The Broad Clinical Spectrum of Disseminated Histoplasmosis in HIV-Infected Patients: A 30 Years' Experience in French Guiana

Abstract

Histoplasmosis is a common but neglected AIDS-defining condition in endemic areas for Histoplasma capsulatum. At the advanced stage of HIV infection, the broad spectrum of clinical features may mimic other frequent opportunistic infections such as tuberculosis and makes it difficult for clinicians to diagnose histoplasmosis in a timely manner. Diagnosis of histoplasmosis is difficult and relies on a high index of clinical suspicion along with access to medical mycology facilities with the capacity to implement conventional diagnostic methods (direct examination and culture) in a biosafety level 3 laboratory as well as indirect diagnostic methods (molecular biology, antibody, and antigen detection tools in tissue and body fluids). Time to initiation of effective antifungals has an impact on the patient's prognosis. The initiation of empirical antifungal treatment should be considered in endemic areas for Histoplasma capsulatum and HIV. Here, we report on 30 years of experience in managing HIV-associated histoplasmosis based on a synthesis of clinical findings in French Guiana with considerations regarding the difficulties in determining its differential diagnosis with other opportunistic infections.

Keywords: French Guiana; HIV; South America; histoplasma; histoplasmosis.

Figure 1

Disseminated histoplasmosis and HIV infection; six characteristic images: (a) Pulmonary form; Chest CT-scan: diffuse micronodular opacities of the two lungs in a patient with severe form. (b) Lymphadenopathic form with IRIS; supraclavicular lymphadenopathy. (c) Direct examination (MGG stain) of bone marrow aspiration: parasitic form of Histoplasma capsulatum; small budding yeasts (2–4 µm) surrounded by a pseudo-capsule, intra, and extra-macrophagic. (d) Digestive form; colonoscopy: colonic ulceration. (e) Cutaneous form; patient with disseminated papules. (f) Mucous form: patient with ulcerations of the oral mucosa.