title: Cutaneous and bone marrow histoplasmosis after 18 years of renal allograft transplant.
abstract: The frequency of histoplasmosis among solid organ transplant (SOT) recipients appears to be low where there are only a few case series, mostly among renal and liver transplant recipients. Herein we report a case of a 44-year-old woman who underwent a living-related renal transplant 18 years prior to evaluation, developed a nodule after followed by ulceration upon her posterior right leg and a second one upon her left leg 3 months and 2 months before her hospitalisation, respectively. The biopsy of lesion revealed the presence of Histoplasma spp. Bone marrow aspiration was performed and also revealed the same organism. She had initially received itraconazole without improvement of lesions, while a new lesion appeared on her left arm. Healing of all lesions could be observed after 40 days of liposomal amphotericin B when she was submitted to skin grafts on the legs and a surgical treatment on the arms, and the myelosuppression improved simultaneously. Histoplasmosis seems to be very uncommon among patients who underwent to organ solid transplantation. Most cases occur within 12-18 months after transplantation, although unusual cases have been presented many years post-transplant. There are cases reported in the literature, occurring from 84 days to 18 years after organ transplantation, but without cutaneous involvement. Our patient developed lesions on limbs and myelosuppression after 18 years of chronic immunosuppression medication. This case suggests that besides cutaneous histoplasmosis is an uncommon infection following iatrogenic immunosuppression and even rarer over a long period after the transplantation. Clinicians who care SOT recipient patients must bear in mind histoplasmosis infection as differential diagnosis in any case of cutaneous injury with prolonged fever and try to use as many tools as possible to make the diagnosis, once this disease presents a good prognosis if it is diagnosed and treated promptly.
authors.affiliation: Division of Infectious and Parasitic Diseases, Hospital das Clínicas, School of Medicine, University of São Paulo, Rua da Consolação, 2920, apt 64, São Paulo, SP, CEP:01416-001, Brazil, karim.yaqub@hc.fm.usp.br.
authors.forename: K Y
authors.initials: KY
authors.lastname: Ibrahim
authors.forename: N B
authors.initials: NB
authors.lastname: Carvalho
authors.forename: E V
authors.initials: EV
authors.lastname: Mimicos
authors.forename: H
authors.initials: H
authors.lastname: Yeh-Li
authors.forename: M N
authors.initials: MN
authors.lastname: Sotto
authors.forename: F O S
authors.initials: FO
authors.lastname: França
mesh_terms: D000328:Adult; D064591:Allografts; D000666:Amphotericin B / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D001853:Bone Marrow / Q000382:microbiology / Q000473:pathology; D001855:Bone Marrow Diseases / Q000175:diagnosis* / Q000382:microbiology* / Q000473:pathology / Q000628:therapy; D003881:Dermatomycoses / Q000175:diagnosis* / Q000382:microbiology* / Q000473:pathology / Q000628:therapy; D005260:Female; D006658:Histoplasma / Q000302:isolation & purification*; D006660:Histoplasmosis / Q000175:diagnosis* / Q000382:microbiology* / Q000473:pathology / Q000628:therapy; D006801:Humans; D016867:Immunocompromised Host; D016030:Kidney Transplantation; D016038:Skin Transplantation; D012883:Skin Ulcer / Q000382:microbiology / Q000473:pathology; D066027:Transplant Recipients; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents; C068538:liposomal amphotericin B; D000666:Amphotericin B
references.citation: Med Mycol. 2008 Nov;46(7):725-8
references.pmid: 18671166
references.citation: Am J Kidney Dis. 1991 Jun;17(6):719-21
references.pmid: 2042657
references.citation: Curr Top Med Mycol. 1996 Dec;7(1):7-18
references.pmid: 9504056
references.citation: Clin Infect Dis. 2007 Oct 1;45(7):807-25
references.pmid: 17806045
references.citation: J Heart Lung Transplant. 2003 Apr;22(4):487-91
references.pmid: 12681429
references.citation: Transpl Infect Dis. 2002 Sep;4(3):148-51
references.pmid: 12421460
references.citation: Am J Med. 1997 Sep;103(3):223-32
references.pmid: 9316555
references.citation: Curr Opin Organ Transplant. 2009 Dec;14(6):601-5
references.pmid: 19812496
references.citation: Transplant Proc. 2005 Dec;37(10):4313-4
references.pmid: 16387107
references.citation: Am J Med Sci. 2000 Dec;320(6):406-7
references.pmid: 11149555
references.citation: J Heart Lung Transplant. 2007 Apr;26(4):407-10
references.pmid: 17403485
references.citation: N Engl J Med. 2000 Oct 19;343(16):1163-6
references.pmid: 11036122
references.citation: Am J Med. 1978 Jun;64(6):923-32
references.pmid: 350045
references.citation: Transpl Infect Dis. 2013 Apr;15(2):E64-9
references.pmid: 23387927
references.citation: Ann Intern Med. 1982 Feb;96(2):159-63
references.pmid: 7059062
references.citation: Br J Haematol. 2004 Nov;127(3):241
references.pmid: 15491282
references.citation: Mycopathologia. 2006 Mar;161(3):161-5
references.pmid: 16482388
references.citation: Clin Transplant. 1996 Apr;10(2):160-5
references.pmid: 8664511
references.citation: Transpl Infect Dis. 2005 Sep-Dec;7(3-4):109-15
references.pmid: 16390398
references.citation: Transpl Infect Dis. 2008 Oct;10(5):351-3
references.pmid: 18194370
references.citation: Clin Infect Dis. 2009 Sep 1;49(5):710-6
references.pmid: 19635026
references.citation: Clin Microbiol Rev. 2007 Jan;20(1):115-32
references.pmid: 17223625