Journal of Medical and Veterinary Mycology (1992), 30, 245-248
CASE REPORT
Disseminated African histoplasmosis in a Congolese patient with AIDS B. CARME 1'2, A. ITOUA NGAPORO 1, A. NGOLET 1, J. R. IBARA 1
Med Mycol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/28/14 For personal use only.
AND B. EBIKILI 1
1Centre Hospitalier et Universitaire de Brazzaville, Congo, and 2Service de Parasitologie et Mycologie, CHRU d'Amiens, HOpital Sud, Amiens, France (Accepted 10 January 1992) We report the first Congolese case of African histoplasmosis in a patient with AIDS which represents the third case to be described in the literature. This contrasts with the now frequent occurrence of Histoplasma capsulatum histoplasmosis in HIV-infected subjects in North America; the difference is likely to be due to differences in exposure to the fungus rather than to differences in behaviour of the fungus or in the epidemiology of HIV.
By the beginning of August 1991, only two cases of African histoplasmosis had been reported in HIV-infected subjects. The first case [2, 5] occurred in an European heterosexual infected with HIV1 and the second in an African child infected with HIV2 [4]. This contrasts with the now frequent occurrence of Histoplasma capsulatum histoplasmosis in HIV-infected subjects in North America [3]. We recently drew attention to this point [1] and noted a large increase in the number of AIDS patients with cryptococcosis in the Congo, whereas the frequency of Histoplasma duboisii histoplasmosis has remained low since 1981 (between one and three cases per year). Furthermore, none of the patients with H. duboisii histoplasmosis was infected with HIV. We suggested that (i) the differences observed between H. capsulatum histoplasmosis seen in America or in Europe and African histoplasmosis are likely to be due to differences in exposure to the fungus rather than to differences in behaviour of the fungus or in the epidemiology of HIV, and (ii) that these questions may be answered in the future with the probable spread of AIDS outside urban zones. Indeed, HIV occurs mainly in urban areas and H. duboisii in rural settings. This hypothesis is supported by the diagnosis of the first case of African histoplasmosis in a Congolese patient with AIDS, which occurred in mid-1990, and is described here. CASE HISTORY The patient was a 26-year-old student from the Brazzaville region. Onset of symptoms occurred 3 months after his arrival in the USSR where he was studying. In March 1990, he was flown back to the Congo under medical supervision and was admitted to the University Hospital in Brazzaville in a critical state. Clinical examination revealed Correspondence address: Pr Bernard Carme, Service de Parasitologie et Mycologie, CHRU d'Amiens, H6pital Sud, 80054 Amiens, France. 245
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246
C A R M E ET AL.
P
FIG. 1. Disseminated cutaneous and subcutaneous lesions on the chest.
FIG. 2, Nodular lesion.
CASE REPORT
247
Med Mycol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/28/14 For personal use only.
disseminated cutaneous and subcutaneous lesions (Figs 1 & 2), predominantly on the face and chest. These were nodular, often umbilicated and fistularized. Multiple adenopathies, hepatomegaly and splenomegaly were also observed. The patient presented with severe infection with jaundice and ascites, and outcome was rapidly fatal. Positive HIV serological tests, Elavia Pasteur ® and Western blot (Dupont®), confirmed the diagnosis of HIV infection. The diagnosis of African histoplasmosis was confirmed by the demonstration of several typical H. duboisii yeasts in the skin lesions
FIG. 3, Typical H, duboisii yeasts seen in the skin lesions (direct examination, ×400).
FIG. 4. Large yeasts in a lymph gland (histological examination, x200).
248
CARME ET AL.
Med Mycol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/28/14 For personal use only.
(Fig. 3) and in a lymph gland (Fig. 4). The patient died before the start of specific treatment. A second case, with a similar clinical picture and outcome was observed in May 1990 in a 50-year-old farmer but could not be associated with AIDS due to a negative HIV1 test. However, the test was only carried out on one occasion (optical density with Elavia = 0.200, not significant) and it was not possible to carry out a double-check or a post-mortem examination. It is probable that with the inevitable spread of AIDS to the rural areas of Africa, the number of cases of disseminated H. duboisii histoplasmosis will increase. As with 11. capsulatum, this fungal disease may thus become classified as an opportunistic infection. REFERENCES 1. CARME,B., NGOLET, A., EBIKIL1, B. & ITOUANGAPORO,A. 1990. Is African histoplasmosis an opportunistic fungal infection in AIDS? Transactions of the Royal Society of Tropical Medicine and Hygiene, 84, 293. 2. DEPRI~,G., COREMANS-PELSENEER,J., PEETERS, P., RICKAERT,E, STRUELENS,M. & SERRUYS,E. 1987. Histoplasmose africaine diss6min6e associ6e ~ un syndrome d'immunod6ficience acquise. Bulletin de la Soci~td Fran~aise de Mycologie MOdicale, 16, 75-80. 3. JOHNSON,P C., KHARDORU,N., NAJJAR, m. E, Burr, E, MANSELL, P. W. A. & SAROSI, G. A. 1988. Progressive disseminated histoplasmosis in patients with AIDS. American Journal of Medicine, 85, 152-158. 4. MATOSALMEIDA,M. J. 1989. Histoplasmose africaine diss6min6e (HAD) chez un enfant noir de Guin6e Bissau s6ropositif pour HIV2. V International Conference on AIDS, No. 2659, Montr6al, 4-9 June, 1989. 5. PEETERS,P~,DEPR.E,G., RICKAERT,E, COREMANS-PELSENEER,J. & SERRUYS,1987. Disseminated African histoplasmosis in a white heterosexual male patient with the acquired immune deficiency syndrome. Mykosen, 30, 449-453.
CASE REPORT
Disseminated African histoplasmosis in a Congolese patient with AIDS B. CARME 1'2, A. ITOUA NGAPORO 1, A. NGOLET 1, J. R. IBARA 1
Med Mycol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/28/14 For personal use only.
AND B. EBIKILI 1
1Centre Hospitalier et Universitaire de Brazzaville, Congo, and 2Service de Parasitologie et Mycologie, CHRU d'Amiens, HOpital Sud, Amiens, France (Accepted 10 January 1992) We report the first Congolese case of African histoplasmosis in a patient with AIDS which represents the third case to be described in the literature. This contrasts with the now frequent occurrence of Histoplasma capsulatum histoplasmosis in HIV-infected subjects in North America; the difference is likely to be due to differences in exposure to the fungus rather than to differences in behaviour of the fungus or in the epidemiology of HIV.
By the beginning of August 1991, only two cases of African histoplasmosis had been reported in HIV-infected subjects. The first case [2, 5] occurred in an European heterosexual infected with HIV1 and the second in an African child infected with HIV2 [4]. This contrasts with the now frequent occurrence of Histoplasma capsulatum histoplasmosis in HIV-infected subjects in North America [3]. We recently drew attention to this point [1] and noted a large increase in the number of AIDS patients with cryptococcosis in the Congo, whereas the frequency of Histoplasma duboisii histoplasmosis has remained low since 1981 (between one and three cases per year). Furthermore, none of the patients with H. duboisii histoplasmosis was infected with HIV. We suggested that (i) the differences observed between H. capsulatum histoplasmosis seen in America or in Europe and African histoplasmosis are likely to be due to differences in exposure to the fungus rather than to differences in behaviour of the fungus or in the epidemiology of HIV, and (ii) that these questions may be answered in the future with the probable spread of AIDS outside urban zones. Indeed, HIV occurs mainly in urban areas and H. duboisii in rural settings. This hypothesis is supported by the diagnosis of the first case of African histoplasmosis in a Congolese patient with AIDS, which occurred in mid-1990, and is described here. CASE HISTORY The patient was a 26-year-old student from the Brazzaville region. Onset of symptoms occurred 3 months after his arrival in the USSR where he was studying. In March 1990, he was flown back to the Congo under medical supervision and was admitted to the University Hospital in Brazzaville in a critical state. Clinical examination revealed Correspondence address: Pr Bernard Carme, Service de Parasitologie et Mycologie, CHRU d'Amiens, H6pital Sud, 80054 Amiens, France. 245
Med Mycol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/28/14 For personal use only.
246
C A R M E ET AL.
P
FIG. 1. Disseminated cutaneous and subcutaneous lesions on the chest.
FIG. 2, Nodular lesion.
CASE REPORT
247
Med Mycol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/28/14 For personal use only.
disseminated cutaneous and subcutaneous lesions (Figs 1 & 2), predominantly on the face and chest. These were nodular, often umbilicated and fistularized. Multiple adenopathies, hepatomegaly and splenomegaly were also observed. The patient presented with severe infection with jaundice and ascites, and outcome was rapidly fatal. Positive HIV serological tests, Elavia Pasteur ® and Western blot (Dupont®), confirmed the diagnosis of HIV infection. The diagnosis of African histoplasmosis was confirmed by the demonstration of several typical H. duboisii yeasts in the skin lesions
FIG. 3, Typical H, duboisii yeasts seen in the skin lesions (direct examination, ×400).
FIG. 4. Large yeasts in a lymph gland (histological examination, x200).
248
CARME ET AL.
Med Mycol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/28/14 For personal use only.
(Fig. 3) and in a lymph gland (Fig. 4). The patient died before the start of specific treatment. A second case, with a similar clinical picture and outcome was observed in May 1990 in a 50-year-old farmer but could not be associated with AIDS due to a negative HIV1 test. However, the test was only carried out on one occasion (optical density with Elavia = 0.200, not significant) and it was not possible to carry out a double-check or a post-mortem examination. It is probable that with the inevitable spread of AIDS to the rural areas of Africa, the number of cases of disseminated H. duboisii histoplasmosis will increase. As with 11. capsulatum, this fungal disease may thus become classified as an opportunistic infection. REFERENCES 1. CARME,B., NGOLET, A., EBIKIL1, B. & ITOUANGAPORO,A. 1990. Is African histoplasmosis an opportunistic fungal infection in AIDS? Transactions of the Royal Society of Tropical Medicine and Hygiene, 84, 293. 2. DEPRI~,G., COREMANS-PELSENEER,J., PEETERS, P., RICKAERT,E, STRUELENS,M. & SERRUYS,E. 1987. Histoplasmose africaine diss6min6e associ6e ~ un syndrome d'immunod6ficience acquise. Bulletin de la Soci~td Fran~aise de Mycologie MOdicale, 16, 75-80. 3. JOHNSON,P C., KHARDORU,N., NAJJAR, m. E, Burr, E, MANSELL, P. W. A. & SAROSI, G. A. 1988. Progressive disseminated histoplasmosis in patients with AIDS. American Journal of Medicine, 85, 152-158. 4. MATOSALMEIDA,M. J. 1989. Histoplasmose africaine diss6min6e (HAD) chez un enfant noir de Guin6e Bissau s6ropositif pour HIV2. V International Conference on AIDS, No. 2659, Montr6al, 4-9 June, 1989. 5. PEETERS,P~,DEPR.E,G., RICKAERT,E, COREMANS-PELSENEER,J. & SERRUYS,1987. Disseminated African histoplasmosis in a white heterosexual male patient with the acquired immune deficiency syndrome. Mykosen, 30, 449-453.
