Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + • Infection occurs after inhalation of spores with male:female ratio of 3:1• In lungs, fungus germinates into yeast; cause caseating necrosis and calcification +++ Acute Infection + • Several different presentations:-Flu-like syndrome-Flu-like syndrome but limited to lungs-Diffuse nodular disease +++ Chronic Infection + • Several presentations: -Asymptomatic solitary nodule < 3 cm with central calcifications in lower lobes (histoplasmoma)-In patients with chronic obstructive pulmonary disease, cavitary histoplasmosis 3-Mediastinal granulomas resulting in broncholithiasis, esophageal traction diverticula, superior vena cava (SVC) compression, transesophageal (TE) fistulas-Fibrosing mediastinitis with SVC, tracheal, or esophageal compression +++ Epidemiology + • Pulmonary fungal infections are rising due to widespread use of broad-spectrum antibiotics, immunosuppressive drugs, and HIV infection• Occur anywhere in world, some with characteristic endemic areas• Histoplasma capsulatum is found in fowl and bat excreta, pigeon roosts, chicken houses, caves, hollow trees, attics and lofts-Endemic to fertile river valleys, such as Mississippi, Missouri, and Ohio Rivers +++ Symptoms and Signs + • Immunocompetent patients, asymptomatic• Cough, malaise, hemoptysis, fever, weight loss (30% have coexistent TB) +++ Acute Infection + • Ranging from flu-like illness to diffuse nodular disease +++ Chronic Infection + • Variety of presentations:-Histoplasmoma most common-Local mediastinal compression can occur• Disseminated disease (acute, subacute, and chronic form): Fever, abdominal pain, hepatosplenomegaly, pancytopenia• Solitary pulmonary nodules: 15-20% are from histoplasmosis• Constrictive pericarditis if pericardium involved +++ Laboratory Findings + • High or rising serum titers• Tissue cultures, sputum cultures +++ Imaging Findings + • Chest film: Hilar adenopathy common, diffuse interstitial pneumonitis (25%)• In acute presentation, chest film ranges from upper lobe opacities to diffuse 3-4 mm nodules• Cavitation indicates advanced disease + • High/rising serum titers (> 1:32 or elevated 4×)• Histoplasmin skin test (positive in 2-6 wks)• Sputum cultures positive in 10%, tissue cultures more reliable +++ Rule Out + • TB + • Chest x-ray• Chest CT scan• Sputum microscopy and cultures + • Medical therapy is indicated in immunocompromised hosts or in cavitary or severe disease +++ Surgery + • Operative therapy only for complications:-Broncholithectomy + pulmonary resection-Repair of TE fistula-Decompression of mediastinal granulomas-Saphenous vein bypass for severe SVC compression +++ Indications + • Complications of histoplasmosis +++ Medications + • Ketoconazole/itraconazole (6 mos) for cavitary disease• Amphotericin B for more serious infections or in immunocompromised patients +++ References ++Piarrouz R et al: Assessment of preemptive treatment to prevent severe candidiasis in critically ill surgical patients. Crit Care Med 2004;32:2443. +... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth