Histoplasmin Skin Test Research Articles

Histoplasmin sensitivity associated with pericardial calcification

A case report of a patient with clinical and x-ray evidence of chronic constrictive pericarditis with a calcific pericardium is presented. The patient had negative tuberculin and positive histoplasmin skin tests. This suggests, along with a previous report, 6 that cases of pericardial calcification should include histoplasmin skin testing when the etiology is in doubt.

Pulmonary Cryptococcosis

It is becoming increasingly evident that Cryptococcus infections must be considered in the differential diagnosis of certain types of pulmonary lesions. The causative organism Cryptococcus neoformans (Torula histolytica) is a single budding fungus of world-wide distribution. It can be distinguished from non-pathogenic Cryptococci occurring in the oropharynx by certain cultural methods and by tissue invasion on animal inoculation. In a review of the English literature on cryptococcosis, it was found that at least 75 cases in which the lungs were affected were recorded prior to 1953. Seven additional cases are presented here, bringing the total to 82. This number is approximately one-third of the total of more than 250 cases of cryptococcal infection reported. It is probable that the lung is involved more often than these figures indicate, since it is believed that the causative organism gains access to the body through the respiratory tract. The infection may remain localized there or may spread to adjacent lymph nodes or other organs. The initial pulmonary lesion may heal with or without dissemination of the disease. Case Reports Case I: E. H., a 28-year-old colored male, complained of headaches, experienced over a period of six months, and gradually developing drowsiness. Three days before admission to Lawson Veterans Administration Hospital, he had a generalized clonic convulsion followed by stupor. On admission he was comatose, his neck was stiff, and his reflexes were increased. Roentgenograms showed multiple small, rounded, nodular densities throughout both lung fields (Fig. 1). Death occurred about ten weeks later. A postmortem examination revealed Cryptococcus meningitis with dissemination of miliary granulomata throughout the lungs, liver, and spleen. Case II: B. S. F., a 58-year-old white female, was admitted to Georgia Baptist Hospital in a stuporous condition in May 1949. Kernig and Brudzinski's signs were positive. The liver and spleen were enlarged. Cryptococci were identified in the spinal fluid in an India ink preparation. Roentgenograms of the chest disclosed linear infiltrations and small nodulations throughout the right lung and similar infiltrates with large confluent areas of consolidation in the left lung (Fig. 2). Similar but less extensive infiltrates had been present since 1947, when the patient had been observed in a tuberculosis sanitarium. At that time, numerous smears, cultures, and animal inoculations of the sputum failed to reveal acid-fast bacilli. During the present admission, tuberculin, blastomycin, coccidioidin, and histoplasmin skin tests were negative. The patient's condition improved while she was hospitalized, but she died later at home. Permission for postmortem examination was not obtained.

Juvenile hyperparathyroidism in association with peptic ulcer.

HYPERPARATHYROIDISM in childhood is a relatively rare occurrence (1,2). The present report is of a 10-year-old child in whom the disease was associated with peptic ulcer. The diagnosis was made difficult by a traumatic fracture of the femur with consequent immobilization. CASE REPORT Patient AVAD, the seventh child of a 37-year-old mother, was considered to be in excellent health until 1953, when he manifested fatigue and abdominal distress. As the result of the latter, in August 1954, an appendectomy was performed on the basis of a preoperative diagnosis of acute appendicitis. The pathologic report of the surgical specimen was “possible tuberculoma of the appendix.” Results of tuberculin and histoplasmin skin tests were negative. X-ray examination showed a normal chest. The symptoms subsided following operation, and the patient was discharged to the clinic. Because of recurrence of abdominal distress, intravenous pyelograms and upper gastro-intestinal x-ray series were carried out in October 1953. The py...

Class session: histoplasmosis.

Those of us who have followed the reports of the United States Public Health Service teams working on histoplasmosis have been fascinated by their detective-like expose of this disease. From the original observation of Palmer that a sizeable percentage of calcification on chest roentgenograms is not associated with tuberculin skin sensitivity, through the various processes of narrowing their observations to the areas of endemic histoplasmosis, and finally the demonstration of previously unsuspected clinical states of this disease, it has been a dramatic demonstration of deductive ciinical and epidemiological research. This whole drama can effectively be recapitulated in an hour's class session. Using the Socratic method, whereby members of the class are encouraged to reason this thing,out as a group exercise, the problem is started by making Palmer's original observation1 that all pulmonary calcification may not be tuberculous. Films to demonstrate this are easily available today. As a matter of fact, we have used the chest roentgenograms of several class members as clinical material to initiate the discussion. The second step to consider is the large scale skin testing of student nurses in different cities throughout the United States2 which focused the attention on the endemic areas, especially the Mississippi Valley. Following this Furcolow and Mantz3 skin tested almost 17,000 school children in Kansas City, Missouri to demonstrate the early age at which histoplasmosis sensitivity is contracted. Their next step, the mass chest roentgenograms of 16,000 school children in Kansas City, Missouri, revealed 72 symptom-free cases with combined pulmonary infiltration and positive histoplasmin skin tests.4 Reproduction on slides of some of these cases, as illustrated in their reports, are valuable at this point. The class generally has little difficulty in suggesting the next procedure which was the confirmation by culture of the organism from 10 of these cases, whose clinical pictures run the gamut of symptom-free infiltrates to fatal systemic disease. Again slide reproductions of some of these cases reported by Bunnell and Furcolow5 create considerable interest. At some point in these slides, generally at the end, the roentgenogram of a patient with pulmonary tuberculosis is unexpectedly thrown in to emphasize the similarity of these two disease infiltrates. This, supposedly,

Histoplasmosis in non-endemic regions

In the past seven years it has become increasingly recognized that histoplasmosis is a frequent cause of pulmonary disease in endemic areas. It is the purpose of this report to show that histoplasmosis is also a common cause of pulmonary involvement in non-endemic regions. Roentgenographically, histoplasmosis may simulate many forms of pulmonary disease. It is necessary, therefore, to perform skin tests with tuberculin, histoplasmin and coccidioidin routinely in the diagnostic work-up of pulmonary conditions if one is to detect histoplasmosis. The complement fixation test for histoplasmosis is of relatively minor importance in detecting inactive cases of this disease. It need only be performed in those individuals reacting to the histoplasmin skin test, in whom a positive serologic reaction can serve as confirmatory evidence of the presence of histoplasmosis. We believe that cases of histoplasmosis will be discovered in increasing numbers in nonendemic regions, in proportion to the awareness of its varied manifestations and the zeal with which the search is made.

Effect of histoplasmin skin testing on serologic results.

ConclusionsRepeated positive histoplasmin skin tests in normal medical students caused false positive reactions in the collodion agglutination test (57.1%) and in the complement-fixation test with histoplasma yeast phase antigen (78.6%) or with histoplasmin as antigen (85.7%). The response was relatively transient in the former 2 tests, and negative titers were usually restored by 21 weeks after the last skin test. However, positive results were noted as late as 21, 25 and 39 weeks in complement-fixation tests employing histoplasmin as antigen. A transient response was observed in complement-fixation studies with cross-reacting yeast phase biastomyces antigens (57.1%), but no sera reacted in the same test with coccidiodin antigen. A single positive skin test and repeated negative skin tests did not alter serologic results. Thus, repeated histoplasmin skin testing of skin-test positive persons may invalidate complement-fixation data for long periods with histoplasmin as antigen, and for much shorter period...

Examination of human appendixes for Histoplasma capsulatum.

The reports of Raftery 1 and Raftery, Trafas, and McClure 2 indicate a high incidence, 12.3% in children 16 years and younger and 5% in an unselected series, of organisms identified morphologically by them as Histoplasma capsulatum in patients'appendixes. These reports stimulated us to analyze our own material critically, since we had not noted H. capsulatum in our routine histological examinations of either appendixes or mesenteric lymph nodes. It was of special interest to us since we were dealing with patients in a presumably endemic area where disseminated cases are being recognized with regularity and the diagnosis substantiated by both histological and cultural methods without apparent difficulty. At the same time there is a high incidence, about 60%, of positive reactions to the histoplasmin skin test (Armstrong, 3 Christie and Peterson, 4 and Palmer 5 ) in subjects who have no clinical evidence of the disease. MATERIALS AND METHODS Routine surgical

A study of the complement fixation reaction in histoplasmosis.

Abstract A complement fixation test for histoplasmosis employing a whole yeast cell preparation as antigen was performed on sera from 2,000 individuals. Seven patients with culturally proved histoplasmosis were encountered. Sera from each of these patients reacted in the test, five at serum dilutions greater than 1:40, and the remaining two at 1:20 dilutions. Only two other reactions above 1:40 were found. These were in two sons of a proved case where there was strong epidemiologic evidence of active Histoplasma infection. Of the forty-nine persons suspected of having active Histoplasma infections on the basis of recent histoplasmin skin test conversion or pulmonary infiltrates along with positive histoplasmin and negative tuberculin skin tests, 50 per cent reacted in the complement fixation test. Conversely, among 300 persons in whom active Histoplasma infections seemed unlikely on the basis of negative histoplasmin skin tests, only one reaction occurred and that at the lowest (1:5) dilution employed. It was concluded that the complement fixation reaction has a definite usefulness in diagnostic studies for histoplasmosis. Some of the advantages and the limitations of the test are discussed.

Pulmonary Histoplasmosis: Report of a Case Long Considered Tuberculous Improved by Acti-Dione

A case * is presented who had a chronic cough following “influenza” in 1918–19 and was considered to have arrested pulmonary tuberculosis from 1925 to 1949 although acid fast bacilli were never recovered. In 1949, during the severest exacerbation he had experienced, Histoplasma capsulatum was repeatedly recovered in sputum cultures. Histoplasmin skin test was positive and coccidioidin and blastomycin were negative. The complement fixation test for histoplasmosis was positive. Right upper lobectomy was performed, although the pulmonary involvement was not entirely in this lobe. Improvement with negative sputum and gain in weight followed prolonged treatment with Acti-dione which was effective when administered either intravenously (Upjohn) or orally (Lilly). Further investigation of Acti-dione in cases of histoplasmosis is indicated.

Results of histoplasmin skin testing in children fromthe St. Louis, Mo., area

Summary<ul><li>1.Histoplasmin skin tests were done on 500 children in the St. Louis, Mo., area.</li><li>2.The incidence of positive histoplasmintests increases rapidly with age up to 10 years.</li><li>3.A higher incidence of positive skin tests in males was found.</li><li>4.Data on subjects under 3 yearsof age have been analyzed separately.</li><li>5.The high incidence of chronic disease among positive histoplasmin reactors is noted.</li><li>6.The rural locale of the homes ofthe large majority of positive histoplasmin reactors is observed.</li><li>7.The findings on chest roentgenogramsof positive reactors are summarized.</li></ul>

Histoplasm, coccidioidin and tuberculin sensitivity in Honduras.

Summary and Conclusion 1. The results of a survey of skin sensitivity to histoplasmin, coccidioidin and tuberculin on the north coast of Honduras are reported. 2. Of 421 hospitalized patients, the histoplasmin skin test was positive in 47.7 per cent, doubtful in 5.2 per cent, and negative in 47.1 per cent. The coccidioidin skin test was positive in 1.0 per cent, doubtful in 2.1 per cent, and negative in 96.9 per cent. 3. Of 360 patients tested with tuberculin (P.P.D. 0.005 mg.), the result was positive in 89.5 per cent, doubtful in 2.2 per cent, and negative in 8.3 per cent. 4. Pulmonary calcifications were present in 84 (59.2 per cent) of 142 selected patients. Of these, 45.2 per cent were tuberculin positive, histoplasmin negative; 42.9 per cent were tuberculin positive, histoplasmin positive; 8.3 per cent were tuberculin negative, histoplasmin positive; and 3.6 per cent were negative to both. 5. These results suggest that, in addition to the high prevalence of tuberculosis in this area, infection with Histoplasma capsulatum is common whereas infection with Coccidioides immitis is rare.

Acute primary pulmonary blastomycosis.

Blastomycosis was first described by Gilchrist in 1894 as a form of chronic dermatitis. Since that time, many articles have appeared in the literature dealing with the chronic cutaneous lesions (11). Numerous reports have been published describing secondary pulmonary invasion (4, 11), and a few on primary chronic pulmonary blastomycosis (11, 12). Review of the literature reveals only one case which can be interpreted as an acute primary pulmonary blastomycosis. Healy and Morrison, in 1931 (9), described an acute pneumonic process in a patient with persistent blastomycetes in the sputum. A roentgenogram showed a left basal infiltration with associated hilar lymphadenopathy. In the absence of follow-up, however, we do not know whether the disease process subsided or became chronic. Primary pulmonary lesions due to other fungi have been described since 1935. Dickson, in 1937 (5), discussed the primary lesions of coccidioidomycosis, which subsided spontaneously. Carter (2, 3) and Jamison and Carter (10) added to the earlier description. The clinical picture is similar to that of other primary infections, with headache, chest pain, temperature of 100–102°, slight elevation of the white blood count, and a moderately productive cough predominating. Roentgenograms early reveal a pulmonary infiltration varying from thickening of the hilar shadows to almost complete consoUdation. About 33 per cent of the cases in which the disease persists for any period of time show some degree of mediastinal or hilar lymphadenopathy; parenchymal infiltrations tend to become nodose, and in some instances cavitation develops. Pleural effusion appears in approximately 20 per cent of all cases. Death is rarely due to the primary invasion except when dissemination occurs. Zwerling and Palmer, in 1946 (13), postulated an acute benign form of histoplasmosis on the basis of pulmonary calcifications associated with a negative response to tuberculin and a positive response to histoplasmin skin tests. Furcolow, Mantz, and Lewis, in 1947 (6), reported 72 asymptomatic cases of pulmonary infiltration with positive histoplasmin skin tests. They divided the infiltrates into three groups. Nodular foci were present in 49 of the 72 cases. These foci varied from 0.5 cm. to 3.5 cm. in diameter and occasionally had calcific centers. In 39 cases of this group there was associated mediastinal or hilar lymphadenopathy. Pneumonic infiltration was present in 17 cases, and in 14 of these there was associated hilar lymphadenopathy. This lesion is described as a single, persistent patch of pneumonitis about 2 cm. in diameter. Disseminated infiltrates occurred in 3 cases, in 2 of which there was associated lymphadenopathy. The lesions in this group varied from the size of a millet seed to large patchy areas. No deaths are reported in the series and follow-up on many of the cases revealed calcification replacing the active process.

Pulmonary calcification in twins

Summary Two cases of pulmonary calcification occurring in twins have been presented, the first patient having had symptoms since January, 1947, and the second being asymptomatic. In neither case has the etiological agent been identified. The tuberculin and coccidioidin skin tests in both children were negative, whereas the histoplasmin skin tests were positive. These cases may represent subclinical forms of histoplasmosis. When and in what locality the pulmonary calcifications first appeared is not known since the children have lived in many different states.