© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Transplant Infectious Disease, ISSN 1398-2273
Case report
Disseminated histoplasmosis in allogeneic bone marrow transplant: a diagnosis not to be missed S. Haydoura, J. Wallentine, B. Lopansri, C.D. Ford, D. Saad, J.P. Burke. Disseminated histoplasmosis in allogeneic bone marrow transplant: a diagnosis not to be missed. Transpl Infect Dis 2014: 16: 822–826. All rights reserved Abstract: Immunosuppressed patients are at highest risk for disseminated histoplasmosis, but only a few cases have been reported in hematopoietic stem cell transplant recipients. We report a case of disseminated histoplasmosis in an allogeneic bone marrow transplant recipient residing in a non-endemic area. Diagnosis was first suspected based on a peripheral blood smear.
S. Haydoura1, J. Wallentine2, B. Lopansri1, C.D. Ford3, D. Saad4, J.P. Burke1 1
Divisions of Infectious Disease, LDS Hospital/ Intermountain Healthcare and University of Utah, Salt Lake City, Utah, USA, 2Division of Hematopathology, LDS Hospital, Salt Lake City, Utah, USA, 3Acute Leukemia and Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, USA, 4Division of Rheumatology, University of Utah Hospital, Salt Lake City, Utah, USA Key words: disseminated histoplasmosis; allogeneic bone marrow transplant; peripheral blood smear; Histoplasma capsulatum Correspondence to: Souha Haydoura, MD, Department of Infectious Disease, University of Utah Medical Center, 50 N. Medical Drive, Salt Lake City, UT 84132, USA Tel: 319 768 3200 Fax: 319 768 3234 E-mails: [email protected] (or) [email protected]
Received 3 December 2013, revised 27 March 2014, accepted for publication 1 April 2014 DOI: 10.1111/tid.12261 Transpl Infect Dis 2014: 16: 822–826
In the United States, most cases of Histoplasma capsulatum infections occur within the Ohio and Mississippi River valleys (1). Immunosuppressed patients are at highest risk for disseminated disease (2), but only a few cases have been reported in detail in hematopoietic stem cell transplant (SCT) recipients (3–5). We report a case of disseminated histoplasmosis in an allogeneic bone marrow transplant recipient residing in a non-endemic area. Diagnosis was first suspected based on peripheral blood smear.
Case report A 60-year-old man of Polynesian descent presented with fever, cough, dyspnea, and abdominal fullness in January 2012. A computed tomography (CT) scan at
822
that time revealed splenomegaly and extensive lymphadenopathy (mediastinal, hilar, axillary, paraaortic, mesenteric, and retroperitoneal) without parenchymal lesions. A diagnosis of stage IVB mantle cell lymphoma was made based on biopsies of right cervical lymph node, colon tissue, and bone marrow. He was transferred to a tertiary care center for further management. In May 2012, chemotherapy was delayed because of prolonged thrombocytopenia and neutropenia. A repeat CT scan at this time revealed regression of pathologic lymphadenopathy, but nodular lesions were observed in the right upper lung lobe, which were not present previously. No residual disease was observed on repeat bone marrow biopsy and the decision was made to pursue autologous SCT. He received maintenance rituximab pending transplant.
Haydoura et al: Histoplasma and transplantation
In August 2012, re-staging was performed and CT/ positron emission tomography scans revealed increased size of pulmonary nodules with development of new nodules in the right upper lobe, all of which had increased metabolic activity. Despite persistent pancytopenia, repeat bone marrow biopsy excluded residual lymphoma. Owing to concerns that disease was progressing, he received salvage chemotherapy. In November 2012, he underwent haploidentical allogeneic SCT from his son and received tacrolimus and mycophenolate mofetil as graft-versus-host disease prophylaxis. Cytomegalovirus viremia was detected following transplant, which was initially managed with ganciclovir that was later switched to foscarnet for persistent viremia. In mid-January 2013, he was admitted to the hospital with nausea and vomiting and was diagnosed with grade I gastrointestinal graft-versus-host disease. He received high-dose prednisone therapy and was discharged home. Two weeks later he was re-admitted to the hospital with fever, weakness, and continued cough. On admission, he was septic and blood cultures were positive for Pseudomonas aeruginosa. He improved clinically with imipenem and tobramycin with clearance of bacteremia. He was subsequently continued on imipenem monotherapy, foscarnet for cytomegalovirus viremia, and micafungin for fungal prophylaxis. He remained afebrile until day 9 of admission, when he began to spike high fevers up to 39.4°C associated with confusion and continued cough. He had a rapid heart rate with baseline oxygen saturation of 97% on room air. He opened his eyes to verbal stimuli but was disoriented. There was no focal neurological finding or skin lesion. He was neutropenic (white blood cell count 800/lL, absolute neutrophil count 200/lL) with elevated liver function tests (total bilirubin 1.8 mg/dL, alkaline phosA
phatase 321 U/L, alanine aminotransferase 63 U/L, aspartate aminotransferase 584 U/L), compared to normal levels on admission. Renal function remained within normal limits and unchanged during hospitalization. Blood and urine cultures had remained negative since admission, and Aspergillus galactomannan became positive at 6.04 (negative index being
Case report
Disseminated histoplasmosis in allogeneic bone marrow transplant: a diagnosis not to be missed S. Haydoura, J. Wallentine, B. Lopansri, C.D. Ford, D. Saad, J.P. Burke. Disseminated histoplasmosis in allogeneic bone marrow transplant: a diagnosis not to be missed. Transpl Infect Dis 2014: 16: 822–826. All rights reserved Abstract: Immunosuppressed patients are at highest risk for disseminated histoplasmosis, but only a few cases have been reported in hematopoietic stem cell transplant recipients. We report a case of disseminated histoplasmosis in an allogeneic bone marrow transplant recipient residing in a non-endemic area. Diagnosis was first suspected based on a peripheral blood smear.
S. Haydoura1, J. Wallentine2, B. Lopansri1, C.D. Ford3, D. Saad4, J.P. Burke1 1
Divisions of Infectious Disease, LDS Hospital/ Intermountain Healthcare and University of Utah, Salt Lake City, Utah, USA, 2Division of Hematopathology, LDS Hospital, Salt Lake City, Utah, USA, 3Acute Leukemia and Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, USA, 4Division of Rheumatology, University of Utah Hospital, Salt Lake City, Utah, USA Key words: disseminated histoplasmosis; allogeneic bone marrow transplant; peripheral blood smear; Histoplasma capsulatum Correspondence to: Souha Haydoura, MD, Department of Infectious Disease, University of Utah Medical Center, 50 N. Medical Drive, Salt Lake City, UT 84132, USA Tel: 319 768 3200 Fax: 319 768 3234 E-mails: [email protected] (or) [email protected]
Received 3 December 2013, revised 27 March 2014, accepted for publication 1 April 2014 DOI: 10.1111/tid.12261 Transpl Infect Dis 2014: 16: 822–826
In the United States, most cases of Histoplasma capsulatum infections occur within the Ohio and Mississippi River valleys (1). Immunosuppressed patients are at highest risk for disseminated disease (2), but only a few cases have been reported in detail in hematopoietic stem cell transplant (SCT) recipients (3–5). We report a case of disseminated histoplasmosis in an allogeneic bone marrow transplant recipient residing in a non-endemic area. Diagnosis was first suspected based on peripheral blood smear.
Case report A 60-year-old man of Polynesian descent presented with fever, cough, dyspnea, and abdominal fullness in January 2012. A computed tomography (CT) scan at
822
that time revealed splenomegaly and extensive lymphadenopathy (mediastinal, hilar, axillary, paraaortic, mesenteric, and retroperitoneal) without parenchymal lesions. A diagnosis of stage IVB mantle cell lymphoma was made based on biopsies of right cervical lymph node, colon tissue, and bone marrow. He was transferred to a tertiary care center for further management. In May 2012, chemotherapy was delayed because of prolonged thrombocytopenia and neutropenia. A repeat CT scan at this time revealed regression of pathologic lymphadenopathy, but nodular lesions were observed in the right upper lung lobe, which were not present previously. No residual disease was observed on repeat bone marrow biopsy and the decision was made to pursue autologous SCT. He received maintenance rituximab pending transplant.
Haydoura et al: Histoplasma and transplantation
In August 2012, re-staging was performed and CT/ positron emission tomography scans revealed increased size of pulmonary nodules with development of new nodules in the right upper lobe, all of which had increased metabolic activity. Despite persistent pancytopenia, repeat bone marrow biopsy excluded residual lymphoma. Owing to concerns that disease was progressing, he received salvage chemotherapy. In November 2012, he underwent haploidentical allogeneic SCT from his son and received tacrolimus and mycophenolate mofetil as graft-versus-host disease prophylaxis. Cytomegalovirus viremia was detected following transplant, which was initially managed with ganciclovir that was later switched to foscarnet for persistent viremia. In mid-January 2013, he was admitted to the hospital with nausea and vomiting and was diagnosed with grade I gastrointestinal graft-versus-host disease. He received high-dose prednisone therapy and was discharged home. Two weeks later he was re-admitted to the hospital with fever, weakness, and continued cough. On admission, he was septic and blood cultures were positive for Pseudomonas aeruginosa. He improved clinically with imipenem and tobramycin with clearance of bacteremia. He was subsequently continued on imipenem monotherapy, foscarnet for cytomegalovirus viremia, and micafungin for fungal prophylaxis. He remained afebrile until day 9 of admission, when he began to spike high fevers up to 39.4°C associated with confusion and continued cough. He had a rapid heart rate with baseline oxygen saturation of 97% on room air. He opened his eyes to verbal stimuli but was disoriented. There was no focal neurological finding or skin lesion. He was neutropenic (white blood cell count 800/lL, absolute neutrophil count 200/lL) with elevated liver function tests (total bilirubin 1.8 mg/dL, alkaline phosA
phatase 321 U/L, alanine aminotransferase 63 U/L, aspartate aminotransferase 584 U/L), compared to normal levels on admission. Renal function remained within normal limits and unchanged during hospitalization. Blood and urine cultures had remained negative since admission, and Aspergillus galactomannan became positive at 6.04 (negative index being
