Definition + Histoplasmosis is the most requent cause fungal respiratory infect spectrum of cial manifest from asellmted, acute flu 2 progressive dsseminat Ie-thretening. ives in decaying bid 9. alngs and ‘at gua + Patents with acquired immunodetces syndrome (D5) or nmunosupressive necrosis factor dserinated inf Microbiology ag, indudng wor itor, ae predsposed to the mycelial form + The mycla produce two size of coniio— micro and ma ght induce disease because they are sll enough to reach the bronchioles and alec, + Conversion to the yeast phase is criven by temperature Diagnosis + Serclogy is useful fr al ut ADS patents omplerent-fxation Sters of 1:32 or greater of the H immunodiffusion band signifies active disease, An M band does iminate + The Histoplasma antigen test either from urine 3 serum particularly useful in agnosis of extrapulmonary seas, tis also useful following response to therapy + Tissue and buty coat ex tion s wef or detecting the orgarism, «+ See Table 265-2 for diagnostic tests. Therapy + Pulmonary histoplasmosis: mild to moderate— no treatment or tvaconazole 200 mg 3 tines dally fllowed by 200 mg twice a day for 6 to "2 weeks; moderate to severe— iid formulated amphotericin 8,3 to 5 maykg or deoxycholate amphotericin 80.7 t01 mak, for to 2 weeks followed by ivaconazle for total of 1010 11 weeks caitay— itraconazole as desorbed above + Disseminated disease: moderate to severe— Same as moderate to severe pulmo dlsease; in chien can use deo hotercn 8,1 mga for 4 to wees. + Rheumatlogi manifesations—nonsterodals + Mesiasinalhmphadenits—no treatment o if smpromatic traconazole as deserbed + See Table 265-3 for treatment options Prevention + Prophais for immunosuppressed patients— se 200 rg dally tin sites, spelunking, ied homes oF farm + Avoid const Histoplasma capsulatum i one ofthe more common causes of infection sn the US. Midwest and Southeast. Histoplasmosis, acquired by inhala sion of mycelial fragments and microconida, i most often self limiting bbut can eause potentially lethal infection in patents with preexisting conditions. It remains a frequent cause of opportunistic infection in patients whose immune system i impaired by pharmaceutic agents oF by the human immunodeficiency virus (HIV). is accelerating trend {5 unlely to abate because the reservoir of H. capsulatum (soi) vail newer disappear. HISTORY. the discovery of FL capsulatum was made in December 1905, when Samuel Darling, a pathologist stationed in Panama, examined viscera \Gesuce and bone marross from a young man from Martinique whose death was originally attributed to miliary tuberculosis’ Peering rough his microseupe, Darling was struck by the presence of many small bodies, most of which were intracellular aving been indluenced by reports (rom Leishman ara Donovan, he mistakenly thought that this organism was a protozoan. Becaure lacked akinetoplat, Dasling assumed that st was a different Leishmania species. He termed this pew species Histoplasma capsulatum because it seemingly exhibited a capsule. Iewas not until 1912, after reviewing tissue specimens, thst da Rocha-Lima suggested thal the organism resembled a yeast rather than a protozoan.” More than 20 yeas later, the organism was finally iso Tated on artificial medium and observed to grow a# 8 meld al room demperstare and asa yeas at 37°C. or many years, the presence of pulmonary caleifications had become synonymous with healed tuberculosis by physicians. Amos Christi, pediatrician at Vanderbilt University, spelled that dictum, ‘The presence of cutaneous reactivity to a skin test reagent, prepared from the mycelial phase of the organism, in an infant with dissemnt- pated histoplasmosis prompted large-scale testing during the 1930s, This endeavor unearthed the surprising finding that histoplasmosis was highly prevalent inthe Ohio and Missisipps River Valleys. More lover, many cafet of presumed tuberculosis that were based on the presence af calcified nodules on chest roentgenograms were deter mined to be histoplasmosis instead Eventelly, many indiidvale residing in tuberculosis sanatorium inthe midwestern and southeast. xn United States were recognized to have been mistakenly admitted. They suffered feom histoplasmosis, act tuberculosis, Some of these individuals contracted tuberculosis while housed in apen wards ith patients who had active pulmonary tuberculosis ECOLOGY AND EPIDEMIOLOGY Cases of histoplasmosis have been reported from every continent xcept Antarctien H. capsulatum i a sol-based fangus that has been tsolaed from many regions of the wotld and is most ofien associated vith er valleys; mentioned above, the most highly elem region isthe Ohio and Mississippi River Valleys (Pig. 263-1). Ihe conditions that favor the growth ofthis fungus in soil are a mean temperature of 22" to 29°C, an annual precipitation of 35 to 50 inches, and a relative humidity of 6796 to 87%. These conditions are typealy found in the temperate zone between latitudes 45 degrees north to 30 degrees south, The organism is usually found within 20cm ofthe surface, and it prefers soll that is acidic, has a high nitrogen content, and moist. In areas where aviane rooet, the fungus ie found mort often where the fuano is decaying and mixed with soll" Tn such areas, infectious par Ules can exceed 10"/g of soi Frech guano is lse likely to contain any infectious particles. There isa strong association between the presence of bird and bat guano and the presence of H. capsulatum. Infact, the 2949KEYworps. acquired immunodeficiency syndrome (AIDS); amphotericin, antigen detection: azols; disseminated infection: histoplasmosis: smmune response; lung; mycoses; pathogenesis; tumor necrosis factor (ENF). inhibitors 2949.1 (ssousedorsn) wmeisae> eusedonen §8z se deyPart Ill Infectious Diseases and Their Etiologic Agents 2950 HISTOPLASMIN Hed2 1100 Reactions 4 mm+ Tuberculosis Program U.S, Publle Health Service FIGURE 265-1. Histoplasmin reactivity 275,558 Navy Recrats "988-1965, white malas 17-21 years in the continental United States among naval recruits 10m Edwards L8, Acquaviva FA Livesay VT fetal An atlas of sensu fo tuberculn, PPD, and histoplasmn in the United States em Rev Besar Ds. 1968;99-1-111) {ies isolation of the organism from an environmental source was from an area adjacent to chicken house. Birde are not infected by the fangus, and attempts to isolate HL. capsulatum from theit cloaca have ‘been unsuccessful. Bats, on the other hand, cary the fungus in their ‘gastrointestinal tacts and shed it! ‘Disruption ofthe soil by excavation or construction is one of the ost common means of releasing infectious cements that ae inhaled and eventually sete into the lungs, Those involved in recreational or ‘work activities that expose them to disrupted soil ae at highest risk for infection, Persons at rsk include spelunkers who roam eaves where bats reside and those who are engaged in agriculture, outdoor con- struction, of rehabilitation of buildings that have been inhabited by birds or bats, Human-to-human transmission va the pulmonary route Ihae not been reported, 'H. capsulatum contains between five to seven chromosomes Dif {erences in numbers of chromosomes are evident among strains. Origi- rally, the organism could be distinguished by two chemotypes, but the advent of molecular biology has improved methods to distinguish strains of HL. capsulatum. Fight clades of this fungus have bees ide lied sing molecular analysis’ —twro North Ametiean, fo Latin American, and one each of Australian, Indonesian, Eurasian, and “African clades, The spread of this fungus appears lo have originated ‘rom Latin America between 3 and 13 million yeats ago, Interestingly, many ofthe isolates recovered from aequired immunodeficiency sy drome (AIDS) patients in St Louis were found to be in clade 1, and these isolates are mut less virulent in mice. Genetic diferences can bbe associated with varied clinical manifestations. 11. capsulatum from specific regions of South America often produce ski lesions, whereas ‘folate from North America do not. The findings svggest that 7. ‘aprulatum ie highly diverse atthe genetic level, perhaps bared on the fact that the fungus undergoes sexual recombination in nature thus allowing fr exchange of genetic material. “The impact af histoplasmosis on health care costs is not precisely known because i s# not a reportable disease. Estimates for the year 2002 indicate that the median hospitalization costs were $20,000 and $17,000 for children and adults, respectively. ‘The in-hospital mortality rate was 5% for children and 8% for adults, Only 14% of adults who ‘were hospitalized were immunosuppressed, whereas a third of children were” Another analysis of mortaty spanning the years 1980 to 1997 demonstrated thatthe incidence of morality in he United States from histoplasmosis ranged from 0.1 to 015 per 100,000 population.” Earlier data indicated that disease develops in males more frequently than in females by a 4:1 rato. Uhis information was likely skewed because ofthe asociaton of chronic pulmonary histoplasmosis with smoking that for many yeare was a male-dominated activity. But that gender bias has not heen observed in secent years mycotocy—— HL capsulatum is classified as a member of the famally of Ascomycetes and har a heterothalc form designated Ajellomyees capaultunn (see ‘Chapter 257), Mating types (+) and (~) have been described and, when ‘combined onto sporulating medium, they produce fciting bodies con. taining ase Isolates from patents carry the (-) mating type two to seven times more frequently than the (+) type although the ratio of ‘mating types in soil 11." ‘The organism has lwo morphotypes, the mycelial and yeast phases, “the former ie present at ambient temperature and the later at 37°C or Inigher. The saprobie or myeclial phase can he dived inte wo colony types, brown (B) and albino (A). The A type grows more rapidly in culture and loss the capability to produce spores after prolonged sub. cltoring. The B type generates a brown pigment. Yest cells fom the B type are more virulent in mice than those from the A type. “The basic elements of the nutritional needs of the organism are poorly defined because of the lack of a standardized medium. ‘The ‘organism requires vitamins, thiamine, biotin, and iron. Sullhydeyl groups in the form of cysteine or cystine are necetsary for growih and maintenance ofthe yeast phase. The mycelial and yeast phases {fer in their requirements for calcium, Chelation of this elementFIGURE 265-2 Mycelial phase of Histoplasma capsulatum. Scth rmacroconicia and mitraconda ae evden? FIGURE 265-3 Yeast cells of Histoplasma capsulatum a section of liver. (Gomori methenamine sive, x1000) from medium inhibits the growth of the mycelial but not the yea phase” “Microscopic evaluation ofthe mycelial phase reveals two types of «conidia. Macroconidia are large ovoid bodies that span 8 to 15 jm in iameter. Ihe surface is decorated with slender protrusions that are referred to as tuberculate, Mieroconida are small, smooth eval bodies witha diameter ranging ftom 2 to 5 um (ig. 265-2). These forms are believed tobe the infective phase because thelr size is small enough to lodge inthe terminal bronchioles and alveoli, “The transition from the saprobic tothe yeast phase i a ciical step sn ingectivity ofthe fungus. On exposure to 37°C, the organism under. gocs genetic, biochemical, and physical alterations that result in the production of yeast cells that are uninuceate. These forme are smal, {ypically 2 to 5 jim in diameter, and reproduce by mulipaar budding (Fig. 265-4). The stimulus forthe wansition is heat, and the shift n Kemperature may be sensed by a change in the fluidity of the yeast ‘membrane. Analysis of the conversion using microarrays has revealed numerous alterations in gene expression, The shill was associated ‘ith induction of genes contributing to conidiaton, cell polarity, and melanin,” Using insertional mutagenesis, a transcription factor termed Rypl has been found tobe estential for growth of yeast cells 37°C. Tm addition, two other genes, Ryp2 and Ryp3, that are crucial forthe gansition have been identilied. Hence, there is a complex regulatory network that dictates the conversion to yeast cell upon an elevation sn temperature.” Three biochemical stages have been identified during the conversion following exposure to 37°C. Stage 1 is characterized by an uncoupling of oxidation: phosphorylation and a decrease in RNA nd protein synthesis In stage 2 n0 respiration is detectable, and in ‘age 3 there isa resumption of respiration, Chitin and a- and B-ghucan content difer Between the two phases 2351 ‘Win auc, yen els may possess a morphology th es fiom the wal ved shape. Mistapen or Inge Yents have beet oterved i sues ad epithelia lis Theeallomerphs may contain Ics et glean and appen oe let arent mice sn ot shaped years, g : PATHOGENESIS. “he stu ofthe pathogenci of hi ngs has accelerated ae arelt af technologie abance, ncn a tansformation system to delete = fenessleneing BNA an eral agenesis wong Aobte & Flom tumefaciens These loos create the foundation for examining the inthence of genes or gene regulators on the pathobiology of 8 gz 5 5 3 H capsulatum “The transition from the mycelial othe yeat phate isthe most cit cal determinant in the xtalishment of mfection "This contention ts supported by several findings, Furs, tie rare to find mycelial particles in tssues of humans or mammals with established infection. Rather, ‘yeast cells are commonly detected. Second, exposure of H. capsulatum riyclia to p-chloromercuriphenylsulfonie aid (PCMS), a suldhydry inhibitor, sreversibly blocks the conversion to yeasts but does not alter growth of yeasts or mycelia PCMS.treated mycelia fall to infect animals tron and zinc are vital cements required for survival of 1. capsu- laturn The oxganism acquires iron trom the intracellular environ~ ‘ment by thtce means release of iron scavenging siderophores, production ofa ferric reductase, and modulating pH to remove iron from iranserrin, 0-1.3-Glucan har been found (o be a key virulence factor in the pathogenesis of FE. capsulatum.” Synthesis ofthis carbo hydrate, which is regulated by an amplase, locks B-glucan binding to Dectin-1 and thereby supprestes generation of important proinflam- matory cytokines “After conidia setle into the alveoli, they bind to the CD11-CD18 family of integrins and are engulfed by neutrophils and macrophages.” Wis bkely chat the conversion of myelia to the yest phase transpires, ax east partially not entirely, inteacllularly The duration ofthe phase loansition ranges from houre to days. Following transformation of conidia into yeast in the hungs, yeaste migrate, presumably intrace- Iulary, to local draining lymph nodes and subsequendy to distant organs rich in mononuclear phagocytes (eg. liver, spleen) The yeasts row within resting macrophages, Activation of clllae immunity 1 ‘ecesary for resiricing growth, and in primary infection thie arm of immunity matures by 2 weeks Innate Immunity Inexperimental pulmonary infection, neutrophils constitute one of the ‘prominent cell populations that emigrate carly into infected fct of Tungs-" These ells are capable of inhibiting the growth of yeast cells. (Constituents from the arcrophiic rantles express fngistaie acity, and defensins also inhibit the growl of yeast cells." Neutrophiis ‘mount a respiralory burst in response (o the fungus, but the oxygen intermediates are trapped intracellularly: Despite the burst, there Iitde evidence that toxic oxygen intermediates contribute tothe ant “Histoplasma activity of thee phagocytes. Resistance to there molecules is mediated in large past by superoxide dismutase 3, a copperfeine- dependent enzyme.” ‘Macrophages and dendritic cells are the principal efector cells in thos resistance to this fungus.” The fate of yeast cll in each ofthese cell populations differs. Yeasts proliferate within resting mononuclear phagocytes, bu this form is killed by dendritic cells. As noted, macro- [phages engulf yeast via CDI1-CD18 receptors, whereas dendritic cells lse the fibronectin receptor. Engagement of two disparate receptors ‘may explhin in part the different fates within these cll populations “The central importance of monocytes or macrophages, of both, controlling 11 capsulatum i bighlighted by the discovery of individ als with congenital monocytopenia who present with disseminated histoplasmosis” In murine macrophages, a high percentage of yeast cll are located within phagolysosomes. Binding to the CD11-CD18 receptors and subsequent entry into human macrophages are mediated by heat shock ‘protein 60 expressed onthe surface of yeast.” The fungus must castend with the adverse contents (eg, acid proteinases) of this intenselyPart Ill Infectious Diseases and Their Etiologic Agents 2952 hostile environment. A mechanism whereby yeasts survive is by alka- linization of the phagolysosome.” Year els raise the pH of the phago- cyte compartment irom to 65. One reason for maintaining the pH. ‘within a narrow range is that yeast cells require iron to grow and, if the pH exceeds 65, they cannot acquire ion from the host = ‘Nilic oxide produced by activated murine macrophages is a major mediator of ants Histoplasma acuity The abiity ofthis nitzogeninter- ‘mediate to oxidize iron may explain its potent fungicidal activity.” However, its influence in human infection remains unknown because Jhuman macrophages infected with H, capsulatus have not beet reported to produce nitric oxide Macrophages from HIV-infected individuals manifest defective activity in thei interaction with IT, capsulatum. These cells bind ewer yeasts than cells fom uninfected individuals, and a direct correlation txsts between the C4 T-cell count and the apacity of macrophages tobind yeast call. On entey into cells, yeasts grow more rapidly within macrophages from HIV snfected sndiidls of in macrophages that Ihave been infected in vito with a macrophage-tropic stain of HIV. ‘The envelope glycoprotein 120 feom the virus is responsible for the inhibition of binding yeasts to macrophages” but not the alkeed ‘owt characteristics ofthe yeasts in phagocytes. Adaptive Immunity ‘Within the elements of the acquired immune response, T ells ate pivotal in clearance ofthe fungus. Experimental studies indicate that ether B cells nor anubosles influence host resistance although the data are limited. CD cells are extemely important in controlling primary infection in mice." The central role of this T-cell subset inthis species is supported by the finding tha in HIV-infected individuals, most cass of histoplasmosis develop when the CDA cell count slower than 200/jum.* Mice defiientin CDS" celle impaired in het ability to reduce the fungal burden, but they can eventually eliminate the fungus." Vaccination of mice with yeast cells gives riseto a CD8'TL-17" ‘Tell population that confers protective immunity ‘The outgrowth of ‘this population provides an adlitiona arm to adaptive immity that «an combat infection.” In secondary infection, the absence of CDS" or CCDS" cells diminishes the efficiency of yeast elimination, but mice survive. The loss of protective immunity only develops when both subsets are eliminated “The primary contribution of T cells to host defense i the release of| cytokines that eventually acivate mononuclear phagocytes. Neutzl- ination af endogenous intrferon-y (TEN-y) or mice congenitally def- cient in this lymphokine are exceptionally susceptible to infection.” Other cytokines in mice that are necessary for host learance are inter- leukin (1-12 and tumor necrosis factor-a. (TNF-0). Blockade of endogenous production of either of these leads tothe death of mice. “The effect of 1-12 is mediated through the induction of TFN." Inte- cstinly I-12 important in primary infection but notin reexpostre histoplasmosis." TNF-a: and IEN-y ae both necessary for coatrlling ‘primary infection, and the formers required for secondary infection” ‘Their importance in humans has been highlighted by the nding that ‘TNF antagonists or indvidals with defective LEN sgnaing manifest an enhanced susceptibility to disseminated infection 1 vito, recombinant TEN-y activates mutine peritoneal macro- phages to inhibit the growth of yeast cells. Macrophages from other Ussue sources are elther nonresponsive to this stimulus of requre costimulation with ipopolysaccharide” The ant-Fstopiasma action of TEN-yis mediated by limiting iton acquisition, and this effet can bo reversed by exposure to aitional iron.” Human macrophages, ob the other hand, do not respond tohuman recombinant IEN-Yto inhibit yeast cell growth" The eytokines that activate these eels axe macro- Phage colony-stimulating factor, granulocyte-macrophage.colony- stimlating. factor, and. 11-3." Granulocyte macrophage colony stumlating factor appears to inhibit intracellsar growth of yeast cells by limiting access to nine in phagosomes." Although the infection is limuted by cell mediated immunity tasues are not sterlzed. Infected individuals contain yeasts, some of which remain viable for many years The dormant organisms pose ite risk wnless the individual ‘becomes immunosuppressed at 2 result of potent smmunosuppresive agents used to combat various clinical conditions or immunosuppres- sive viruses such as HIV. The metabolic state of HL. capsulatum in JURE 265-4 Granuloma in the lung of a patient with histoplasmosis. tissues is unknown. I lkely that some of the yeasts remain viable because individvals whe have moved from endemic to nonendemic areas many years ago may have reactivated infection. The caseade of {immunologic events tha leads to activation of this form ofthe infec- tion remains largely unknown, A murine madel of reactivation histo plarmosie has been developed, and st shotld faiktate studies of the ‘organism and the host in this form of infection. Ip mice, CD4”, CDS, sand a Thy-12, CD4, CD¥ cell must be eliminated to achieve progres five infection. B cells alko appeat to be important in the severity of reactivation disease, Granulomas "The hallmark of the tissue response to thi fungus is the development ‘of easeating of noncaseating granslomas in which calcism may be deposited (Fig. 265-4). The granuloma consists of an admixture of ‘mononuclear phagocytes and lymphocytes, principally T cells. The putative function of the granuloma is to contain fungal growth. ‘Although IPN-y and TNE-c.are important i the generation of granu- Jomas formed in response to other microbes, neutralization of these ‘oro cytokines does not prevent their formation in response to IL. cap- sulatum. The organization of the Histoplasma granuloma has been characterized im mouse livers and lungs, CD4" and CD&" eels are present in the granulomae of mice. T-cell composition is polyclonal, and these cells are the source of IFN-yandT1-17, whereas macrophages {re the principal source of INE-c.”™ Orginized granulomatous silammation is typically observed in, self mited disease. Conversely in progressive disseminated histoplas: ‘mosis, the more common histopathologic appearance of tissue is a massive influx of macrophages with scattered lymphocytes, Well: circumscribed granulomas ae infrequently present, and the lack of an ‘organized inflammatory response is indicative of a perturbed cellular ‘immune response, Occasionally. the inilammatory eepanse in medi- astinalIymph nodes is exaggerated, resulting in excessive grancloma ormationfellowed by fibrosis. The progressive scarring may allect the patency of the airways and major biood vessels.” Delayed-type Hypersensitivity In experimental infection, either cutaneous or in vitro delayed-type Ihypertensitivity responses to 17 capsulatum antigens are detected approximately 2 weeks afer exposure” Th humans, delayed-type hypersensitivity responses are manifest within 3 to 6 weeks aftr expo- sure.” These values are simply approximations because the precise time at which individuals are exposed in endemic areas is exceptionally Siiclt to determine. Reexposure to H. capsulatum in previously sen sized individuals is characterized by a more rapid issue response “Thisfinding isnot surprising because H. capsulatu induces amemory response in which the immune sytem Feats ina much shorter time frame Tafection with 1. capsulatum produces abroad array of clinical and pathologie manifestations that must be recognized to diagnose and