Abstract
Disseminated histoplasmosis is one the main AIDS-defining opportunistic infections in HIV-infected patients, notably in Latin America. The non-specific and proteiform clinical presentation leads to diagnostic delays that may lead to fatal outcomes. This retrospective multicentric study aimed to describe the frequency and manifestations of gastrointestinal histoplasmosis in French Guiana, and to compare patients with disseminated histoplasmosis with or without gastrointestinal involvement.Between January 1, 1981 and October 1, 2014 co-infections with HIV and histoplasmosis were enrolled. Inclusion criteria were: age >18 years, confirmed HIV infection; first proven episode of histoplasmosis.Among 349 cases of disseminated histoplasmosis, 245 (70%) had a gastrointestinal presentation. Half of patients with gastrointestinal signs had abdominal pain or diarrhea, mostly watery. Half of patients with abdominal pain had diarrhea (63/124) and half of those with diarrhea (63/123) had abdominal pain. A significant proportion of patients also had hepatomegaly and, to a lesser degree, splenomegaly. After adjusting for potential confounding, the presence of lymphadenopathies >2cm (AOR = 0.2, IC95 = 0.04–0.7, P = 0.01), Haitian origin (AOR = 0.04, IC95 = 0.004–0.4, P = 0.006) were associated with a lower prevalence of gastrointestinal signs and positive gastrointestinal presence of H. capsulatum. Persons with a gastrointestinal H. capsulatum were more likely to have a decreased prothrombin time, lower ferritin, lower liver enzymes, and lower concentrations of LDH than those without gastrointestinal signs and symptoms. They also had a shorter interval between symptoms onset and diagnosis. Patients with a positive gastrointestinal identification of H. capsulatum were less likely to die at 1 month than those without a gastrointestinal presentation (respectively, 4.6% vs 18.5%, P = 0.01).Subacute or chronic gastrointestinal presentations are very frequent during disseminated histoplasmosis, they seem less severe, and should lead to suspect the diagnosis in endemic areas. There were populational or geographic differences in the frequency of gastrointestinal manifestations that could not be explained.
Highlights
French Guiana, a French overseas territory between Brazil and Suriname, has been afflicted by the HIV epidemic with seroprevalence exceeding 1% since the 1990s
Subacute or chronic gastrointestinal presentations are very frequent during disseminated histoplasmosis, they seem less severe, and should lead to suspect the diagnosis in endemic areas
After adjusting for potential confounding, the presence of lymphadenopathies >2cm, Haitian origin were associated with a lower prevalence of gastrointestinal signs and presence of H. capsulatum
Summary
French Guiana, a French overseas territory between Brazil and Suriname, has been afflicted by the HIV epidemic with seroprevalence exceeding 1% since the 1990s. Among patients with advanced HIV, disseminated histoplasmosis has been the most frequent AIDS-defining infection and the first cause of death.[1,2] Realization of this fact started with the dermatologists and with the implementation of fungal culture, spread to all physicians accelerating the identification of the fungal pathogen from a variety of samples where H. capsulatum has disseminated.[3,4] tissue samples from the skin, oral mucosa, bone marrow, lymphnodes, liver, and, very frequently, the gastrointestinal system, were examined and cultured in order to identify H. capsulatum. Histoplasmosis is often presented as a counterpoint to tuberculosis [5,6], its main differential diagnosis, it is often a disease with a non-specific and proteiform presentation.[7,8] One of the common presentations, albeit less well known, is a presentation with febrile gastrointestinal signs and symptoms. Several authors have described cases and mention the frequency and polymorphism of such presentations.[9,10,11,12,13,14]
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