1448. Histoplasmosis in patients with cell-mediated immunodeficiency:  HIV infection, organ transplantation, or TNF-? inhibition
Session: Poster Abstract Session: Fungal Infections
Saturday, October 5, 2013
Room: The Moscone Center: Poster Hall C
Posters
  • 1448_IDWposter.pdf (530.7 kB)
  • Background:

    Histoplasmosis is known to cause severe disease in patients with defects of cell-mediated immunity who live in an endemic area. It is not known whether disease presentation or outcome varies related to the type of immunodeficiency.

    Methods:

    All cases of active histoplasmosis at Vanderbilt University Medical Center occurring in patients with HIV infection, a history of transplantation, or TNF-α inhibitor use from July 1999 to June 2012 were retrospectively reviewed. These groups were compared for differences in clinical presentation and outcomes.

    Results:

    Ninety cases were identified including 56 with HIV infection, 23 with solid organ transplants and 11 with TNF-α inhibitor therapy.  Presenting symptoms were similar among the 3 groups. TNF-α patients were more likely to have mild disease and present for care in an outpatient setting compared to HIV patients.  All HIV patients had CD4 T cell counts < 200/mL and were noted to have more cytopenias than transplant and TNF-α patients.  Fungemia was seen in 51% of HIV patients, 27% of organ transplant recipients (p= 0.095 vs. HIV), and in no TNF-α patients (p=0.04 vs. HIV).  The frequency of Histoplasma antigenuria was similar among the three groups (HIV 88%, transplant 95%, TNF-α 91%), but median antigen levels were quantitatively higher in HIV patients than TNF-α patients (19.6 vs. 6.9 ng/mL; p=.02).  Organ transplant recipients were less likely to receive initial amphotericin therapy (21% vs 57% HIV vs 55% TNF-α; p=.006), but failure rates with initial azole therapy were not different among the three groups (HIV 16%, transplant 22%, TNF-α 0%; p=NS).  Patients who failed azole therapy had higher median urine antigen levels (27.1 vs 4.8 ng/mL; p=.02).  There was no difference in 90 day histoplasmosis-related mortality (9% for all groups).

    Conclusion:

    Histoplasmosis caused milder disease in patients receiving TNF-α inhibitors than patients with HIV or solid organ transplantation.  HIV patients had more bone marrow suppression and fungemia.  The presence of Histoplasma antigenuria was high in all three groups, but antigen levels were lower in TNF-α patients.  The majority of transplant recipients were successfully managed without the use of amphotericin, but azole failures correlated with higher urine antigen levels. Ninety day mortality did not differ among the groups and was less than 10%.

    Keith Luckett, MD1, Lora Thomas, MD1, Geraldine Miller, MD1, Sydney Hester, MD2 and Stephen Dummer, MD1, (1)Vanderbilt University, Nashville, TN, (2)Tristar Medical Group, Nashville, TN

    Disclosures:

    K. Luckett, None

    L. Thomas, None

    G. Miller, None

    S. Hester, None

    S. Dummer, None

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