Histoplasmosis Infection of Aortobifemoral Graft Treated with a Neoaortoiliac System.

Aortic graft infections are a feared complication of aortic bypass operations and impart significant morbidity and mortality when they occur. The most common etiology is bacterial, with a presentation ranging from subclinical to acutely symptomatic depending on the organism. Fungal infections of prosthetic grafts are rare, especially in immunocompetent patients. Graft infections remain a clinical diagnosis. We report a rare case of an aortobifemoral graft infection with Histoplasma capsulatum that was diagnosed on surgical pathology, as the preoperative infectious evaluation was negative. The neoaortoiliac system operation was successfully used to solve this patient's highly morbid condition.

Histoplasmosis mimicking adrenal carcinoma.

OBJECTIVES: The incidence of unilateral adrenal histoplasmosis in nonendemic areas is rare. This is even rarer if the host is immunocompetent. METHODS: We report a patient who was referred for unexplained weight loss who underwent a computed tomography scan of abdomen revealing a large unilateral adrenal nodule measuring 7.6 cm in size. RESULTS: Hormonal workup was negative including urine 24-hour free metanephrines, and the patient underwent unilateral adrenalectomy. The pathology showed budding yeast that stained with Gomori's methenamine silver (GMS) revealed the diagnosis of adrenal histoplasmosis. CONCLUSION: We encourage clinicians to include infection by Histoplasma capsulatum as well as other granulomatous diseases and tumors in the differential diagnosis of unilateral adrenal enlargement even in immunocompetent hosts living in nonendemic areas.

A case in Europe of feline histoplasmosis apparently limited to the skin.

BACKGROUND: Histoplasma capsulatum has a worldwide distribution, but reports in Europe remain rare. We present the second report of histoplasmosis in a cat in Europe and, to the best of our knowledge, the first case of feline histoplasmosis infection apparently limited to the skin. CASE REPORT: A 6-year-old male castrated outdoor cat was presented to the dermatology service with a history of skin lesions evolving over 1 month and consisting of multiple papules and nodules on the head and neck. General examination was unremarkable. Cytological examination of the ulcerated nodules revealed a pyogranulomatous infiltrate, with numerous macrophages containing oval yeast-like cells, 2-5 µm in size, with a central, lightly basophilic core surrounded by a clear halo. A tentative diagnosis of fungal infection was made, and skin biopsy specimens were taken. Histological examination confirmed the cytology findings, and Grocott staining showed numerous organisms suggestive of Histoplasma within macrophages. Thoracic radiographs, abdominal ultrasound and routine laboratory testing were unremarkable. Fungal culture of a nodule was negative. PCR of total DNA extracted from the infected tissue and subsequent sequencing confirmed the diagnosis of H. capsulatum var. capsulatum. Surgical excision of the other nodules was performed, and the cat was treated with oral itraconazole 5 mg/kg once daily; 12 weeks after initial consultation, no lesions were visible. No recurrence was observed during an 8 month follow-up period. CONCLUSIONS AND CLINICAL IMPORTANCE: Histoplasmosis should be included in the differential diagnosis of nodular diseases of cats worldwide.

Retroperitoneal pyogranulomatous and fibrosing inflammation secondary to fungal infections in two dogs.

CASE DESCRIPTIONS: A 4-year-old spayed female Golden Retriever (dog 1) was examined because of acute edema and erythema in the left hind limb and an inguinal mass, and a 5-year-old female Jack Russell Terrier (dog 2) was examined because of a recurring retro-peritoneal mass. CLINICAL FINDINGS: Dog 1 had an edematous, hyperemic left hind limb with a fixed inguinal mass. Monocytic neutrophilic leukocytosis and hypoalbuminemia were detected. Diagnostic imaging revealed abnormal tissue surrounding the larger vessels and ureters and complete occlusion of the left limb veins. Surgery resulted in incomplete removal of the mass. Histologic examination revealed fibrosing pyogranulomatous inflammation. Results of a Histoplasma antigen test were positive, and reanalysis of the tissues revealed yeast cells indicative of Histoplasma capsulatum. Dog 2 had incomplete removal of a retroperitoneal mass. Histologic examination revealed fibrosing pyogranulomatous inflammation. The mass recurred 8 months later in dog 2; exploratory abdominal surgery at that time resulted in substantial hemorrhage from the adhered caudal aorta. Histologic examination of tissue sections from the second surgery revealed yeast cells consistent with Blastomyces dermatitidis. TREATMENT AND OUTCOME: Both dogs had temporary improvement after surgery. Full clinical resolution required treatment for fungal disease. Dog 1 was treated with itraconazole, then fluconazole (total treatment time, 23 weeks). Dog 2 was treated with fluconazole for 36 weeks. CLINICAL RELEVANCE: Retroperitoneal pyogranulomatous fibrosis caused by fungal infections has not been reported in veterinary medicine. There was substantial morbidity, but the prognosis can be good when this abnormality is recognized and antifungal medications are administered.

Granulomatous Inflammation Presenting as a Pulmonary Artery Mass.

Granulomatous fungal infections are common worldwide, and they can result in mediastinal lymphadenopathy. However, infectious pulmonary artery masses are rare and have only been associated with tuberculosis or mucormycosis. Here, we present a case of histoplasmosis resulting in a pulmonary artery mass, which was treated with debulking and reconstruction of pulmonary vasculature.

Risk factors for rhegmatogenous retinal detachment in the submacular surgery trials: SST report No. 22.

OBJECTIVE: To identify risk factors associated with the development of rhegmatogenous retinal detachment (RRD) in patients enrolled in the Submacular Surgery Trials. METHODS: One thousand fifteen patients with eligible subfoveal neovascular lesions in the study eye were assigned randomly to observation or to surgery. Eyes were examined at 3 months, 6 months, 12 months, and 24 months after enrollment to assess study outcomes and adverse events, including RRDs. Adverse events also were reported at other times as clinical personnel became aware of them. Potential risk factors for the development of RRD in study eyes were evaluated using recursive partitioning and logistic regression analysis. RESULTS: Among 506 eyes assigned to surgery, RRD developed in 44 (8.7%) compared with 4 (0.8%) of 509 eyes assigned to observation. Of the 44 eyes in which RRD developed, 27 had age-related macular degeneration (AMD) and large (>3.5 MPS disk areas) hemorrhagic subfoveal neovascular lesions at baseline and represented 16.1% of all eyes with such lesions assigned to surgery. Eyes with AMD and larger hemorrhagic lesions (>16 MPS disk areas) together with relatively poor visual acuity (best-corrected visual acuity < or =20/1280) had a higher risk of RRD (odds ratio = 6.2, 95% confidence interval: 2.2-16.7) compared with those with smaller lesions and better visual acuity at baseline. CONCLUSION: Poor visual acuity and very large, predominantly hemorrhagic subfoveal neovascular AMD lesion type were the greatest risk factors for RRD after submacular surgery. Submacular surgery should be undertaken in such eyes with full awareness of the risk of RRD during subsequent follow-up.

Histoplasmosis mimicking metastatic spinal tumour.

Histoplasmosis is an infection caused by a fungus called Histoplasma. Diagnosis of histoplasmosis is based on the culture of biological samples and detection of fungus in tissues. Histoplasmosis can mimic malignant lesions. We report a 65-year-old, immunocompetent, male patient with back pain. We describe the main clinical and radiological characteristics in our patient who had vertebral histoplasmosis that mimicked cancer. A computed tomography scan showed lytic lesions of the right side of T4, T5, and T6 vertebral bodies. Magnetic resonance imaging displayed abnormal marrow signals in T4, T5, and T6 vertebral bodies (low signal on T1, high on T2 and short time inversion recovery (STIR)). Which was mimicking malignancy, such as haematological malignancy and metastatic bone cancer. Therefore, thoracic spinal surgery using the anterior approach was performed. An intraoperative frozen section examination and routine postoperative pathology showed thoracic histoplasmosis infection. Treatment of histoplasmosis was performed with oral itraconazole. The lesions did not progress and the patient symptomatically improved at a follow-up of 26 months.

Gastrointestinal histoplasmosis in the acquired immunodeficiency syndrome: report of 18 cases and literature review.

No large case series of gastrointestinal histoplasmosis (GIH) in patients with AIDS has been published. We report 18 cases and review 34 published cases in the medical literature. We did a retrospective chart review from patients seen in our medical practices between 1989 and 2004. Most of our patients were men who had sex with men and who were not receiving highly active antiretroviral therapy. Median CD4 count was 34/muL. The most common presenting symptoms were diarrhea, fever, abdominal pain, and weight loss. The most commonly involved site was the colon or cecum. Biopsies revealed visible Histoplasma capsulatum organisms in 89%. Cultures from any site were positive in 76.9%. Four patients died from GIH. Gastrointestinal histoplasmosis occurs in severely immunocompromised patients with AIDS not receiving highly active antiretroviral therapy. Typical manifestations include diarrhea, fever, abdominal pain, and weight loss. Diagnosis is confirmed by blood or gastrointestinal tissue culture. Improvements in antiretroviral and antifungal therapies appear to have reduced the incidence of GIH and may improve the prognosis of this disease.

Health- and vision-related quality of life among patients with ocular histoplasmosis or idiopathic choroidal neovascularization at enrollment in a randomized trial of submacular surgery: Submacular Surgery Trials Report No. 5.

OBJECTIVES: To (1) summarize vision-targeted and general health-related quality-of-life scores at baseline and quantify the effect of the ophthalmic problem, (2) evaluate the strength of relations between visual acuity and interview scores, and (3) compare scores for patients who also had choroidal neovascular lesions in the fellow eye (bilateral cases) with those of patients who had choroidal neovascularization in only the study eye (unilateral cases) at time of enrollment in a randomized trial of surgical removal of subfoveal choroidal neovascularization, either associated with the ocular histoplasmosis syndrome or of idiopathic origin. DESIGN: Eligible patients had subfoveal choroidal neovascularization (including some classic choroidal neovascularization) and a visual acuity of 20/50 to 20/800 (Snellen equivalent), inclusive, in the eye to be assigned randomly to surgery or observation. Interviews that incorporated the 39-item version of the National Eye Institute Visual Function Questionnaire (NEI-VFQ) and 2 other instruments were conducted by telephone by trained interviewers before patients enrolled and were assigned randomly to surgery or observation. Information from baseline clinical examinations and fluorescein angiograms interpreted centrally by masked readers was used to classify patients as unilateral or bilateral cases and to provide potential explanations for variability of interview responses using linear regression models. RESULTS: The median overall NEI-VFQ score was 75 (interquartile range, 60-84). The median scores on individual subscales ranged from 55 (general vision) to 100 (color vision). The visual acuity of the better-seeing eye accounted for much of the variability in scores on most NEI-VFQ subscales; a 3-line difference in visual acuity was associated with a 10-point or greater difference in scores on 5 subscales after adjustment for other characteristics of patients and eyes. Scores on most scales of all 3 instruments differed between unilateral cases (n = 167) and bilateral cases (n = 58). Even after adjustment for visual acuity and reading speed of the better-seeing eye, age, gender, and scores on the other instruments, scores on the NEI-VFQ near and distance activities subscales differed by almost 13 and 10 points, respectively, between unilateral and bilateral cases. Neither age nor gender was an important independent explanatory variable for NEI-VFQ scores. CONCLUSIONS: Unilateral and bilateral cases had vision-targeted health-related quality-of-life scores worse than those published for a reference population without eye disease. Furthermore, despite younger age, better visual acuity, and better short-term visual prognosis, bilateral cases had NEI-VFQ scores at baseline similar to those published for 2 groups of patients with age-related macular degeneration. Unidentified factors, in addition to the visual acuity of the better-seeing eye, affected patients' perceptions of visual function.

Evaluation of the traveling vision examiner program in the submacular surgery trials pilot study.

PURPOSE: To describe methods and results and to assess the value of a Traveling Vision Examiner (TVE) Program designed to provide masked vision measurements by expert vision examiners who were independent of, and traveled to, local clinical centers. METHODS: The Submacular Surgery Trials (SST) Pilot Study was conducted to refine the design and methods for a set of multicenter, randomized clinical trials to evaluate submacular surgery in patients with subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration (AMD) or ocular histoplasmosis (OHS), or idiopathic CNV in which the primary study outcome would be change in 2-year best-corrected vision from baseline. As part of the SST Pilot Study, the feasibility and value of a TVE Program was assessed. The goal of the program was to obtain unbiased vision measurements, according to a standard protocol, of best-corrected visual acuity, reading speed, and contrast threshold, of each patient at 2 and 4 years after enrollment. RESULTS: Eighty-three visits by TVEs were made to 16 centers participating in the SST Pilot Study; 239 patients had at least one masked vision examination. Comparison of pairs of vision measurements of the traveling vision examiners and local vision examiners for 71 patients made on the same day showed good agreement overall (intraclass correlation coefficient > or = 0.81). CONCLUSIONS: The proposed TVE Program was judged to be a feasible and useful method of providing standardized, unbiased, masked vision measurements. This approach was incorporated into the larger clinical trials conducted by the SST Research Group.

Left atrial myxoma infected with Histoplasma capsulatum.

A patient is presented in whom a left atrial myxoma was found to be infected with Histoplasma capsulatum. Histoplasmosis has not been previously associated with this tumor, nor has any fungus without preceding bacterial endocarditis and long-term antibiotic therapy. The clinical course in foru previously reported cases of bacterially infected myxoma is reviewed. There have been 18 prior cases of Histoplasma endocarditis and in two the patients have survived. Their clinical presentation and response to therapy are also reviewed, and pertinent therapeutic conclusions drawn. The role of echocardiography in this patient's evaluation and the ultimate successful therapy are discussed.

Mediastinal granuloma.

In a group of 47 patients with mediastinal granulomas, the most common clinical symptoms were cough, chest pain, dysphagia, hemoptysis, and dyspnea. The main laboratory findings were right paratracheal or hilar mass on chest roentgenogram, positive histoplasmin skin test, and caseating granuloma on histopathologic examination. Complications included fibrosing mediastinitis with superior vena cava obstruction, esophageal compression, and major upper airway compression. Treatment was usually surgical resection or evacuation of caseous contents. The prognosis in most patients with mediastinal granulomas appears to be good--long-term survival with minimal or no disability.

Pulmonary fungal infection. Survey of 159 cases with surgical implications.

A survey of 159 cases of pulmonary fungal disease treated at the Hospital of the University of Mississippi is presented. The fungal diseases encountered were blastomycosis, 75 cases (47%); histoplasmosis, 38 cases (24%); aspergillosis, 17 cases (11%); cryptococcosis, 13 cases (8%); nocardiosis, nine cases (6%); and actinomycosis, seven cases (4%). Coccidioidomycosis is not endemic to Mississippi. Histoplasmosis was probably more common than diagnosed, but clear cytologic evidence or detection of the organisms was the rigid criterion required for diagnosis. Immunosuppressed patients appeared to be especially susceptible to infection by certain of the fungi. Fungal diseases were found to mimic numerous other pulmonary lesions, and specific diagnosis was often long delayed. Seventy-one operations were required for diagnosis or therapy or both, with two deaths. The major pulmonary complications of the several fungal diseases have been reviewed. Pulmonary hemorrhage constituted the major emergency. Amphotericin B was the mainstay of drug therapy, but upon occasion stilbamidine, penicillin, sulfonamides, and other agents were useful in specific circumstances. Accurate diagnosis, appropriate drug therapy, and judicious operative intervention when required will achieve gratifying clinical results in the vast majority of pulmonary fungal diseases.

Persistent and recurrent neovascularization after krypton laser photocoagulation for neovascular lesions of ocular histoplasmosis. Macular Photocoagulation Study Group.

Persistence and recurrence of choroidal neovascularization after initial treatment with laser photocoagulation have been shown to be major contributors to loss of visual acuity. The 144 eyes assigned to krypton red laser photocoagulation in the Ocular Histoplasmosis Study-Krypton Laser were examined to describe persistence and recurrence in these patients. Persistent neovascularization was observed among 23% of treated patients and recurrent neovascularization was observed among an additional 8%. Both persistence and recurrence were accompanied by an increased frequency of severe visual loss. Patients with high blood pressure were more than 2.5 times as likely to have persistent neovascularization as patients without high blood pressure (95% confidence interval = 1.5, 4.8). Eyes in which the neovascular component of the complex was within 200 microns of the center of the foveal avascular zone were twice as likely to have persistent neovascularization (95% confidence interval = 1.2, 4.6). Eyes in which the treatment did not cover the neovascularization completely or did not meet the required level of intensity on the foveal side had a persistence rate approximately three times that of eyes in which the neovascularization was covered completely by intense, confluent burns (95% confidence interval = 1.7, 6.5). This last finding is of particular importance for ophthalmologists who treat similar patients.

The evolution of argon laser photocoagulation scars in patients with the ocular histoplasmosis syndrome.

In 34 patients (35 eyes) with successfully treated histoplasmic choroidal neovascular membranes with a mean follow-up of 10.1 years, neither the neovascular membrane size nor the distance to the center of the foveal avascular zone (FAZ) affected final visual acuity. For a subgroup of 18 patients who had a two-year follow-up visit, the average chorioretinal scar expanded in area 50.1% per year for the first two years and 4.6% per year thereafter. This corresponded to a migration rate toward the FAZ of 152 micron/y for the first two years and 22 micron/y thereafter. After ten years, the average scar was 3.23 times larger than the initial treatment area and 480 micron closer to the FAZ than the initial treatment edge. Of the eight patients whose scars expanded to involve the center of the FAZ, six had final visual acuities either equal to or better than the initial visual acuities.

De novo subretinal neovascularization in the histoplasmosis syndrome.

A 22-year-old man was seen with the ocular histoplasmosis syndrome. This case demonstrates that spontaneous or "de novo" neovascularization without prior pigmentary changes can occasionally, although rarely, give rise to the disciform macular disease process and the potential for loss of central vision. The lesion initially responded favorably to treatment with heavy argon laser photocoagulation in the parafoveal area, including the papillomacular area, but subsequent areas of neovascularization proved intractable to laser therapy.

Long-term results of laser treatment in the ocular histoplasmosis syndrome.

OBJECTIVE: To determine the long-term visual outcome, rate of persistent choroidal neovascularization, and rate of recurrent choroidal neovascularization in eyes undergoing laser photocoagulation for choroidal neovascularization secondary to ocular histoplasmosis syndrome. DESIGN AND PATIENTS: One hundred one eyes with 5 to 16 years of follow-up that presented with choroidal neovascularization secondary to ocular histoplasmosis were retrospectively evaluated. Patients were grouped according to location of choroidal neovascularization and assignment to observation or laser photocoagulation. MAIN OUTCOME MEASURES: Visual acuity outcome and loss for all groups were compared. The rates of persistent and recurrent choroidal neovascularization for the treated eyes were also evaluated. RESULTS: Visual acuity of 20/40 or better was obtained in 71% of eyes with treated extrafoveal choroidal neovascularization and 68% with treated juxtafoveal choroidal neovascularization. Recurrent choroidal neovascularization was observed in 23% of treated eyes during a mean follow-up of 9.6 years. CONCLUSION: Results support the long-term benefit of photocoagulation and need for careful follow-up.

Argon laser photocoagulation for ocular histoplasmosis. Results of a randomized clinical trial.

The Ocular Histoplasmosis Study (OHS) is a multicenter controlled clinical trial designed to determine whether argon laser photocoagulation is useful in preventing severe visual acuity loss in eyes with choroidal neovascular membranes (NVMs) 200 to 2,500 microns from the center of the foveal avascular zone and evidence of ocular histoplasmosis. Eligible patients were assigned to photocoagulation (n = 124) or to observation only (n = 121) groups. Recruitment of patients who have extrafoveal NVMs for the OHS has been terminated because more untreated eyes than treated eyes had experienced severe visual acuity loss. At the most recent follow-up visit (median follow-up, 18 months), 34.2% (39/114) of untreated eyes v 9.4% (11/117) of treated eyes had lost six or more lines of visual acuity from the baseline level. The superiority of argon laser photocoagulation was evident in all subgroups and at every point in follow-up time, indicating that patients who meet the eligibility criteria will benefit from treatment. Follow-up of all patients continues in order to assess long-term results of treatment.

Argon laser photocoagulation for neovascular maculopathy. Three-year results from randomized clinical trials. Macular Photocoagulation Study Group.

The Macular Photocoagulation Study randomized controlled clinical trials designed to determine whether argon laser photocoagulation is effective for preventing or delaying severe visual loss in eyes with an extrafoveal choroidal neovascular membrane secondary to senile macular degeneration (Senile Macular Degeneration Study [SMDS]), ocular histoplasmosis (Ocular Histoplasmosis Study [OHS]), or idiopathic neovascularization (Idiopathic Neovascularization Study [INVS]). Eligible patients were assigned randomly to a "treatment" group or to a "no treatment" group until recruitment was terminated in 1982 (SMDS) and 1983 (OHS and INVS) because of demonstrated short-term treatment benefit. As of Aug 31, 1985, three or more years of scheduled follow-up examinations had been completed for 208 (88%) of 236 eyes in the SMDS, 203 (77%) of 262 eyes in the OHS, and 51 (76%) of 67 eyes in the INVS. The relative risk of experiencing severe loss of vision after three years in eyes initially assigned to the no treatment group in comparison with eyes assigned to the argon laser photocoagulation group was 1.4 in the SMDS (95% confidence interval [CI]: 1.1 to 1.9), 5.5 in the OHS (95% CI: 3.9 to 10.8), and 2.3 in the INVS (95% CI: 0.8 to 6.5). The beneficial effects of argon laser treatment have persisted in all three studies in spite of the fact that some eyes in the "no treatment" groups were treated later in their clinical course as a result of the evidence of early benefit. Follow-up of all patients continues so that treatment effectiveness over a five-year period can be assessed.