Posaconazole as rescue therapy in African histoplasmosis

Abstract

African histoplasmosis is a granulomatous mycosis caused by Histoplasma capsulatum var. duboisii. Treatment is usually extrapolated from guidelines for classical histoplasmosis, and includes 2-4 weeks of amphotericin B followed by a step-down maintenance therapy with itraconazole. Pediatric usage of posaconazole, an oral second-generation azole, remains off-label, but recent surveys show that it is safe and well tolerated in children. We report a case of disseminated African histoplasmosis in a 12-year-old boy from Guinea-Bissau. Therapy with amphotericin B and itraconazole led to a progressive clinical deterioration. A dramatic and lasting improvement was observed using posaconazole. He completed 12 months of therapy. No relapse was noted during or 3 months after treatment. We report that posaconazole may be a safe and efficacious drug in the salvage management of disseminated AH, either in patients with disease refractory to conventional anti-fungal therapy, or in patients whose serious adverse effects of first-line drugs preclude its use.

Fig. 1

Histology from a cervical nodule – remark the presence of numerous uninucleate thick-walled large yeasts Histoplasma capsulatum var. duboisii (Hcd) along with numerous histiocytes (HE – 400×). Below a Grocott stain displays the thick wall of the yeasts as well as the budding (600×).

Fig. 2

Abdominal computerized tomography showing multiple retroperitoneal lymphadenopathies.

Fig. 3

Cervical nodular formations at days 4 (A) and 22 (B) of posaconazole therapy, along with cervical (C) and inguinal (D) regions after complete cicatrization.