The dimorphic fungus Histoplasma capsulatum is endemic along the Ohio and Mississippi River Valleys and can cause clinically significant disease in those with impaired cellular immunity, including solid-organ transplant recipients on chronic immunosuppression, HIV/AIDS patients, and those receiving TNF-alpha inhibitors¹. Our institution is located in a region endemic for H. capsulatum, and currently cares for 3,000+ kidney transplant recipients with a greater than 90% retention rate in our clinics. A retrospective analysis of all kidney transplant recipients cared for at our center from 2004-2015 identified 41 patients with confirmed histoplasmosis. Prior published studies of this population were limited by small numbers of patients at single centers, or larger numbers obtained from multiple institutions where there are differences in prevalence of the pathogen in the environment, as well as different approaches to diagnosis and management of these patients². This is the largest single-center cohort reported thus far. Of the 41 patients, 87.8% had disseminated disease, 7.3% had disease restricted to the lungs, and 4.8% had ocular disease. The median time from transplantation to presentation was 2 years, with 34% presenting in the first year. Of note, 17% of patients had been treated for a recent rejection of the renal allograft. The most common presenting symptoms were fever (73%), respiratory symptoms (56%), and diarrhea (32%). Treatment was initiated for disseminated disease with an amphotericin formulation in 25% of patients, with subsequent transition to a triazole, most commonly itraconazole. Of those taking itraconazole, the medication had to be discontinued due to an adverse reaction in 18%, with the development of congestive heart failure accounting for 50% of these adverse reactions. Subsequent graft failure was seen in 14.6% of the patients, and overall mortality was 9.8% during our study period. Histoplasmosis should be suspected in endemic regions where patients present with fever and/or pulmonary infections not otherwise explained. Early recognition and diagnosis of histoplasmosis may improve outcomes in infected individuals.

References:

1. Luckett K et al. Histoplasmosis in Patients with Cell-Mediated Immunodeficiency: Human Immunodeficiency Virus Infection, Organ Transplantation, and Tumor Necrosis Factor-a Inhibition. Open Forum Infect Dis. 2015 Feb 20;2(1).

2. Assi M et al. Histoplasmosis after solid organ transplant. Clin Infect Dis. 2013 Dec;57(11): 1542-9.

CITATION INFORMATION: Mashayekhi M, Langone A. Analysis of a Large Single-Center Cohort of Renal Transplant Recipients with Histoplasmosis. Am J Transplant. 2016;16 (suppl 3).

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