Histoplasma capsulatum endocarditis: multicenter case series with review of current diagnostic techniques and treatment

Abstract

Infective endocarditis is an uncommon manifestation of infection with Histoplasma capsulatum. The diagnosis is frequently missed, and outcomes historically have been poor. We present 14 cases of Histoplasma endocarditis seen in the last decade at medical centers throughout the United States. All patients were men, and 10 of the 14 had an infected prosthetic aortic valve. One patient had an infected left atrial myxoma. Symptoms were present a median of 7 weeks before the diagnosis was established. Blood cultures yielded H. capsulatum in only 6 (43%) patients. Histoplasma antigen was present in urine and/or serum in all but 3 of the patients and provided the first clue to the diagnosis of histoplasmosis for several patients. Antibody testing was positive for H. capsulatum in 6 of 8 patients in whom the test was performed. Eleven patients underwent surgery for valve replacement or myxoma removal. Large, friable vegetations were noted at surgery in most patients, confirming the preoperative transesophageal echocardiography findings. Histopathologic examination of valve tissue and the myxoma revealed granulomatous inflammation and large numbers of organisms in most specimens. Four of the excised valves and the atrial myxoma showed a mixture of both yeast and hyphal forms on histopathology. A lipid formulation of amphotericin B, administered for a median of 29 days, was the initial therapy in 11 of the 14 patients. This was followed by oral itraconazole therapy, in all but 2 patients. The length of itraconazole suppressive therapy ranged from 11 months to lifelong administration. Three patients (21%) died within 3 months of the date of diagnosis. All 3 deaths were in patients who had received either no or minimal (1 day and 1 week) amphotericin B.

FIGURE 1

Histopathology of resected prosthetic aortic valve from Case 1 (Patient 12 in Table 1). Grocott methenamine silver stain demonstrating both yeast forms and hyphal elements.

FIGURE 2

Transesophageal echocardiogram of Case 2 (Patient 11 in Table 1) demonstrating a large mass (arrow) extending from the left atrium (LA), to the left ventricle (LV) across the mitral valve.

FIGURE 3

Resected atrial myxoma from Case 2 (Patient 11 in Table 1).

FIGURE 4

Histopathology of resected myxoma from Case 2 (Patient 11 in Table 1). Grocott methenamine silver stain demonstrating both typical yeast forms and enlarged atypical yeast structures.