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LETTER TO EDITOR
Year : 2016  |  Volume : 31  |  Issue : 2  |  Page : 162-164  

Disseminated histoplasmosis demonstrated on F18-fluorodeoxyglucose positron emission tomography/computed tomography in a renal transplant recipient


1 Department of Nuclear Medicine and PET/CT, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication9-Mar-2016

Correspondence Address:
Madhavi Tripathi
Department of Nuclear Medicine and PET/CT, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.178342

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How to cite this article:
Sahoo MK, Tripathi M, Deepak R, Gupta RK, Damle N, Bal C. Disseminated histoplasmosis demonstrated on F18-fluorodeoxyglucose positron emission tomography/computed tomography in a renal transplant recipient. Indian J Nucl Med 2016;31:162-4

How to cite this URL:
Sahoo MK, Tripathi M, Deepak R, Gupta RK, Damle N, Bal C. Disseminated histoplasmosis demonstrated on F18-fluorodeoxyglucose positron emission tomography/computed tomography in a renal transplant recipient. Indian J Nucl Med [serial online] 2016 [cited 2019 Sep 16];31:162-4. Available from: http://www.ijnm.in/text.asp?2016/31/2/162/178342

Sir,

We report a 30-year-old male recipient of an allogenic renal transplant 10 years back who presented with signs and symptoms of pneumonia and pleural effusion. High resolution computed tomography (CT) of chest revealed features of miliary tuberculosis and patient was started on anti-tubercular medication, despite which his clinical condition did not improve. Keeping in mind the possibility of posttransplant lymphoproliferative disorder (PTLD) patient was referred for F-18 fluorodeoxyglucose (F-18 FDG) positron emission tomography/CT (PET/CT). PET/CT revealed increased FDG uptake over multiple cutaneous sites in the body [[Figure 1]a - arrow]. These corresponded to cutaneous and subcutaneous thickening with stranding [[Figure 1]b and c - arrow]. In addition to this, a tree in bud appearance and cavitory lesions with mild FDG uptake were noted in both lungs [Figure 1]d and e. On examining the patient he had macular skin lesions which had not been evaluated and in view of the PET findings a biopsy from the skin lesions was advised. The biopsy revealed infiltration of dermis by inflammatory granulation tissue rich in plasma cells and foamy histiocytes with fungal spores [Figure 1]f, without involvement of the epidermis. Periodic acid Schiff [Figure 1]g and Gomori methanamine silver [Figure 1]h stain highlighted the fungal structures, confirming the diagnosis of histoplasmosis.
Figure 1: Positron emission tomography/computed tomography revealed increased cutaneous positron emission tomography/computed tomography uptake over multiple sites in the body (a - arrow) that corresponded to cutaneous and subcutaneous thickening with stranding (b and c - arrow). Tree in bud appearance and cavitory lesions with mild positron emission tomography/computed tomography uptake noted in both lungs (d and e). Biopsy revealed dermis infiltrated by inflammatory granulation tissue rich in plasma cells and foamy histiocytes with fungal spores (f). Periodic acid Schiff (g) and Gomori methanamine silver (h) stain highlighted the fungal structures

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Exposure to Histoplasma capsulatum is exceedingly common for persons living within areas of endemicity, but symptomatic infection is uncommon. Acute self-limited pulmonary histoplasmosis is commonly presented with rheumatologic and/or dermatologic manifestations in approximately 5% of patients. Acute infection commonly manifested as myalgias and arthralgias. Patients who have hilar lymphadenopathy, arthralgias, and erythema nodosum may confuse with a diagnosis of sarcoidosis. Acute severe pulmonary infection presents as abrupt onset of illness and fever, chills, malaise, dyspnea, cough, and chest pain.

Chronic cavitary pulmonary histoplasmosis is seen older patients. Chronic cavitary pulmonary histoplasmosis include fatigue, fever, night sweats, anorexia, and weight loss. Specific pulmonary symptoms include cough, sputum production, hemoptysis, and dyspnea. Granulomatous mediastinitis, mediastinal fibrosis, or fibrosing mediastinitis and pericarditis may be seen as complications. Broncholithiasis occurs when a calcified node adjacent to a bronchus erodes into the bronchus, causing obstruction, inflammation, and subsequent bronchial scarring. The symptoms of disseminated histoplasmosis include fever, malaise, anorexia, and weight loss. Physical examination will often show hepatosplenomegaly, lymphadenopathy, pallor and petechiae if pancytopenia is present, and, in some patients, mucous membrane ulcerations as well as skin ulcers, nodules, or molluscum-like papules. Gastrointestinal tract involvement is common during disseminated infection as determined by autopsy studies but remains asymptomatic or with only vague abdominal symptoms in many patients histoplasmosis can involve every organ system during the course of dissemination, but symptomatic disease is rare at some sites. Osteoarticular infection, endocarditis, chronic meningitis are among the uncommon manifestations of histoplasmosis. [1] Cutaneous involvement occurs in about 17% of patients with disseminated disease and can manifest as papules, pustules, plaques, ulcers, molluscum or wart-like lesions and rarely as erythema nodosum. [2]

PET/CT is an important diagnostic tool to ascertain the exact extent of disease and help in guiding the site of biopsy for a definite diagnosis in patients with fungul infections. [3] F-18 FDG PET/CT is also an effective imaging modality in the staging and follow-up of PTLD after transplantation where in it has the ability to detect occult lesions not identified by other imaging modalities. [4] Also PET/CT have shown its efficacy in detecting mediastinal histoplasmosis and its response evaluation after starting antifungals in a known case of melanoma. [5] In the present case the identification of metabolically active skin lesions on PET/CT enabled timely diagnosis and institution of appropriate therapy for histoplasmosis.

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Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Kauffman CA. Histoplasmosis: A clinical and laboratory update. Clin Microbiol Rev 2007;20:115-32.  Back to cited text no. 1
    
2.
Sayal SK, Prasad PS, Mehta A, Sanghi S. Disseminated histoplasmosis: Cutaneous presentation. Indian J Dermatol Venereol Leprol 2003;69:90-1.  Back to cited text no. 2
  Medknow Journal  
3.
Sharma P, Mukherjee A, Karunanithi S, Bal C, Kumar R. Potential role of 18F-FDG PET/CT in patients with fungal infections. AJR Am J Roentgenol 2014;203:180-9.  Back to cited text no. 3
    
4.
Bianchi E, Pascual M, Nicod M, Delaloye AB, Duchosal MA. Clinical usefulness of FDG-PET/CT scan imaging in the management of posttransplant lymphoproliferative disease. Transplantation 2008;85:707-12.  Back to cited text no. 4
    
5.
Mackie GC, Pohlen JM. Mediastinal histoplasmosis: F-18 FDG PET and CT findings simulating malignant disease. Clin Nucl Med 2005;30:633-5.  Back to cited text no. 5
    


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