- Email: [email protected]
Histoplasmosis in Malaya, oro-pharyngeal and disseminated: Treatment with amphotericin B
92 TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE.
Vol. 60.
No.
1.
1966.
HISTOPLASMOSIS IN MALAYA, ORO-PHARYNGEAL AND DISSEMINATED: TREATMENT WITH AMPHOTERICIN B BY J. T. PONNAMPALAM AND G. KUMAR*
From the Department of Bacteriology, Institutefor Medical Research, and the General Hospital, Kuala Lumpur, Malaya Histoplasmosis has been described as a world-wide disease. Most of the cases have been reported from the United States of America, but some have been reported in England (SYMM~RS, 1961) in persons who had recently returned from abroad, and the disease has been recognized in Australia, Indonesia and South Africa. A case of pulmonary histopiasmosis was described in Malaya (Pom~aMPAL~, 1964) and the only recorded isolation of Histoplasma capsulatum from soil in Asia was from a cave infested with bats in Central Malaya (PorzNAMP~AM, 1963). 2 cases are described in this paper, bringing to 3 the total number proved in Malaya by the isolation of the organism on culture. Greater awareness of the disease may bring others to light. Case I. A male Chinese aged 63 years was seen at the out-patient depaxia,ient of the general hospital, Ipoh, North Malaya, with a chronic ulcer of the tongue of several months' duration. A preliminary diagnosis of squamous carcinoma was made and a biopsy specimen of the tissue was sent to the Institute for Medical Research for histological studies. Sections stained with haematoxylin and eosin showed numerous yeastlike cells lying scattered among chronic inflammatory cells, giving the appearance o f a granuloma, but there was nothing to suggest neoplasia. The specimen was referred to this department so that attempts could be made to culture the fungus from fresh biopsy tissue. Small portions of the tissue were inoculated into Petri dishes of Sabouraud's dextrose agar containing chloramphenicol in a concentration of 200 units per ml. and left at room temperature after *_he edges of the Petri dishes had been sealed with wax to prevent drying of the medium. 10 days later a small white colony with short aerial mycelium was noticed. Examination of a mount in lactophenol blue revealed the presence of large tuberculate cblamydospores characteristic of H. capsulatum. The fungus reverted to the yeast phase on repeated subculture on to blood brain heart infusion agar maintained at 37°C. over about one month. This patient was offered treatment and further investigation but refused. Case II. A male Chinese patient aged 39 years had been a rubber tapper since childhood. He had lived at the estate for more than 20 years, rearing poultry and ducks during his leisure time. *Our thanks are due to the Medical Officer, General Hospital, Ipoh, who sent the biopsy specimen of the first patient; Mr. K. L. /_,am, Ear, Nose and Throat Surgeon, General Hospital, Kuala Lumpur, under whose care the second patient was admitted; and to Messrs. Lira and DhiUon for the photographs.
J.
T.
PONNAMPALAM
AND
G.
93
KUMAR
He first consulted his general practitioner in December 1962 with cough which had lasted for a year; the sputum was mucoid and yellow, but there was no haemoptysis at any time. There was no family history of tuberculosis, neither did the patient suffer from the disease. He received symptomatic treatment for the cough, which cleared. He subsequently noticed soreness of the mouth and throat, with pain in the left leg and toes for a month. The oral lesions showed no improvement with treatment, and as his general condition was deteriorating he was referred to the Ear, Nose and Throat Department of the General Hospital, Kuala Lumpur. On examination there was profuse salivation with difficulty in swallowing. The entire oral cavity showed marked ulceration particularly over the palate, with scattered haemorrhagic areas and sloughing (Fig. 1). The nasal septum also showed similar changes. Raised nodular patches were noticed on the body and both arms (Fig. 2). ~
ii~
~
•"
~ i ~ ~
~
~i~i!~i~i~ii!~!i i~;zii~iiii;;i!!i~ ~ii~!il
,!~!~i~;~ii!!!~ ¸
~,~
"
;~: ]iii!iii~)!~ ~
•
: ~i~i' ~ ~;~!~
iii ii iii¸' ~,~
~ ~~ z . . . .
i
~!~!~!!~~ ~~i~L~il iii!~,~,~,~,,~¸ ,~ ~z~¸i~!iiii~¸i~¸ili!¸¸¸ii!i!i ~i~i!~
j,
FIG. 1. Oral lesions in Case 2 from which Histoplasma capsultaum was isolated.
~:;~ FIG. 2. Nodule on skin from which H. capsulatum was isolated.
94
HISTOPLASMOSIS, TREATMENT WITH AMPHOTERICIN B
There was a deep fungating ulcer on the left foot between the hallux and second toe. The liver and spleen were not palpable and nothing else of significance was noted. The blood picture was within normal limits. No bony lesion was seen on X-ray of the foot. X-ray of the chest showed bronchiectasis affecting both lower lobes. A biopsy specimen was taken of an ulcer in the hard palate. The pathologist reported that the material consisted of inflammatory granulation tissue with large numbers of yeast-like bodies, and suggested that a culture should be made in order to isolate the fungus. A repeat biopsy was carried out after admission of the patient to hospital. Attempts were made to culture the fungus by direct inoculation of small pieces of the tissue on to Sabouraud's medium containing chloramphenicol in a concentration of 200 units per ml., and by indirect culture after mouse passage. This was done by grinding the tissue in a mortar with sterile sand, making a suspension of this in normal saline and inoculating 1 ml. of the resulting fluid intraperitoneally into each of several white mice. The animals were killed at intervals of one week from the 2nd to the 7th week. The livers and spleens were pooled and finely ground in a mortar with sterile sand, and inoculated on to Sabouraud's dextrose agar. The Petri dishes were sealed and the cultures left at room temperature. After varying periods from 10 to 14 days small fluffy fungus colonies made their appearance and were identified as H. capsulatum from the presence of the large tuberculate chlamydospores. The yeast phase of the organism was demonstrated by serial subcultures on to brain heart infusion agar containing 10% blood, incubated at 37°C. Direct culture of the pieces of biopsy tissue were contaminated and the fungus was not isolated. Biopsy of one of the skin nodules on the forearm grew H. eapsulatum on direct inoculation on to Sabouraud's agar. No specimen was taken from the ulcer on the foot. The complement-fixation test for histoplasmosis, done on 27 November 1963 before treatment with amphotericin B, gave the following results: histoplasmin (mycelial phase) negative histoplasmin (yeast phase) positive (1 : 16). The histoplasmin skin test was not done as it was considered that this might interfere with subsequent complement-fixation tests if the skin test became positive. Treatment with amphotericin B was begun on 21 December 1963. The recommended dose is 1 rag. per kg. body weight, but the patient was started on one-quarter of the recommended dose, which was calculated to be 12.5 rag. amphotericin B in 500 ml. of 5% dextrose, given intravenously over a period of 6 hours. This was repeated on alternate days. 10 rag. Piriton (chlorpheniramine) and 20 nag. hydrocortisone were introduced into the infusion to reduce any side effects, e.g., rigors, pyrexia, headache. The drug was given into each arm alternately. Blood urea estimations were started on the day after intravenous therapy. On 10 January 1964 the amphotericin B was increased to 0"5 rag. per kg. body weight. This was continued for a week and then increased to 0.75 nag. per kg. and finally to the recommended dose of i mg. per kg. body weight, which he was receiving on 20 January 1964. Treatment was continued with this dose on alternate days until 10 May 1964, two days before discharge. The only side effects noticed were rigors, during which the body temperature was raised to 102°F., the temperature returning to normal ½-1 hour after the transfusion was discontinued and the patient had received his dose of the drug for the day. The blood urea was in the region of 38 rag. % after the first dose of amphotericin B, but subsequently settled to 15-20 rag. %.
J. T. PONNAMPALAM AND G. KUMAR
95
On 23 March 1964 the complement-fixation test with yeast-phase and mycelialphase antigens was negative. At the time of discharge the oral (Fig. 3) and skin lesions, as well as the ulcer on the foot, had healed and his general condition had improved. He had received ampho-
Fro. 3. Roof of mouth showing complete healing of lesions following treatment with amphotericin B. tericin B for a period of 4 months xn a total dose of nearly 2,800 mg. A repeat biopsy of the palate still showed the presence of yeast cells. Culture for the fungus was not done before discharge at the end of March 1964. On 26 June of the same year, 2½ months later, he was re-admitted to hospital for review. A small ulcer was noticed in the posterior pharyngeal wall. A swab from this ulcer grew H. capsulatum. Blood for complement-fixation test with mycelial-phase and yeast-phase antigens was negative. He was given a further course of amphotericin B, receiving 18 doses of 50 mg. each on alternate days. A repeat biopsy of the palate on 8 September 1964 showed the absence of yeast cells, and the culture was negative for H. capsulatum. He was discharged home on 31 September 1964. The total dose of amphotericin B received during the second course of treatment was 900 mg. No attempts were made to culture the fungus from the sputum. Discussion
SALIBA and BEATTY (1962) treated 22 patients suffering from the deep mycoses with amphotericin B over a period of 2{ years; treatment was of some benefit in most cases of histoplasmosis. They observed toxic reactions of varying degrees in all cases after the institution of amphotericin B; the commonest were headaches, thrombophlebitis and, less commonly, malaise and vertigo. They found a great decrease in toxic reactions when 20 mg. of hydrocortisone was added to the infusion; no side effects were noted from the prolonged use of hydrocortisone. There was no alternative but to treat this patient with amphotericin B, without which the prognosis would have been hopeless. With the addition of Piriton and hydrocortisone, side effects were reduced to a minimum. Although the complement-fixation test was negative on 2 occasions, and the last
96
HISTOPLASMOSIS~ TREATMENT WITH AMPHOTERICIN B
culture was negative for 11. capsulatum, the possibility of recurrence must be borne in mind in the ultimate prognosis. This patient received a total dose of 3,700 nag. of amphotericin B over a period of 10 months and side effects were minimal in spite of the large dose of drug administered.
Summary 2 cases of histoplasmosis are described; one with disseminated disease, was treated with amphotericin B. This drug appears to be of definite value in the treatment of disseminated histoplasmosis, and is the only effective drug available at the moment. REFERENCES PONNAMPALAM, J. T. (1963). Amer. J. trop. Med. Hyg., 12, 775. (1964). Med. J. Malaya, 18, 201. SALmA, A. & BEATTY,O. A. (1962). Dis. Chest, 41, 214. SYMMERS~W. ST. C. (1961). Trans. R. Soc. trop. Med. Hyg., 55, 209,
Vol. 60.
No.
1.
1966.
HISTOPLASMOSIS IN MALAYA, ORO-PHARYNGEAL AND DISSEMINATED: TREATMENT WITH AMPHOTERICIN B BY J. T. PONNAMPALAM AND G. KUMAR*
From the Department of Bacteriology, Institutefor Medical Research, and the General Hospital, Kuala Lumpur, Malaya Histoplasmosis has been described as a world-wide disease. Most of the cases have been reported from the United States of America, but some have been reported in England (SYMM~RS, 1961) in persons who had recently returned from abroad, and the disease has been recognized in Australia, Indonesia and South Africa. A case of pulmonary histopiasmosis was described in Malaya (Pom~aMPAL~, 1964) and the only recorded isolation of Histoplasma capsulatum from soil in Asia was from a cave infested with bats in Central Malaya (PorzNAMP~AM, 1963). 2 cases are described in this paper, bringing to 3 the total number proved in Malaya by the isolation of the organism on culture. Greater awareness of the disease may bring others to light. Case I. A male Chinese aged 63 years was seen at the out-patient depaxia,ient of the general hospital, Ipoh, North Malaya, with a chronic ulcer of the tongue of several months' duration. A preliminary diagnosis of squamous carcinoma was made and a biopsy specimen of the tissue was sent to the Institute for Medical Research for histological studies. Sections stained with haematoxylin and eosin showed numerous yeastlike cells lying scattered among chronic inflammatory cells, giving the appearance o f a granuloma, but there was nothing to suggest neoplasia. The specimen was referred to this department so that attempts could be made to culture the fungus from fresh biopsy tissue. Small portions of the tissue were inoculated into Petri dishes of Sabouraud's dextrose agar containing chloramphenicol in a concentration of 200 units per ml. and left at room temperature after *_he edges of the Petri dishes had been sealed with wax to prevent drying of the medium. 10 days later a small white colony with short aerial mycelium was noticed. Examination of a mount in lactophenol blue revealed the presence of large tuberculate cblamydospores characteristic of H. capsulatum. The fungus reverted to the yeast phase on repeated subculture on to blood brain heart infusion agar maintained at 37°C. over about one month. This patient was offered treatment and further investigation but refused. Case II. A male Chinese patient aged 39 years had been a rubber tapper since childhood. He had lived at the estate for more than 20 years, rearing poultry and ducks during his leisure time. *Our thanks are due to the Medical Officer, General Hospital, Ipoh, who sent the biopsy specimen of the first patient; Mr. K. L. /_,am, Ear, Nose and Throat Surgeon, General Hospital, Kuala Lumpur, under whose care the second patient was admitted; and to Messrs. Lira and DhiUon for the photographs.
J.
T.
PONNAMPALAM
AND
G.
93
KUMAR
He first consulted his general practitioner in December 1962 with cough which had lasted for a year; the sputum was mucoid and yellow, but there was no haemoptysis at any time. There was no family history of tuberculosis, neither did the patient suffer from the disease. He received symptomatic treatment for the cough, which cleared. He subsequently noticed soreness of the mouth and throat, with pain in the left leg and toes for a month. The oral lesions showed no improvement with treatment, and as his general condition was deteriorating he was referred to the Ear, Nose and Throat Department of the General Hospital, Kuala Lumpur. On examination there was profuse salivation with difficulty in swallowing. The entire oral cavity showed marked ulceration particularly over the palate, with scattered haemorrhagic areas and sloughing (Fig. 1). The nasal septum also showed similar changes. Raised nodular patches were noticed on the body and both arms (Fig. 2). ~
ii~
~
•"
~ i ~ ~
~
~i~i!~i~i~ii!~!i i~;zii~iiii;;i!!i~ ~ii~!il
,!~!~i~;~ii!!!~ ¸
~,~
"
;~: ]iii!iii~)!~ ~
•
: ~i~i' ~ ~;~!~
iii ii iii¸' ~,~
~ ~~ z . . . .
i
~!~!~!!~~ ~~i~L~il iii!~,~,~,~,,~¸ ,~ ~z~¸i~!iiii~¸i~¸ili!¸¸¸ii!i!i ~i~i!~
j,
FIG. 1. Oral lesions in Case 2 from which Histoplasma capsultaum was isolated.
~:;~ FIG. 2. Nodule on skin from which H. capsulatum was isolated.
94
HISTOPLASMOSIS, TREATMENT WITH AMPHOTERICIN B
There was a deep fungating ulcer on the left foot between the hallux and second toe. The liver and spleen were not palpable and nothing else of significance was noted. The blood picture was within normal limits. No bony lesion was seen on X-ray of the foot. X-ray of the chest showed bronchiectasis affecting both lower lobes. A biopsy specimen was taken of an ulcer in the hard palate. The pathologist reported that the material consisted of inflammatory granulation tissue with large numbers of yeast-like bodies, and suggested that a culture should be made in order to isolate the fungus. A repeat biopsy was carried out after admission of the patient to hospital. Attempts were made to culture the fungus by direct inoculation of small pieces of the tissue on to Sabouraud's medium containing chloramphenicol in a concentration of 200 units per ml., and by indirect culture after mouse passage. This was done by grinding the tissue in a mortar with sterile sand, making a suspension of this in normal saline and inoculating 1 ml. of the resulting fluid intraperitoneally into each of several white mice. The animals were killed at intervals of one week from the 2nd to the 7th week. The livers and spleens were pooled and finely ground in a mortar with sterile sand, and inoculated on to Sabouraud's dextrose agar. The Petri dishes were sealed and the cultures left at room temperature. After varying periods from 10 to 14 days small fluffy fungus colonies made their appearance and were identified as H. capsulatum from the presence of the large tuberculate chlamydospores. The yeast phase of the organism was demonstrated by serial subcultures on to brain heart infusion agar containing 10% blood, incubated at 37°C. Direct culture of the pieces of biopsy tissue were contaminated and the fungus was not isolated. Biopsy of one of the skin nodules on the forearm grew H. eapsulatum on direct inoculation on to Sabouraud's agar. No specimen was taken from the ulcer on the foot. The complement-fixation test for histoplasmosis, done on 27 November 1963 before treatment with amphotericin B, gave the following results: histoplasmin (mycelial phase) negative histoplasmin (yeast phase) positive (1 : 16). The histoplasmin skin test was not done as it was considered that this might interfere with subsequent complement-fixation tests if the skin test became positive. Treatment with amphotericin B was begun on 21 December 1963. The recommended dose is 1 rag. per kg. body weight, but the patient was started on one-quarter of the recommended dose, which was calculated to be 12.5 rag. amphotericin B in 500 ml. of 5% dextrose, given intravenously over a period of 6 hours. This was repeated on alternate days. 10 rag. Piriton (chlorpheniramine) and 20 nag. hydrocortisone were introduced into the infusion to reduce any side effects, e.g., rigors, pyrexia, headache. The drug was given into each arm alternately. Blood urea estimations were started on the day after intravenous therapy. On 10 January 1964 the amphotericin B was increased to 0"5 rag. per kg. body weight. This was continued for a week and then increased to 0.75 nag. per kg. and finally to the recommended dose of i mg. per kg. body weight, which he was receiving on 20 January 1964. Treatment was continued with this dose on alternate days until 10 May 1964, two days before discharge. The only side effects noticed were rigors, during which the body temperature was raised to 102°F., the temperature returning to normal ½-1 hour after the transfusion was discontinued and the patient had received his dose of the drug for the day. The blood urea was in the region of 38 rag. % after the first dose of amphotericin B, but subsequently settled to 15-20 rag. %.
J. T. PONNAMPALAM AND G. KUMAR
95
On 23 March 1964 the complement-fixation test with yeast-phase and mycelialphase antigens was negative. At the time of discharge the oral (Fig. 3) and skin lesions, as well as the ulcer on the foot, had healed and his general condition had improved. He had received ampho-
Fro. 3. Roof of mouth showing complete healing of lesions following treatment with amphotericin B. tericin B for a period of 4 months xn a total dose of nearly 2,800 mg. A repeat biopsy of the palate still showed the presence of yeast cells. Culture for the fungus was not done before discharge at the end of March 1964. On 26 June of the same year, 2½ months later, he was re-admitted to hospital for review. A small ulcer was noticed in the posterior pharyngeal wall. A swab from this ulcer grew H. capsulatum. Blood for complement-fixation test with mycelial-phase and yeast-phase antigens was negative. He was given a further course of amphotericin B, receiving 18 doses of 50 mg. each on alternate days. A repeat biopsy of the palate on 8 September 1964 showed the absence of yeast cells, and the culture was negative for H. capsulatum. He was discharged home on 31 September 1964. The total dose of amphotericin B received during the second course of treatment was 900 mg. No attempts were made to culture the fungus from the sputum. Discussion
SALIBA and BEATTY (1962) treated 22 patients suffering from the deep mycoses with amphotericin B over a period of 2{ years; treatment was of some benefit in most cases of histoplasmosis. They observed toxic reactions of varying degrees in all cases after the institution of amphotericin B; the commonest were headaches, thrombophlebitis and, less commonly, malaise and vertigo. They found a great decrease in toxic reactions when 20 mg. of hydrocortisone was added to the infusion; no side effects were noted from the prolonged use of hydrocortisone. There was no alternative but to treat this patient with amphotericin B, without which the prognosis would have been hopeless. With the addition of Piriton and hydrocortisone, side effects were reduced to a minimum. Although the complement-fixation test was negative on 2 occasions, and the last
96
HISTOPLASMOSIS~ TREATMENT WITH AMPHOTERICIN B
culture was negative for 11. capsulatum, the possibility of recurrence must be borne in mind in the ultimate prognosis. This patient received a total dose of 3,700 nag. of amphotericin B over a period of 10 months and side effects were minimal in spite of the large dose of drug administered.
Summary 2 cases of histoplasmosis are described; one with disseminated disease, was treated with amphotericin B. This drug appears to be of definite value in the treatment of disseminated histoplasmosis, and is the only effective drug available at the moment. REFERENCES PONNAMPALAM, J. T. (1963). Amer. J. trop. Med. Hyg., 12, 775. (1964). Med. J. Malaya, 18, 201. SALmA, A. & BEATTY,O. A. (1962). Dis. Chest, 41, 214. SYMMERS~W. ST. C. (1961). Trans. R. Soc. trop. Med. Hyg., 55, 209,