hepatosplenomegaly. Peripheral lymph nodes were not enlarged. He had a history of pulmonary tuberculosis 20 years back and had completed 9 months of antituberculous treatment. He was diagnosed with diabetes 2 years back and was put on insulin. However, he was irregular with the treatment. In last 2 years, the patient had recurrent episodes of upper respiratory tract infection and had taken antibiotics and bronchodilators for the same. The patient denied any history of parenteral drug abuse, homosexual behavior, or blood transfusion. In view of clinical presentation and radiological findings, a diagnosis of tuberculosis was highly suspected. Laboratory investigations revealed normocytic normochromic anemia with neutrophilia. The platelet count was normal. AST-74 U/L, (normal 5-50 U/L), ALT-56 U/L (normal 0-50), serum alkaline phosphatase 248 U/L (normal 25-125 U/L), serum bilirubin 1.1 mg/dl (normal 0.2-1.1), blood sugar random 312 mg, Mantoux test and antiretroviral antibody were negative. Malarial antigen and rapid test for typhoid were negative. A chest radiograph showed bilateral nodular opacities. Abdominal ultrasound revealed mild hepatosplenomegaly with few lymph nodes in the preaortic region. A computed tomography scan of the chest and abdomen revealed a single lymph node of 3 cm diameter in the subcarinal area and two lymph nodes of 1.5 cm diameter in the preaortic region near the celiac artery. EUS examination also revealed lymph nodes in preaortic and subcarinal area [Figure 1]. A 22 G Wilson cook Echotip needle was used for EUS-FNA. The cytology smears prepared were stained with Diff-Quick stain and examined. An immediate on-site examination of the aspirated material from both the sites, that is, subcarinal and preaortic lymph node showed high cellularity with a predominant reactive lymphoid cell population. An increase in histiocytes was noted with small necrotic fragments. Many intracellular round to oval organisms with peripheral halo conforming to the morphology of H. capsulatum were found [Figure 2]. No kinetoplast was seen, thereby excluding Leishmania donovani, morphologically. These organisms were positive for periodic acid-Schiff's stain. No granulomas were seen. Further history taken later revealed that he had been residing in an old haweli, which had bat infestation.
Figure 1: Endoscopic ultrasound shows a large triangular hypoechoic lymph node in the subcarinal region

Click here to view
Figure 2: Intracellular round to oval organisms with peripheral halo confirming to the morphology of Histoplasma capsulatum (Diff -Quick, ×400)

Click here to view


He was started immediately on amphotericin B for 7 days, followed by itraconazole for 2 weeks and responded well to the treatment. After a follow-up for 12 months, the patient is doing well and is negative for histoplasma serology. A repeat EUS showed a regression in the size of the lymph nodes with EUS-FNA showing normal morphology.


   Discussion Top


Immunocompromised patients who reside in H. capsulatum-endemic regions were more prone to suffer from disseminated histoplasmosis. The usual patient profile includes small children (especially infants), aged persons, and patients with AIDS, cancer, solid organ or bone marrow transplant. [2] H. capsulatum is a dimorphic fungus that remains in a mycelial form at ambient temperatures and grows as yeast at body temperature in mammals. In endemic areas, soil provides an acidic damp environment with high organic content good for mycelial growth. Highly infectious soil is found near areas inhabited by bats and birds. Birds cannot be infected neither can transmit the disease; however, bird excretions contaminate the soil, thereby enriching the growth medium for the mycelium. In contrast, bats can become infected, and they transmit the fungus through droppings. Contaminated soil remains potentially infectious for years. [3],[4]

In India, it is an uncommon disease. [5],[6],[7] Since the first report of disseminated histoplasmosis in 1954, sporadic cases have been reported from different parts of India. Most of the cases reported are from West Bengal followed by Maharashtra.

Our index case is a resident in a part of Meerut, Uttar Pradesh and had been residing in an old haweli which was infested by bats and had been in close contact with bats guano. In this case, they might have served as the potential source of infection with uncontrolled diabetes and old age serving as additional predisposing factors. We perform nearly 450 EUS-FNA per year. This is the first case of disseminated histoplasmosis diagnosed by EUS-FNA of lymph node observed in our institute and probably in this region. An immediate on-site examination of the cytology material, in this case, obviated the need for unnecessary tests in this patient, and the treatment was started early.

Presenting clinical features of histoplasmosis can range from skin and mucous involvement, lymphadenopathy, fever, hepatosplenomegaly, pulmonary, and ocular involvement. Chest radiograph may show focal infiltrates and hilar or mediastinal lymphadenopathy. [3] Progressive disseminated histoplasmosis is rare in an immunocompetent adult. The chronic progressive disease is slowly progressive and generally fatal infection due to H. capsulatum that occurs mostly in older adults who are not overtly immunosuppressed. These patients have no obvious immunosuppression, but their macrophages clearly cannot effectively kill the organism. It is thought that there is a specific defect in the cellular immune response to this organism. This is in contrast to the rapidly fatal acute form of dissemination that occurs in infants and immunosuppressed patients. [8] Awareness and prompt diagnosis of H. capsulatum are important because 100% mortality is seen in an untreated group, whereas early treatment is very effective. [9]

The diagnosis can be established by Wright-stained smear of aspirate samples and by cultures. Careful examination of the peripheral blood smears might yield an early diagnosis of systemic histoplasmosis. [10] In this case, EUS-FNAC from both the abdominal and subcarinal lymph nodes revealed H. capsulatum and confirmed the diagnosis of a disseminated form of the disease. In addition, EUS was helpful in the follow-up of the patient also.


   Conclusion Top


Infective diseases can be diagnosed by EUS-FNA. Though due to overlapping cytological picture diagnosis can be complex in a certain situation. However, identification of specific organism during on-site examination obviates the need of unnecessary test and helps in the prompt initiation of therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Gerke H. If cancer is not the answer: Endoscopic ultrasound-guided biopsies in the diagnosis of infections. Gastroenterol Hepatol (N Y) 2010;6:727-9.  Back to cited text no. 1
    
2.
Kauffman CA. Histoplasmosis: A clinical and laboratory update. Clin Microbiol Rev 2007;20:115-32.  Back to cited text no. 2
    
3.
Kauffman CA. Histoplasmosis. Clin Chest Med 2009;30:217-25, v.  Back to cited text no. 3
    
4.
Wheat LJ, Kauffman CA. Histoplasmosis. Infect Dis Clin North Am 2003;17:1-19, vii.  Back to cited text no. 4
    
5.
Randhawa HS, Khan ZU. Histoplasmosis in India: Current status. Indian J Chest Dis Allied Sci 1994;36:193-213.  Back to cited text no. 5
    
6.
Gopalakrishnan R, Nambi PS, Ramasubramanian V, Abdul Ghafur K, Parameswaran A. Histoplasmosis in India: Truly uncommon or uncommonly recognised? J Assoc Physicians India 2012;60:25-8.  Back to cited text no. 6
    
7.
Subbalaxmi MV, Umabala P, Paul R, Chandra N, Raju YS, Rudramurthy SM. A rare presentation of progressive disseminated histoplasmosis in an immunocompetent patient from a non-endemic region. Med Mycol Case Rep 2013;2:103-7.  Back to cited text no. 7
    
8.
Goodwin RA Jr, Shapiro JL, Thurman GH, Thurman SS, Des Prez RM. Disseminated histoplasmosis: Clinical and pathologic correlations. Medicine (Baltimore) 1980;59:1-33.  Back to cited text no. 8
    
9.
Chakrabarti A, Slavin MA. Endemic fungal infections in the Asia-Pacific region. Med Mycol 2011;49:337-44.  Back to cited text no. 9
    
10.
Ecka RS, Bhatia P, Varma N, Marwaha RK. Disseminated histoplasmosis with peripheral blood spill over. Indian J Pediatr 2014;81:313-4.  Back to cited text no. 10
    

Top
Correspondence Address:
Ruth Shifa Ecka
Department of Cytopathology, Jaswant Rai Speciality Hospital, Saket, Meerut - 250 001, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9371.160597

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]

This article has been cited by
1 A Twenty-First-Century Perspective of Disseminated Histoplasmosis in India: Literature Review and Retrospective Analysis of Published and Unpublished Cases at a Tertiary Care Hospital in North India
Ayush Gupta,Arnab Ghosh,Gagandeep Singh,Immaculata Xess
Mycopathologia. 2017; 182(11-12): 1077
[Pubmed] | [DOI]
2 “…That which we call a rose…”: A critical analysis of rapid on-site evaluation
Maureen F. Zakowski
Cancer Cytopathology. 2016; 124(12): 857
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed1771    
    Printed25    
    Emailed0    
    PDF Downloaded59    
    Comments [Add]    
    Cited by others 2    

Recommend this journal