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CASE REPORT  
Year : 2020  |  Volume : 63  |  Issue : 4  |  Page : 645-647
Disseminated Histoplasmosis detected on peripheral blood smear examination in immunocompetent patients from non endemic region – Report of two cases from a tertiary care hospital


1 Department of Pathology, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
2 Department of Botany, Jai Narain Vyas University, Jodhpur, Rajasthan, India
3 Department of Internal Medicine, Dr. S. N. Medical College, Jodhpur, Rajasthan, India

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Date of Submission16-Nov-2019
Date of Decision09-Jan-2020
Date of Acceptance10-Jan-2020
Date of Web Publication28-Oct-2020
 

   Abstract 


Histoplasmosis is an opportunistic systemic infection caused by inhaling spores of a thermal dimorphic fungus Histoplasma capsulatum. Disseminated histoplasmosis is the most common form associated with acquired immune deficiency syndrome (AIDS). However, only a few cases of disseminated histoplasmosis are reported in immuno-competent hosts. Most infections in the immunocompetent hosts are asymptomatic or result in mild pulmonary disease. However the presence of Disseminated Histoplasmosis in immunocompetent host probably results due to prolonged exposure and delayed presentation We report two cases of progressive disseminated histoplasmosis in two immunocompetent patients from non-endemic region in Western Rajasthan, India. Also in both the cases, the first diagnosis was suggested by a peripheral blood smear, which is not a classical biological diagnostic method for fungal infection. Careful examination of Peripheral blood smear along with correct clinical history can aid in early diagnosis of disseminated histoplasmosis even in immunocompetent patients.

Keywords: Disseminated histoplasmosis, histoplasma capsulatum, HIV

How to cite this article:
Bagga N, Sharma K, Tuteja RK, Sharma S, Negi S R, Mathur S L. Disseminated Histoplasmosis detected on peripheral blood smear examination in immunocompetent patients from non endemic region – Report of two cases from a tertiary care hospital. Indian J Pathol Microbiol 2020;63:645-7

How to cite this URL:
Bagga N, Sharma K, Tuteja RK, Sharma S, Negi S R, Mathur S L. Disseminated Histoplasmosis detected on peripheral blood smear examination in immunocompetent patients from non endemic region – Report of two cases from a tertiary care hospital. Indian J Pathol Microbiol [serial online] 2020 [cited 2020 Dec 1];63:645-7. Available from: https://www.ijpmonline.org/text.asp?2020/63/4/645/299334





   Introduction Top


Histoplasmosis is an opportunistic systemic infection caused by inhaling spores of a thermal dimorphic fungus Histoplasma capsulatum.[1] Histoplasmosis usually presents in two forms; pulmonary and extra pulmonary, which is also known as disseminated histoplasmosis (DH). Immunocompromised host especially those with advanced HIV infection are at the greatest risk for developing progressive and DH.[1] However, only a few cases of DH are reported in immunocompetent hosts. We report two cases of progressive DH in immunocompetent patients from non-endemic region in Western Rajasthan, probably due to prolonged exposure. Also in both the cases, the first diagnosis was suggested by a peripheral blood smear, which is not a classical biological diagnostic method for fungal infection.


   Case Report Top


A 56-year-old man, carpenter by occupation was admitted in the medical unit with a history of intermittent high grade fever, weakness, breathlessness upon exertion, and easy fatigability since 20 days. On physical examination the patient had conjunctival pallor. His oral temperature was 100°F, with a pulse 96 beats per minute and blood pressure of 110/80 mmHg. No lymphadenopathy/hepatosplenomegaly were noted. Electrocardiogram (ECG) and chest X-ray were normal. Laboratory test results revealed pancytopenia with hemoglobin of 6.5 g/dL, total leukocyte count 0.94 × 103/μl, and platelet count 15 × 106/mm3. HIV, HBs Ag HCV, and dengue serology were negative. His serum vitamin B12 and folic acid were within normal limits. The peripheral blood film was negative for malarial parasite/atypical cells, but a single monocyte revealed the presence of yeast-like organisms retracted from poorly stained cell wall with clear halo and eccentric chromatin suggesting the morphology of Histoplasma capsulatum [Figure 1]a and [Figure 1]b The bone marrow aspiration smears were hypocellular and revealed abundant intra-cytoplasmic yeast bodies in granulocytic precursors and histiocytes confirming the diagnosis of DH. Blood and bone marrow culture isolated histoplasma. Absolute CD4 count and CD4/CD8 ratio of patient was within normal limit. The patient recovered after a complete regimen of antifungal antibiotics and supportive treatment. Another similar case was reported in which a 60-year-old male patient presented to the Emergency Department with chief complains of high grade fever, weakness, and easy fatigability since 15 days. On physical examination, his temperature was 102°F, with a pulse 102 beats per minute and blood pressure of 130/90 mmHg. No hepatosplenomegaly/lymphadenopathy were noted. ECG and chest X-ray were normal. Laboratory test results revealed pancytopenia with hemoglobin of 9.7 g/dL, WBC count 4000/mm3, and platelet count 15,000/mm3. SGOT was 178 IU/L and SGPT 117 IU/L. HIV, HBs Ag and HCV serology were negative. The peripheral blood film showed neutrophils and monocytes with the presence of yeast-like organisms morphology favoring Histoplasma capsulatum. However, the bone marrow aspirate smears were reported from outside lab as positive for L.D bodies. While serology was sent for confirmation of diagnosis, the patient was managed on the lines of Kala-Azar. Surprisingly the serology reported ruled out leishmaniasis as the Leishmania IgG titre came out to be 05 (positive > 11). The bone marrow aspiration slides were re-evaluated at our centre which revealed PAS positive intra-cytoplasmic yeast bodies in RE cells/histiocytes confirming the diagnosis of DH. Blood culture in Sabouraud medium isolated the fungus. The patient was treated with antibiotics and intravenous amphoterecin B with transfusion support. But his condition deteriorated and he died of cardiac arrhythmia on the second day of starting therapy. In both the above cases, patients had a negative history of any immunodeficient disorders, malignancy, diabetes mellitus immunosuppressive or immuno-modulating therapy intake, tuberculosis or chronic renal failure.
Figure 1: (a) Peripheral blood smear showing intracellular yeast form of H. capsulatum in monocytes. These organisms show eccentric chromatin surrounded by clear halo (Geimsa stain, ×1000). (b) Magenta colored yeast forms of H capsulatum highlighted on periodic acid-Schiff (PAS) stain (PAS stain × 1000)

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   Discussion Top


Histoplasmosis also known as Darling Disease is not very common in Indian subcontinent except for the eastern Indian states such as West Bengal, which is considered as the endemic region for histoplasmosis.[2] It is the most common opportunistic fungal infection in HIV-affected individuals in areas where it is endemic and hence DH has been included in the definition of diagnostic criteria of AIDS by the Center of Disease Control and Prevention (CDC) since 1987.[3] Most infections in the immunocompetent hosts are asymptomatic or result in mild pulmonary disease.[4] However, the presence of DH in immunocompetent host probably results due to prolonged exposure and delayed presentation. It is sometimes difficult to differentiate among L.D bodies and cells of H capsulatum (yeast phase) on a peripheral blood smear. Histoplasma capsulatum cells are about 2–5 μm in size, PAS positive, and have a densely stained crescent-shaped cytoplasmic component. Leishmania forms Leishman-Donovan (LD) bodies, which is distinguished by a nucleus and bar-shaped kinetoplast within each amastigote and it is negative for periodic acid-Schiff (PAS) stain.[5]

Occurrence of DH in immunocompetent patient living in non-endemic region is a rare finding. Moreover, the first diagnosis of both the cases was made on Geimsa stained peripheral blood smear even before culture reports were available. This highlights the importance of peripheral blood smear examination in diagnosis of DH even in immunocompetent patients.


   Conclusion Top


DH can occur in HIV-negative immunocompetent patients due to prolonged exposure or delayed presentation. Careful examination of peripheral blood smear along with correct clinical history can aid in early diagnosis of DH even in immunocompetent patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Loulergue P, Bastides F, Baudouin V. Literature review and case histories of Histoplasma capsulatum var. duboisii infections in HIV-infected patients. Emerg Infect Dis 2007;13:1647-52.  Back to cited text no. 1
    
2.
Chande C, Menon S, Gohil A, Lilani S, Bade J, Mohammad S. Cutaneous histoplasmosis in AIDS. Indian J Med Microbiol 2010;28:404-6.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Marty S, Brun M, Gari-Toussaint M. Les mycoses syst´emiques tropicales. Med Trop 2000;60:281-90.  Back to cited text no. 3
    
4.
Wheat LJ, Freifeld AG, Kleiman MB, Baddley JW, McKinsey DS, Loyd JE. Clinical practice guidelines for the management of patients with histoplasmosis, update by the infectious diseases society of America. Clin Infect Dis 2007;45:807-25.  Back to cited text no. 4
    
5.
Koley S, Mandal RK, Khan K, Choudhary S, Banerjee S. Disseminated cutaneous histoplasmosis, an initial manifestation of HIV, diagnosed with fine needle aspiration cytology. Indian J Dermatol 2014;59:182-85.  Back to cited text no. 5
[PUBMED]  [Full text]  

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Correspondence Address:
Satyaprakash Sharma
Shankar Sadan, Behind Govt Girls School, Soorsagar, Jodhpur - 342 024 , Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_898_19

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