RESUMO
Histoplasma capsulatum is a thermally dimorphic fungal pathogen endemic to the Mississippi and Ohio River Valley regions of North America and much of Central and South America. As an opportunistic pathogen, H. capsulatum can assume a latent infection that can be reactivated by immunocompromised states or immunosuppressive therapy. We report a case of a 72-year-old man who lived in rural regions of Panama, Honduras, and Nicaragua while serving in the U.S. military from 1987 to 1991. Three decades after his initial exposure, the patient presented for evaluation of a painful tongue ulcer that originated when he began taking adalimumab to manage his psoriatic arthritis 2 years earlier. Tissue scraping of the tongue ulcer grew a whitish to cream-colored, fluffy-textured mold that was morphologically identified as Histoplasma. Molecular analysis of the fungus confirmed H. capsulatum var. Latin American group A, known as Histoplasma suramericanum. Further testing showed a positive H. capsulatum antibody mycelial complement fixation, and a 1-cm calcified nodule in the lower lobe of the left lung on computed tomography. Here, we highlight the importance of recognizing disseminated histoplasmosis in patients with exposure to endemic regions before initiating immunosuppressive therapy.
RESUMO
BACKGROUND: Antidepressants are among the most commonly prescribed medications, but evidence on comparative weight change for specific first-line treatments is limited. OBJECTIVE: To compare weight change across common first-line antidepressant treatments by emulating a target trial. DESIGN: Observational cohort study over 24 months. SETTING: Electronic health record (EHR) data from 2010 to 2019 across 8 U.S. health systems. PARTICIPANTS: 183 118 patients. MEASUREMENTS: Prescription data determined initiation of treatment with sertraline, citalopram, escitalopram, fluoxetine, paroxetine, bupropion, duloxetine, or venlafaxine. The investigators estimated the population-level effects of initiating each treatment, relative to sertraline, on mean weight change (primary) and the probability of gaining at least 5% of baseline weight (secondary) 6 months after initiation. Inverse probability weighting of repeated outcome marginal structural models was used to account for baseline confounding and informative outcome measurement. In secondary analyses, the effects of initiating and adhering to each treatment protocol were estimated. RESULTS: Compared with that for sertraline, estimated 6-month weight gain was higher for escitalopram (difference, 0.41 kg [95% CI, 0.31 to 0.52 kg]), paroxetine (difference, 0.37 kg [CI, 0.20 to 0.54 kg]), duloxetine (difference, 0.34 kg [CI, 0.22 to 0.44 kg]), venlafaxine (difference, 0.17 kg [CI, 0.03 to 0.31 kg]), and citalopram (difference, 0.12 kg [CI, 0.02 to 0.23 kg]); similar for fluoxetine (difference, -0.07 kg [CI, -0.19 to 0.04 kg]); and lower for bupropion (difference, -0.22 kg [CI, -0.33 to -0.12 kg]). Escitalopram, paroxetine, and duloxetine were associated with 10% to 15% higher risk for gaining at least 5% of baseline weight, whereas bupropion was associated with 15% reduced risk. When the effects of initiation and adherence were estimated, associations were stronger but had wider CIs. Six-month adherence ranged from 28% (duloxetine) to 41% (bupropion). LIMITATION: No data on medication dispensing, low medication adherence, incomplete data on adherence, and incomplete data on weight measures across time points. CONCLUSION: Small differences in mean weight change were found between 8 first-line antidepressants, with bupropion consistently showing the least weight gain, although adherence to medications over follow-up was low. Clinicians could consider potential weight gain when initiating antidepressant treatment. PRIMARY FUNDING SOURCE: National Institutes of Health.
