Should histoplasmosis be screened for before initiation of tumour necrosis factor alpha inhibitors?
  • Srujan Edupuganti
    Department of Internal Medicine-Pediatrics, Hurley Medical Center, Flint, USA
  • Yashitha Chirumammilla
    Department of Internal Medicine, Hurley Medical Center, Flint, USA
  • Manoj Upadhyay
    Department of Internal Medicine, Hurley Medical Center, Flint, USA
  • Danielle Osterholzer
    Department of Infectious Diseases, Hurley Medical Center, Flint, USA

Keywords

Histoplasmosis, GPA, ANCA positivity, TNF-alpha inhibitors

Abstract

Histoplasmosis is a soil based dimorphic fungus endemic to the Midwest and Southeastern United States and is responsible for infection through inhalation of conidia. Infection is usually asymptomatic, as the fungal growth is contained by formation of granulomas. However, dissemination can occur in immunocompromised hosts due to the lack of optimal activity of interferon gamma, tumor necrosis factor-alpha (TNF-alpha) and interleukin-17. There is a significant overlap between the symptomatology of histoplasmosis and granulomatosis with polyangiitis (GPA). We are reporting a case of a 48-year-old female who presented with high grade fever, worsening generalized weakness and tachycardia. She had a previous history of bilateral cavitary lung lesions for which she was evaluated at an outside facility. As her entire infectious work up was negative and found to be positive for antineutrophil cytoplasmic antibody (ANCA), a diagnosis of GPA was made and she was initiated on rituximab infusions 7 weeks prior to her presentation to our facility. Repeat infectious work up at our facility was positive for (1,3) beta-D-glucan test and urine histoplasma antigen. Prompt discontinuation of rituximab and initiation of systemic antifungal therapy led to clinical improvement. Based on this experience we would like to highlight the association of histoplasma with ANCA positivity along with the importance of closely monitoring these patients, for possible clinical worsening after the initiation of immunosuppressive therapy, despite the negative infectious work up. 



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References

  • Centers for Disease Control and Prevention (CDC). Histoplasmosis outbreak associated with the renovation of an old house. MMWR Morb Mortal Wkly Rep 2014;62:1041–1044.
  • Akram SM, Koirala J. Histoplasmosis. 2023 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.
  • Garlapati P, Qurie A. Granulomatosis with polyangiitis. 2022 Dec 5. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.
  • Contreras-Rodríguez FJ, Alba MA, Rivera-Rosales RM, Flores-Suárez LF. An immunocompetent woman with pulmonary granulomatous vasculitis. Ann Am Thorac Soc 2021;18:1907–1911.
  • Mukhopadhyay S, Katzenstein AL. Biopsy findings in acute pulmonary histoplasmosis: unusual histologic features in 4 cases mimicking lymphomatoid granulomatosis. Am J Surg Pathol 2010;34:541–546.
  • Masiak A, Zdrojewski Z, Peksa R, Smolenska Z, Czuszynska Z, Sieminska A, et al. The usefulness of histopathological examinations of non-renal biopsies in the diagnosis of granulomatosis with polyangiitis. Reumatologia 2017;55:230–236.
  • Mead GE, Wilks D, McLaren K, Fergusson RJ. Oral histoplasmosis: a case report. J Infect 1998;37:73–75.
  • van Weelden M, Viola GR, Kozu KT, Aikawa NE, Ivo CM, Silva CA. Disseminated histoplasmosis in adolescent mimicking granulomatosis with polyangiitis. Rev Bras Reumatol Engl Ed. 2017;57:479–482.
  • Bajad S, Durgarao Yadavalli JN, Tanna D, Ekbote G, Kazi W, Gupta R. A rare case of disseminated histoplasmosis with oral manifestations in a rheumatoid arthritis patient treated with rituximab: diagnostic and management challenges-a review. Amrita Journal of Medicine 2020;16:27–29.
  • Mazi PB, Arnold SR, Baddley JW, Bahr NC, Beekmann SE, McCarty TP, et al. Management of histoplasmosis by infectious disease physicians. Open Forum Infect Dis 2022;9:ofac313.
  • Cipolat MM, Rodrigues DRR, Silveira LG, Silveira IG, Nothaft MSV, Brenol CV, et al. Screening with urine histoplasma antigen test in asymptomatic patients starting TNF-alpha inhibitor therapy: a cohort study. Ther Adv Infect Dis 2024;11:20499361231222134.
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    Published: 2024-04-16
    Issue: 2024: Vol 11 No 5 (view)


    How to cite:
    1.
    Edupuganti S, Chirumammilla Y, Upadhyay M, Osterholzer D. Should histoplasmosis be screened for before initiation of tumour necrosis factor alpha inhibitors?. EJCRIM 2024;11 doi:10.12890/2024_004467.