Histoplasmosis Treatment & Management

  • Author: Jazeela Fayyaz, DO; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Aug 26, 2011
 

Medical Care

Most infections in individuals who are immunocompetent are self-limiting and do not require therapy. In cases of prolonged infection, cases of systemic infection, or those involving individuals who are immunocompromised, medical treatment is recommended.[17]

  • Acute pulmonary histoplasmosis
    • No treatment is required for individuals who are asymptomatic.
    • Monitor mild symptoms (without treatment).
    • In patients with prolonged symptoms (>4 wk) or those with overwhelming pulmonary involvement, initiate medical therapy with itraconazole for 6-12 weeks. Response to therapy should be monitored via chest imaging. Patients should be monitored for several years after treatment for possible relapse.[17]
    • Patients with severe infection should be treated with amphotericin B for 1-2 weeks; once the patient is stable, amphotericin B may be changed to itraconazole and should be continued for 1 year.[18] Patients with acute respiratory distress symptoms may require methylprednisone for 1-2 weeks.[17]
  • Chronic pulmonary histoplasmosis
    • This often is fatal if not treated; the mortality rate may be as high as 50% without treatment, compared with a mortality rate of 28% with treatment.[3]
    • Patients may have a progressive loss of pulmonary function.
    • Patients with cavitary lesions must be treated, in most patients itraconazole is sufficient and should be given for one year. Relapse may occur in up to 15% of patients.
    • Persistent cavitations despite multiple courses of medical treatment warrant surgical consideration.
  • Progressive disseminated histoplasmosis and meningitis
    • Initiate medical therapy for all patients with progressive disseminated histoplasmosis and meningitis.
    • Hemodynamic and respiratory compromise from pericardial and pleural involvement warrants immediate procedural intervention. Perform thoracentesis or pericardiocentesis in patients with severe pleural effusions and pericardial tamponade, respectively.
  • Cutaneous and rheumatologic histoplasmosis: Lesions are self-limiting. Therapy is indicated only for prolonged episodes or in individuals who are immunosuppressed.
  • Broncholithiasis: Antifungal therapy does not play a role. Bronchoscopic or surgical removal may be required.[17]
  • Ocular histoplasmosis: Treat extensive maculopathy in presumed ocular histoplasmosis with steroids.
  • Mediastinal histoplasmosis
    • Treatment for mediastinal granuloma is not recommended in asymptomatic patients; for symptomatic patients, itraconazole may be used for 6-12 weeks, although clinical trials to support this are lacking.[18]
    • Antifungal therapy is not effective for fibrosing mediastinitis; corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) also are ineffective. Surgery is not recommended.
    • Antifungals are not recommended for pericarditis because it is an inflammatory reaction.
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Surgical Care

Use surgical procedures for diagnostic purposes when other modalities are unrevealing. Intervention is also required when medical therapy is insufficient to alleviate the effects of progressive fibrosis, calcification, and scarring.

  • Thoracic surgery
    • In rare cases when serologic and procedural modalities cannot indicate a definitive diagnosis, consider obtaining sufficient tissue samples using thoracoscopy or by performing an open lung biopsy.
    • Surgical resection of pulmonary cavitary lesions is required when repeated relapses or progressive disease occurs despite repeated intensive medical therapy.
    • Progressive fibrosis of the mediastinum can produce traction or invade into adjacent structures and cause a distorted anatomy. Surgery with spiral vein grafts or vascular stents may be necessary to treat SVC syndrome associated with fibrosing mediastinitis. Surgery may also be required to alleviate scarring, to retain structural integrity, and to alleviate symptoms. The possibility of extensive adhesion and distortion associates surgery with high mortality rates.
    • Mechanical compression by mediastinal and hilar granulomatosis may require surgical excision. However, surgery is risky because of the possibility of spilling necrotic material into the mediastinum and initiating further fibrotic reaction. Patients may develop extensive symptoms from compression of pulmonary, vascular, and rarely, esophageal structures.
  • Cardiac surgery
    • Pericardial window placement may be needed when pericardiocentesis is insufficient to alleviate pericardial tamponade.
    • Endovascular histoplasmosis may result in infected valves and aneurysm formation, which requires surgical excision of infected valves and aneurysm repair. Treating endovascular histoplasmosis with medical therapy alone is rarely curative.
  • Ophthalmologic treatment
    • Laser photocoagulation treatment may be needed in patients with active neovascular membrane formation due to choroiditis.
    • Overgrowth may result in progressive vision loss.
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Consultations

Obtain consultations when complications of histoplasmal infection compromise organ systems. Seek out a specialist to perform diagnostic procedures if other modalities do not provide adequate information to make a diagnosis.

  • Pulmonary specialist
    • Bronchoscopy may be needed for diagnostic purposes.
    • Bronchial washings and aspirates are sent for culture and analysis.
    • Transbronchial tissue biopsy provides specimens for histiologic examination.
  • Cardiology specialist: Pericardiocentesis is required to restore hemodynamic stability in patients with pericardial tamponade.
  • Cardiothoracic or ophthalmologic surgeon: Such surgery may be needed if complications arise or if further diagnostic options are required.
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Contributor Information and Disclosures
Author

Jazeela Fayyaz, DO  Pulmonologist, Department of Pulmonology, Unity Hospital

Jazeela Fayyaz, DO is a member of the following medical societies: American College of Physicians and American Thoracic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Klaus-Dieter Lessnau, MD, FCCP  Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital

Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Sepracor None None

Specialty Editor Board

Michael Peterson, MD  Chief of Medicine, Vice-Chair of Medicine, University of California, San Francisco, School of Medicine; Endowed Professor of Medicine, University of California, San Francisco-Fresno, School of Medicine

Michael Peterson, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H  Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California Keck School of Medicine

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Osler Society, American Thoracic Society, New York Academy of Medicine, and Royal Society of Medicine

Disclosure: Nothing to disclose.

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Ryan C. Chang, MD, and Irawan Susanto, MD, to the development and writing of this article.

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