Abstract
Adrenal histoplasmosis and primary adrenal insufficiency are mostly described in immunocompetent patients. This particular tropism is attributed to the presence of cortisol within the adrenal gland, a privileged niche for Histoplasma growth. In French Guiana, disseminated histoplasmosis is the main opportunistic infection in HIV patients. Our objective was to search in our HIV-histoplasmosis cohorts to determine how frequent adrenal insufficiency was among these patients. Between January 1, 1981 and October 1, 2014, a multicentric retrospective, observational study of histoplasmosis was conducted. Patients co-infected by HIV and histoplasmosis were enrolled in French Guiana’s histoplasmosis and HIV database. Among 349 cases of disseminated histoplasmosis between 1981 and 2014, only 3 had adrenal insufficiency (0.85%). Their respective CD4 counts were 10, 14 and 43 per mm3. All patients had regular electrolyte measurements and 234/349 (67%) had abdominal ultrasonography and 98/349 (28%) had abdominopelvic CT scans. None of these explorations reported adrenal enlargement. Overall, these numbers are far from the 10% reports among living patients and 80-90% among histoplasmosis autopsy series. This suggests 2 conflicting hypotheses: First, apart from acute adrenal failure with high potassium and low sodium, less advanced functional deficiencies, which require specific explorations, may have remained undiagnosed. The second hypothesis is that immunosuppression leads to different tissular responses that are less likely to incapacitate the adrenal function. Furthermore, given the general immunosuppression, the adrenal glands no longer represent a particular niche for Histoplasma proliferation.
Highlights
Histoplasmosis was discovered over a century ago
In a hospital cohort of 349 cases of disseminated histoplasmosis in patients with advanced HIV disease the proportion of patients with adrenal deficiency was 0.85%, and among patients having benefitted from abdominal imaging, none had reports of adrenal enlargement
In French Guiana, fungal culture was first implemented in 1998, liposomal amphotericin B became available in 2003, and, perhaps more importantly for the capacity to detect adrenal enlargement, over time the use of thoraco-abdomino-pelvic CTscan became increasingly frequent. These factors could lead to a cohort effect but given the relative frequency of blood electrolyte measurements and decades of CT-scans, it seems likely that patent adrenal failure and adrenal enlargement are rare
Summary
Histoplasmosis was discovered over a century ago. Its severity varies with the intensity of exposure and host immunity. In advanced HIV disease, adrenal exhaustion, infection with opportunistic pathogens, and development of anticorticosteroid and anti-adrenal gland cells antibodies (Salim et al, 1988; Sinha et al, 2011) often low level of ACTH are considered as potential mechanisms for progression to overt adrenal insufficiency even when no apparent lesion with medical imagery. In French Guiana, disseminated histoplasmosis has been the main opportunistic infection and cause of death in HIV patients for decades. Among 349 cases of disseminated histoplasmosis between January 1, 1981 and October 1, 2014, only 3 had adrenal insufficiency (0.85%) Their respective CD4 counts were 10, 14 and 43 per mm. The first patient, a 30-year-old male from Suriname, died 34 days after the diagnosis of acute adrenal failure the reported cause of death was disseminated histoplasmosis.
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