VirologyHistoplasmosis in HIV-infected patients in a southern regional medical center: poor prognosis in the era of highly active antiretroviral therapy☆
Introduction
Histoplasmosis is an endemic fungal infection caused by the soil-based fungus Histoplasma capsulatum, which affects primarily those who live in the Ohio and Mississippi river valleys of the United States and in Central and South America. Despite the increased use of highly active antiretroviral therapy (HAART), histoplasmosis remains an important opportunistic infection among HIV patients in endemic areas and frequently presents as the 1st manifestation of HIV infection or an AIDS-defining illness (Couppie et al., 2004). Histoplasmosis is typically a subclinical illness or mild self-limited pulmonary syndrome in healthy individuals; however, in patients with HIV/AIDS, manifestations of disseminated infection are almost universal and outcomes are poor (Antinori et al., 2006, Chu et al., 2006, Sarosi and Johnson, 1992, Wheat et al., 1990, 2000). In disseminated histoplasmosis in AIDS patients, mortality may approach 50% and is especially high in those with the severe disease manifestations of sepsis, respiratory failure, acute renal failure, or multiorgan failure (Couppie et al., 2004, Couppie et al., 2006, de Francesco Daher et al., 2006, Wheat et al., 2000). A limited number of studies have evaluated prognostic factors in HIV-infected patients with histoplasmosis, but recent reports suggest that renal failure, hypoalbuminemia, elevated lactate dehydrogenase (LDH), thrombocytopenia, and anemia are independently associated with poor outcomes such as severe disease or death (Couppie et al., 2004, de Francesco Daher et al., 2006, Hajjeh et al., 2001, Wheat et al., 2000). In Montgomery County, AL, an area endemic for histoplasmosis, we have noticed increased morbidity and mortality accompanying HIV-associated histoplasmosis. Moreover, histoplasmosis as the presenting manifestation of HIV infection and AIDS is not uncommon. Herein, we examine the epidemiology, clinical presentation, outcomes, and prognostic factors of HIV-infected patients with histoplasmosis in this underserved southern city.
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Patients
We prospectively identified HIV-infected patients aged 19 or older with a diagnosis of histoplasmosis during a 7-year period (1999–2006) in Montgomery County, AL. Montgomery is the state capital and the 2nd largest city in Alabama. On the basis of data from the Alabama Department of Public Health, Montgomery County has had the highest per capita incidence of HIV/AIDS statewide for more than a decade. Montgomery County has received the designation of a medically underserved area from the Health
Results
Forty-six HIV-infected patients from the greater Montgomery County, AL, area were diagnosed with histoplasmosis during the 7-year study period. During the study period, the average rate of new HIV infection was 50 cases/100 000 population. The mean age of patients was 38.3 years, 34 (73.9%) were male and 33 (71.7%) were African American. Forty-three (93.5%) of 46 patients had disseminated disease, and 3 had pulmonary disease alone. Twenty (43.5%) patients had pneumonia plus disseminated
Discussion
Histoplasmosis continues to be an important infectious disease among HIV-infected patients in endemic areas, and we aimed to evaluate the impact of disease on mortality among our patient population. On the basis of our review, we found increased morbidity and mortality in Montgomery County, AL, despite the general availability of antiretroviral therapy to all citizens through the state drug programs. Of those patients who died, very few were receiving antriretroviral therapy at time of death.
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There was no financial support for this work. The authors do not have associations that might pose a conflict of interest.