Methods: We performed a query of our medical records for all cases of disseminated histoplasmosis in patients receiving TNF-a inhibitors between the years 1999 to 2014 at University Hospitals Case Medical Center in Cleveland, Ohio; a 1032-bed tertiary referral medical center that serves the greater Northeast Ohio community; an area of moderate histoplasmosis endemnicity.
Results: A total of 357 cases of disseminated histoplasmosis were identified, eight (2.2%) of whom were receiving TNF-a inhibitor therapy at the time of diagnosis. Five patients were receiving infliximab and three were receiving adalimumab. All patients had generalized, non-specific presenting symptoms and all but one had a complete response to anti-fungal treatment and the cessation of the inciting TNF-a inhibitor. Two patients eventually resumed TNF-a inhibitor therapy a year following their initial diagnosis. The only patient who succumbed to the infection had a delayed diagnosis - 19 days after initial presentation to an outside hospital.
Conclusion: The increasing use of TNF-a inhibitors should come with an increased awareness of its association with opportunistic infections including disseminated histoplasmosis and infections by other endemic fungi in endemic areas. This case series highlights the importance of early diagnosis in order to achieve a favorable outcome. This entails a higher degree of suspicion on initial presentation, as these infrequent opportunistic infections tend to have a non-specific presentation in immune-compromised hosts. This series also demonstrates the need for further studies to better understand the precise role that TNF-a plays in the dysfunctional immunologic response promoted by these compounds in order to prevent such infections in patients planning to receive TNF-a inhibitors.
R. Salata, None