Progressive disseminated histoplasmosis in patients with acquired immunodeficiency syndrome

I

/ CORRESPONDENCE

PROGRESSIVE DISSEMINATED HISTOPLASMOSIS IN PATIENTS WITH AC UIRED IMMUNO s EFICIENCY SYNDROME To the Editor: The review of 48 cases of progressive disseminated histoplasmosis (PDH) in the acquired immunodeficiency syndrome (AIDS) by Johnson et al (Am J Med 1988; 85: 152-158) was of great interest to us because we, too, are in an endemic area for histoplasmosis and are seeing more cases in AIDS patients. With reference to positive test results that confirmed histoplasmosis in these patients, we would be interested to know which tests were the first to provide such information. As outlined, more than one bipsy or culture may have been positive in each patient, and although bone marrow biopsylculture was the most reliable, it may not have been the most rapid means of establishing the diagnosis. This could, perhaps, give an indication of the most efficacious method in arriving at an early diagnosis. It would also be of interest to know if a case-controlled comparison of similar patients with AIDS but without PDH would clarify whether PDH has an impact on the morbidity and mortality of AIDS.

STEPHENB.PALTE,M.D. DANNYJ. LANCASTER,M.D. STEPHENT. M~LLER,M.D.

University

Tennessee, Memphis Health Science Center 66 North Pauline, Suite 232 Memphis, Tennessee 38105

Submitted

of

September

9, 1988. and accepted November 7, 1988

The Reply: We appreciate the kind words of Dr. Palte and his colleagues. To answer their first question, it is helpful to put our series (Am J Med 1988; 85: 152-158) in historical perspective, dating from 1983 to the present. We have all learned a lot about the diagnosis of fever in patients with AIDS since 1983. In fact, the case definition of AIDS has been changed to include PDH since that time [l]. Whereas we and our clinical laboratory were not accustomed to diagnosing histoplasmosis using bone marrow biopsy or

TABLE I Hisfoplasma

capsulatum

First Observed or Cultured

in 48 patients with AIDS

Procedure

Number

(percent)

Bone marrow biopsy/culture Lung biopsy/culture* Lymph node biopsy/culture Blood smear/culture Skin biopsy/culture

* Includes bronchoscopic

specimens.

observing yeast on a peripheral blood smear in 1983, we are now more experienced with these procedures. This, and the fact that the data in our series were obtained from numerous physicians in Houston and East Texas, should be kept in mind when examining Table I, which shows the procedures that were first diagnostic for PDH in patients with AIDS. On the basis of our most recent experiences, we would suggest histologic examination for Histoplasma capsulatum in the bone marrow, peripheral blood, skin, or lymph nodes, since these procedures are quick and easy. For follow-up of patients being treated, we would recommend blood cultures with the new lysis centrifugation technique, which assists in the isolation of mycobacteria and yeast

PI*

With regard to the second question, we do not have case-control data to analyze the impact of PDH in AIDS. These patients usually have several ongoing processes that contribute to their morbidity and mortality, which makes it difficult to answer this question.

PHILIP C. JOHNSON,M.D. NANCYKHARDORI,M.D. AMJAD F.NAJJAR,M.D. FAHEEMBUTT,M.D. PETER W. A.MANSELL,M.D. GEORGEA. SAROSI,M.D. University of Texas Health Science Center and the M. D. Anderson Hospital and Tumor Institute Houston, Texas 77225 1. Centers for Disease Control: Revision of the case definition of acquired immune deficiency syndrome for national reporting-united States. MMWR 1985; 34: 373-375. 2. Kiehn T, Wong B, Edwards FF, Armstrong D: Comparative recovery of bacteria and yeast from lysis centrifugation and a conventional blood culture system. J Clin Microbial 1983; 18: 300-304. January

1989

To the Editor: The discussion of disseminated histoplasmosis in AIDS by Johnson et al (Am J Med 1988; 85: 152158) was interesting. Among the earliest AIDS cases seen in New York City in 1979-1980 was a 34year-old black man recently relocated from Los Angeles. He had fevers, profound weight loss, hepatosplenomegaly, adenopathy, diarrhea, painful perianal ulcers, and pulmonary infiltrates. Mycobacterium tuberculosis had been isolated from his sputum at Wadsworth Veterans Administration Medical Center and appropriate therapy was begun prior to his transfer to the Brooklyn Veterans Administration Medical Center. Persistent symptoms and rapidly progressive clinical deterioration prompted further diagnostic workup. Herpes and bacterial cultures of the ulcers showed no growth; routine Bactec blood cultures also showed no growth. Permission for biopsies of bone marrow and liver was finally obtained immediately antemortem. These proved positive for H. capsulatum, as were autopsy specimens of liver, spleen, marrow, colonic mucosa, and the perianal ulcers. Lung, heart, and brain were apparently uninvolved. No residual mycobacteria were found in cultures or stains. This case was discussed as a possible retrospective AIDS case with public health officials in 1981, but was only accepted as such in 1985 with the expansion of Centers for Disease Control definitions at that time. The lower diagnostic percentage in Houston between 1983 and 1985 than between 1985 and 1987 was perhaps similarly derived. This case is typical of those discussed by Johnson et al, with a

The American

Journal

of Medicine

Volume

86

141