title: Histoplasmosis in renal transplant patients in an endemic area at a reference hospital in Medellin, Colombia.
abstract: BACKGROUND
  Histoplasmosis is an uncommon systemic fungal infection, but it is potentially fatal in immunosuppressed populations. In Latin America, which is considered an endemic area for this mycosis, there have been no published reports regarding the incidence, clinical presentation, morbidity, and mortality of histoplasmosis in renal transplant patients. The objective of this study was to describe cases of histoplasmosis in renal transplant patients treated at the Pablo Tobon Uribe Hospital (Medellin, Colombia) between 2006 and 2013.
  
  
  METHODS
  This is a descriptive, retrospective study.
  
  
  RESULTS
  The incidence of histoplasmosis in our renal transplant population was 1.1%. The ages of the 9 patients (4 men and 5 women) ranged between 27 and 59 years. In 2 of these patients, histoplasmosis appeared during the first year after transplantation. At the time of transplantation, 66% of patients received induction with alemtuzumab; 88% had a prior rejection episode and required increased immunosuppressive medication; 88% had renal graft dysfunction with creatinine levels >1.5 mg/dL; and the primary clinical presentation was disseminated histoplasmosis followed by the pulmonary form of the disease. Diagnoses were performed by histology in 6 patients, blood culture in 2 patients, and antigenuria in 1 patient. Three patients required treatment with amphotericin B for the severity of their infection, and 2 of these patients died before receiving the cumulative dose of amphotericin B. The 7 remaining patients received itraconazole for 12 months and had a successful treatment response. Regarding complications, 2 patients had hemophagocytic syndrome. At the 1-year follow-up appointment, renal function remained stable in all patients, and no patients had acute rejection or required renal replacement therapy. Thus, the overall mortality rate observed was 22.2%.
  
  
  CONCLUSIONS
  In this series, histoplasmosis in renal transplant patients presented as an aggressive opportunistic infection with a higher incidence than that previously reported in the literature. The following risk factors have been associated with histoplasmosis: renal graft dysfunction, previous acute rejection, immunosuppression with tacrolimus-mycophenolate, and induction with alemtuzumab. The clinical presentation of histoplasmosis was nonspecific, which complicated disease diagnosis, and the treatment regimens were highly toxic and associated with significant morbidity and mortality rates.
authors.affiliation: Hospital Pablo Tobon Uribe, Universidad de Antioquia, Medellín-Colombia. Electronic address: johnfredynieto@gmail.com.
authors.forename: J F
authors.initials: JF
authors.lastname: Nieto-Ríos
authors.affiliation: Hospital Pablo Tobon Uribe, Universidad de Antioquia, Medellín-Colombia. Electronic address: lm.serna@hotmail.com.
authors.forename: L M
authors.initials: LM
authors.lastname: Serna-Higuita
authors.affiliation: Hospital Pablo Tobon Uribe, Universidad de Antioquia, Medellín-Colombia.
authors.forename: C E
authors.initials: CE
authors.lastname: Guzman-Luna
authors.affiliation: Hospital Pablo Tobon Uribe, Universidad de Antioquia, Medellín-Colombia.
authors.forename: C
authors.initials: C
authors.lastname: Ocampo-Kohn
authors.affiliation: Hospital Pablo Tobon Uribe, Universidad de Antioquia, Medellín-Colombia.
authors.forename: A
authors.initials: A
authors.lastname: Aristizabal-Alzate
authors.affiliation: Hospital Pablo Tobon Uribe, Universidad de Antioquia, Medellín-Colombia.
authors.forename: I
authors.initials: I
authors.lastname: Ramírez
authors.affiliation: Hospital Pablo Tobon Uribe, Universidad de Antioquia, Medellín-Colombia.
authors.forename: C
authors.initials: C
authors.lastname: Velez-Echeverri
authors.affiliation: Hospital Pablo Tobon Uribe, Universidad de Antioquia, Medellín-Colombia.
authors.forename: J J
authors.initials: JJ
authors.lastname: Vanegas-Ruiz
authors.affiliation: Hospital Pablo Tobon Uribe, Universidad de Antioquia, Medellín-Colombia.
authors.forename: J J
authors.initials: JJ
authors.lastname: Zuleta
authors.affiliation: Hospital Pablo Tobon Uribe, Universidad de Antioquia, Medellín-Colombia.
authors.forename: G A
authors.initials: GA
authors.lastname: Zuluaga-Valencia
mesh_terms: D000328:Adult; D003105:Colombia; D019353:Endemic Diseases; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000517:prevention & control; D006660:Histoplasmosis / Q000453:epidemiology* / Q000209:etiology; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects* / Q000627:therapeutic use; D015994:Incidence; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D009894:Opportunistic Infections / Q000453:epidemiology* / Q000209:etiology; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology; D012189:Retrospective Studies; D012307:Risk Factors; D062606:Tertiary Care Centers
chemical_list: D007166:Immunosuppressive Agents