Download PDF
J Neurol Surg Rep 2015; 76(01): e167-e172
DOI: 10.1055/s-0035-1554932
Case Report
Georg Thieme Verlag KG Stuttgart · New York

Histoplasmosis with Deep CNS Involvement: Case Presentation with Discussion and Literature Review

Omid R. Hariri
1   Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, California, United States
,
Tanya Minasian
1   Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, California, United States
,
Syed A. Quadri
1   Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, California, United States
,
Anya Dyurgerova
2   Division of Neurosurgery, Department of Surgery, Western University of Health Sciences, Pomona, California, United States
,
Saman Farr
2   Division of Neurosurgery, Department of Surgery, Western University of Health Sciences, Pomona, California, United States
,
Dan E. Miulli
1   Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, California, United States
,
Javed Siddiqi
1   Department of Neurosurgery, Arrowhead Regional Medical Center, Colton, California, United States
› Author Affiliations
Further Information

Publication History

09 December 2014

06 April 2015

Publication Date:
26 June 2015 (online)

   Permissions and Reprints

Abstract

Central nervous system (CNS) histoplasmosis is rare and difficult to diagnose because it is often overlooked or mistaken for other pathologies due to its nonspecific symptoms. A 32-year-old Hispanic man with advanced acquired immunodeficiency virus presented with altered mental status and reported confusion for the past 3 months. He had a Glasgow Coma Scale of 12, repetitive nonfluent speech, and a disconjugate gaze with a right gaze preference. Lung computed tomography (CT) findings indicated a pulmonary histoplasmosis infection. Magnetic resonance imaging of the brain revealed a ring-enhancing lesion in the left caudate nucleus. A CT-guided left retroperitoneal node biopsy was performed and indicated a benign inflammatory process with organisms compatible with fungal yeast. Treatment with amphotericin B followed by itraconazole was initiated in spite of negative cerebrospinal fluid (CSF) cultures and proved effective in mitigating associated CNS lesions and resolving neurologic deficits. The patient was discharged 3 weeks later in stable condition. Six weeks later, his left basal ganglia mass decreased. Early recognition of symptoms and proper steps is key in improving outcomes of CNS histoplasmosis. Aggressive medical management is possible in the treatment of intracranial deep mass lesions, and disseminated histoplasmosis with CNS involvement can be appropriately diagnosed and treated, despite negative CSF and serology studies.

Keywords

Histoplasma capsulatum - disseminated histoplasmosis - CNS infection - fungal yeast - CSF culture - ring-enhancing lesion - immunocompromised - human immunodeficiency virus
 

  • References

  • 1 Kauffman CA. Histoplasmosis: a clinical and laboratory update. Clin Microbiol Rev 2007; 20 (1) 115-132
    CrossrefPubMedGoogle Scholar
  • 2 Eissenberg LG, Goldman WE, Schlesinger PH. Histoplasma capsulatum modulates the acidification of phagolysosomes. J Exp Med 1993; 177 (6) 1605-1611
    CrossrefPubMedGoogle Scholar
  • 3 Sebghati TS, Engle JT, Goldman WE. Intracellular parasitism by Histoplasma capsulatum: fungal virulence and calcium dependence. Science 2000; 290 (5495) 1368-1372
    CrossrefPubMedGoogle Scholar
  • 4 Trofa D, Nosanchuk JD. Histoplasmosis of the central nervous system. J Neuroparasitology 2012; 3: 1-7
    PubMedGoogle Scholar
  • 5 Veeravagu A, Ludwig C, Camara-Quintana JQ, Jiang B, Lad N, Shuer L. Fungal infection of a ventriculoperitoneal shunt: histoplasmosis diagnosis and treatment. World Neurosurg 2013; 80 (1-2) 222.e5-222.e13
    PubMedGoogle Scholar
  • 6 Goldman M, Zackin R, Fichtenbaum CJ , et al; AIDS Clinical Trials Group A5038 Study Group. Safety of discontinuation of maintenance therapy for disseminated histoplasmosis after immunologic response to antiretroviral therapy. Clin Infect Dis 2004; 38 (10) 1485-1489
    CrossrefPubMedGoogle Scholar
  • 7 McKinsey DS, Spiegel RA, Hutwagner L , et al. Prospective study of histoplasmosis in patients infected with human immunodeficiency virus: incidence, risk factors, and pathophysiology. Clin Infect Dis 1997; 24 (6) 1195-1203
    CrossrefPubMedGoogle Scholar
  • 8 Wheat LJ, Musial CE, Jenny-Avital E. Diagnosis and management of central nervous system histoplasmosis. Clin Infect Dis 2005; 40 (6) 844-852
    CrossrefPubMedGoogle Scholar
  • 9 Black KE, Baden LR. Fungal infections of the CNS: treatment strategies for the immunocompromised patient. CNS Drugs 2007; 21 (4) 293-318
    CrossrefPubMedGoogle Scholar
  • 10 Saccente M. Central nervous system histoplasmosis. Curr Treat Options Neurol 2008; 10 (3) 161-167
    CrossrefPubMedGoogle Scholar
  • 11 Carod-Artal F, Venturini M, Gomes E, de Mello M. Chronic central nervous system histoplasmosis in an immunocompetent patient [in Spanish]. Neurologia 2008; 23 (4) 263-268
    PubMedGoogle Scholar
  • 12 Hamada M, Tsuji S. Central nervous system histoplasmosis [in Japanese]. Brain Nerve 2009; 61 (2) 129-134
    PubMedGoogle Scholar
  • 13 Vullo V, Mastroianni CM, Ferone U , et al. Central nervous system involvement as a relapse of disseminated histoplasmosis in an Italian AIDS patient. J Infect 1997; 35 (1) 83-84
    CrossrefPubMedGoogle Scholar
  • 14 Guarner J, Brandt ME. Histopathologic diagnosis of fungal infections in the 21st century. Clin Microbiol Rev 2011; 24 (2) 247-280
    CrossrefPubMedGoogle Scholar
  • 15 Aravalli RN, Hu S, Woods JP, Lokensgard JR. Histoplasma capsulatum yeast phase-specific protein Yps3p induces Toll-like receptor 2 signaling. J Neuroinflammation 2008; 5: 30
    CrossrefPubMedGoogle Scholar
  • 16 Khasawneh FA, Ahmed S, Halloush RA. Progressive disseminated histoplasmosis presenting with cachexia and hypercalcemia. Int J Gen Med 2013; 6: 79-83
    PubMedGoogle Scholar
  • 17 Nguyen FN, Kar JK, Zakaria A, Schiess MC. Isolated central nervous system histoplasmosis presenting with ischemic pontine stroke and meningitis in an immune-competent patient. JAMA Neurol 2013; 70 (5) 638-641
    CrossrefPubMedGoogle Scholar
  • 18 Ramireddy S, Wanger A, Ostrosky L. An instructive case of CNS histoplasmosis in an immunocompetent host. Med Mycol Case Rep 2012; 1 (1) 69-71
    CrossrefPubMedGoogle Scholar
  • 19 Cleary JD, Pearson M, Oliver J, Chapman SW. Association between Histoplasma exposure and stroke. J Stroke Cerebrovasc Dis 2008; 17 (5) 312-319
    CrossrefPubMedGoogle Scholar
  • 20 Paphitou NI, Barnett BJ. Solitary parietal lobe histoplasmoma mimicking a brain tumor. Scand J Infect Dis 2002; 34 (3) 229-232
    CrossrefPubMedGoogle Scholar
  • 21 Loughan AR, Perna R, Hertza J. Cognitive impairment and memory loss associated with histoplasmosis: a case study. Clin Neuropsychol 2014; 28 (3) 514-524
    CrossrefPubMedGoogle Scholar
  • 22 Shapiro JL, Lux JJ, Sprofkin BE. Histoplasmosis of the central nervous system. Am J Pathol 1955; 31 (2) 319-335
    PubMedGoogle Scholar
  • 23 Azizirad O, Clifford DB, Groger RK, Prelutsky D, Schmidt RE. Histoplasmoma: isolated central nervous system infection with Histoplasma capsulatum in a patient with AIDS. Case report and brief review of the literature. Clin Neurol Neurosurg 2007; 109 (2) 176-181
    CrossrefPubMedGoogle Scholar
  • 24 Hott JS, Horn E, Sonntag VKH, Coons SW, Shetter A. Intramedullary histoplasmosis spinal cord abscess in a nonendemic region: case report and review of the literature. J Spinal Disord Tech 2003; 16 (2) 212-215
    CrossrefPubMedGoogle Scholar
  • 25 John AM, Vasanthi N, Khurana A , et al. An unusual cause for rings in the brain. Hong Kong Med J 2012; 18 (4) 346-347
    PubMedGoogle Scholar
  • 26 Klein CJ, Dinapoli RP, Temesgen Z, Meyer FB. Central nervous system histoplasmosis mimicking a brain tumor: difficulties in diagnosis and treatment. Mayo Clin Proc 1999; 74 (8) 803-807
    CrossrefPubMedGoogle Scholar
  • 27 Murata M, Furusyo N, Otaguro S, Nabeshima S, Ariyama I, Hayashi J. HIV infection with concomitant cerebral toxoplasmosis and disseminated histoplasmosis in a 45-year-old man. J Infect Chemother 2007; 13 (1) 51-55
    CrossrefPubMedGoogle Scholar
  • 28 Parihar A, Tomar V, Ojha BK, Husain N, Gupta RK. Magnetic resonance imaging findings in a patient with isolated histoplasma brain abscess. Arch Neurol 2011; 68 (4) 534-535
    CrossrefPubMedGoogle Scholar
  • 29 Saccente M, McDonnell RW, Baddour LM, Mathis MJ, Bradsher RW. Cerebral histoplasmosis in the azole era: report of four cases and review. South Med J 2003; 96 (4) 410-416
    CrossrefPubMedGoogle Scholar
  • 30 Smith JS, Quiñones-Hinojosa A, Phillips JJ, Bollen AW, McDermott MW, Cha S. Limitations of diffusion-weighted imaging in distinguishing between a brain tumor and a central nervous system histoplasmoma. J Neurooncol 2006; 79 (2) 217-218
    CrossrefPubMedGoogle Scholar
  • 31 Kastrup O, Wanke I, Maschke M. Neuroimaging of infections. NeuroRx 2005; 2 (2) 324-332
    CrossrefPubMedGoogle Scholar
  • 32 Rangel-Castilla L, Hwang SW, White AC, Zhang YJ. Neuroendoscopic diagnosis of central nervous system histoplasmosis with basilar arachnoiditis. World Neurosurg 2012; 77 (2) E9-E13
    CrossrefPubMedGoogle Scholar
  • 33 Wheat LJ, Connolly P, Smedema M , et al. Activity of newer triazoles against Histoplasma capsulatum from patients with AIDS who failed fluconazole. J Antimicrob Chemother 2006; 57 (6) 1235-1239
    CrossrefPubMedGoogle Scholar
  • 34 Wheat LJ, Freifeld AG, Kleiman MB , et al; Infectious Diseases Society of America. Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis 2007; 45 (7) 807-825
    CrossrefPubMedGoogle Scholar