Virology
Histoplasmosis in HIV-infected patients in a southern regional medical center: poor prognosis in the era of highly active antiretroviral therapy

https://doi.org/10.1016/j.diagmicrobio.2008.05.006Get rights and content

Abstract

Histoplasmosis is an important opportunistic infection among HIV-infected patients in endemic areas, and clinical outcomes are often poor. Additional data on factors associated with outcomes are needed to better identify patients who may require aggressive care. Using a cohort of 46 HIV-infected patients with histoplasmosis from an underserved city endemic for histoplasmosis, we explored epidemiology, outcomes, and prognostic factors. Histoplasmosis was the 1st recognized manifestation of HIV infection in 12 (26.1%) of 46 patients. Death occurred in 18 (39%) patients within 3 months of diagnosis of histoplasmosis. Fungemia (odds ratio [OR], 12.1; 95% confidence interval [CI], 1.9–76; P = 0.008), renal insufficiency (OR, 11.3; 95% CI, 1.7–77.2; P = 0.01), and age (OR, 0.9; 95% CI, 0.8–0.98; P = 0.02) were independent predictors of poor prognosis. Histoplasmosis in HIV patients is associated with poor outcomes. Identification of prognostic factors may be helpful in identifying patients who require more aggressive care.

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.

Section snippets

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.

References (13)

  • S. Antinori et al.

    Histoplasmosis among human immunodeficiency virus-infected people in Europe: report of 4 cases and review of the literature

    Medicine (Baltimore)

    (2006)
  • M.R. Chang et al.

    Study of 30 cases of histoplasmosis observed in Mato Grosso do Sul State, Brazil

    Rev. Inst. Med. Trop. Sao Paulo

    (2007)
  • J.H. Chu et al.

    Hospitalizations for endemic mycoses: a population-based national study

    Clin. Infect. Dis.

    (2006)
  • P. Couppie et al.

    American histoplasmosis in developing countries with a special focus on patients with HIV: diagnosis, treatment, and prognosis

    Curr. Opin. Infect Dis.

    (2006)
  • P. Couppie et al.

    Histoplasmosis and acquired immunodeficiency syndrome: a study of prognostic factors

    Clin. Infect. Dis.

    (2004)
  • E.F. Daher et al.

    Clinical and laboratory features of disseminated histoplasmosis in HIV patients from Brazil

    Trop. Med. Int. Health

    (2007)
There are more references available in the full text version of this article.

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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.

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