Disseminated Histoplasmosis in HIV-Infected Patients: A Description of 34 Years of Clinical and Therapeutic Practice.

Mathieu Nacher,Loïc Epelboin,Pierre Couppié,Kinan Drak Alsibai,Magalie Demar,Balthazar Ntab,Caroline Misslin,Philippe Abboud,Félix Djossou,Audrey Valdes,Romain Blaizot,Antoine Adenis

doi:10.3390/jof6030164

Abstract

Disseminated histoplasmosis is the main AIDS-defining infection of French Guiana. We aim to describe our therapeutic experience for 349 patients with disseminated histoplasmosis between 1 January 1981 and 10 January 2014 in French Guiana. Survival, delays for treatment initiation, duration of induction therapy, and associated initial treatments are described. The death rate was 14.9 per 100 person-years, with an early drop in survival. Among those who died, >1/3 died within a year of HIV diagnosis, and ¾ of all patients with histoplasmosis had been diagnosed for HIV within a year. As induction treatment, 29% received liposomal amphotericin B, 12.9% received deoxycholate amphotericin B, 54% received itraconazole alone, and 21.8% received liposomal amphotericin B and itraconazole. The median delay between symptoms-onset and hospitalization was 19.5 days (IQR = 5–105). Liposomal amphotericin B or itraconazole was initiated shortly after admission. Treatment initiation was often presumptive for liposomal amphotericin B (27%) and itraconazole (20%). The median duration of liposomal amphotericin B treatment was 7 days (IQR = 5–11 days). The present study shows that ¾ of the patients were profoundly immunocompromised and had been diagnosed for HIV within the past year. Antifungal treatment was often initiated presumptively on admission. Over time there was a significant gradual decline in early death.

Highlights

The HIV epidemic has grown since the early 1980s in French Guiana, a French overseas territory between Brazil and Suriname
We aim to describe our therapeutic experience in French Guiana, notably, the delays for treatment initiation, the duration of induction therapy, and the associated initial treatments
The study population consisted of coinfections with HIV and histoplasmosis that were enrolled in the Histoplasmosis and HIV database of French Guiana

Summary

Introduction

The HIV epidemic has grown since the early 1980s in French Guiana, a French overseas territory between Brazil and Suriname. One of the greatest particularities of patients with advanced HIV in French Guiana is the high incidence of disseminated histoplasmosis, which is the most frequent. AIDS-defining infection and cause of death among HIV-infected patients [1,2]. Awareness of this epidemiological fact has grown since the 1980s, starting with the dermatologists, spreading to all physicians, when the implementation of fungal culture increasingly allowed the identification of the fungal pathogen [3,4]. In Latin America, the frequent lack of awareness about histoplasmosis and the lack of availability of diagnostic methods translate into thousands of annual deaths among persons with advanced HIV [5]. For moderately severe to severe disseminated histoplasmosis, the updated 2007 guidelines of the Infectious Diseases Society of America [6,7] recommend induction with liposomal amphotericin B for 1–2 weeks, followed by oral itraconazole for a total of at least 12 months

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