disseminated histoplasmosis and childhood leukemia

DISSEMINATED HISTOPLASMOSIS AND CHILDHOOD LEUKEMIA

FREDERICK Cox, MD, AND WALTER T. HUGHES, MD

The course of histoplasmosis in patients with childhood leukemia is poorly understood. Past attempts to characterize the disease have relied on single case reports, without benefit of a series of patients with similar types of leukemia and chemotherapy. Described here are the clinical course of infection, laboratory findings, and therapy in six children with acute lymphocytic leukemia and disseminated histoplasmosis. A diagnosis of histoplasmosis was most commonly encountered during remission of the leukemia in patients presenting with fever, hepatosplenomegaly, variable chest roentgenogram findings, leukopenia, and/or neutropenia. Bone marrow cultures revealed the presence of Histo- plasma capsulatum in each. All six children were treated with amphotericin B and recovered from the infection.

Cancer 33:1127-1133,1974.

HE CHEMOTHERAPY PRESENTLY EMPLOYED T for children with leukemia has created a dramatic increase in the number and types of opportunistic infections. Among the more per- plexing are those infections caused by both opportunistic and pathogenic fungi which produce nonspecific but similar signs and symptoms. Therapy is often delayed since isolation of the organism in culture is usually required for diagnosis. Disseminated fungal infections are frequently fatal unless specific therapy is initiated soon after the infection becomes generalized.

Disseminated histoplasmosis is known to oc- cur in the immunosuppressed host7,11~16,17 and in patients with reticuloendothelial malig- nancies59689 or leukemia.l,2,4,'0.15,~6 Occasion- ally, the infection may present with symptoms similar to those of leukemia.3.14 Attempts to characterize the course of disease in leukemia have been based on scattered case reports in adults and children1,2,4,5.10,15,]6 and not on a series of patients with simiIar types of leukemia and chemotherapy.

A previous report from St. Jude Children's Research Hospital (SJCRH)8 has described

From the Infectious Diseases Service, St. Jude Chil- dren's Research Hospital, Memphis, Tenn.

Supported by Childhood Cancer Research Center Grant CA-08480 and Cancer Research Training Grant CA-05176, National Cancer Institute, General Research Support Grant RR-05584 from the Division of Re. search Resources, National Institutes of Health, and by ALSAC.

Address for reprints: Frederick Cox, MD, St. Jude Children's Research Hospital, 332 North Lauderdale, P.O. Box 318, Memphis, Tenn. 38101.

Received for publication July 11, 1973.

the frequency of fungal infections in leukemia as determined by routine bone marrow cultures. By this method, early diagnosis is possible when the signs and symptoms are not specific. This report describes the clinical course, laboratory findings, and therapy of disseminated histoplasmosis in six children with acute lymphocytic leukemia, in whom the diagnosis was made by bone marrow and/or blood culture. T h e cases occurred over a 36-month period from January, 1970 to December, 1972.

Bone marrow fungal cultures were performed by the addition of 0.5 to 1.0 cm3 of marrow aspirate to 4.0 cm3 of brain-heart infusion broth and the subsequent inoculation of 1.0 cm3 of this mixture onto each of two Sabouraud's dextrose agar slants. Blood cultures were done by adding 1.0 cm3 of whole blood into 18.0 cm3 of Columbia broth con- taining sodium polyanethol sulfonate, and inoculating a 2.0 cm3 aliquot of this mixture as previously. Cultures were incubated at 25C and maintained for 1 month before being considered as showing no growth.

COMPOSITE OF CLINICAL DATA

T h e six children, all Caucasian, consisted of four males and two females, whose ages ranged from 4 to 13 years a t the time of diagnosis of the histoplasmosis. They resided in Arkansas, Tennessee, Missouri, and Louisi- ana. A summary of the clinical, laboratory, and therapeutic events occurring in the six patients is listed in Tables 1 and 2.

1127

1128 CANCER April 1974 Vol. 33

TABLE 1 . Clinical Data on Six Children with Disseminated Histoplasmosis and Acute Lymphocytic Leukemia ~~

Duration of Hematologic symptoms before Isolation Hepato-

status cultural isolation site(s) of spleno- (days) H . capsdatum megaly Pneumonitis Tachypnea

Age Patient (years) Sex leukemia

1 7 M Remission 42 BM Yes Yes No 2 4 M Remission 43 BM, rectal Yes No No 3 13 F Remission 25 BM No Yes Yes

(P. carinii infection)

4 5 M Remission 39 BM, blood Yes Yes Yes 5 12 M Relapse 6 BM, blood Yes No No 6 4 F Remission 21 BM. blood Yes No No

All patients had acute lymphocytic leukemia and had been receiving chemotherapy for 4 to 27 months when symptoms of infection began. Five had been treated 16 months or longer. In the month prior to isolation of the organism, 'five patients were receiving methotrexate, cyclophosphamide, and 6-mercaptopurine. Two patients (1 and 2) received prednisone, and one (2) received vincristine in addition. Patient 3 received vincristine, methotrexate, and 6-mercaptopurine.

All of the patients presented with fever: five of the six had symptoms of upper respiratory tract infection from 1 to 6 weeks before cultural isolation of H . capsulatum. Symp- toms consisted of nonproductive cough, rhinorrhea, and/or pharyngitis. Patient 5, in

hematologic relapse, had 6 days of fever as the only presenting complaint. Hepatosplenomeg- aly was present in five children, and diffuse, bilateral pneumonitis in three. Respiratory distress of moderate severity with retractions, tachypnea, rales, and pleuritic chest pain was present in Patient 3 who had concurrent Pneu- mocystis carinii infection. These symptoms persisted for 3 weeks. Patient 4 had mild respiratory distress manifested by tachypnea alone.

Anemia with a hemoglobin 5 8 gm/lOO ml occurred in only two patients. Leukopenia (12,000 WBC/mm3) and neutropenia (5500 polymorphonuclear cells/mm3) were present in four patients, leukopenia alone in one, and neutropenia alone in one during the illness.

TABLE 2. Laboratory and Therapeutic Data

Leukopenia (L) skin test antibody titer total dose Days of therapy Outcome (months Histoplasmin Maximum C F Amphotericin B Therapy

Patient Neutropenia (N) (number) Yeast Mycelial mg/kg until afebrile post-therapy) 1 LN (2) NR NR NR 2 6 . 9 0 (afebrile a t on- Died (as therapy

hematologic relapse, no histoplasmosis at autopsy

2 LN (1) NR. 1:8 NR 2 1 . 5 5 Recovery (33 mo) Died (22 mo) from

set of therapy) ended) from

(1) Positive 3 LN 1:128 NR 2 2 . 9 4 unrelated causes,

healed granulomas at autopsy but no organisms

4 N (2) Positive 1 :8 NR 2 3 . 6 2 Recovery (18 mo)

5 LN (1) NR 1:128 1:64 1 6 . 3 4 Died (4 mo) of (1) NR

unrelated causes, no autopsy

6 L (2) NR 1:16 1:16 3 1 . 1 5 Recovery ( 5 mo) NR-Nonreactive CF-Complement Fixing BM-Bone Marrow Neutropenia ( 5 2,000 WBC/mma) Leulcopenia ( 5 500 polymorphonuclear cells/mm3)

No. 4 HISTOPLASMOSIS IN LEUKEMIA * Cox and Hughes 1129

These findings occurred in Patients 1 and 6 only after the initial cultural isolation of fungus. Eosinophilia up to ISYO was present in Patient 1, and thrombocytopenia (<50,000/ mm3) in two patients (1 and 6). Abnormal liver function, determined by elevation of the SGOT (240 I.U.), was present in four patients before treatment. An elevated lactic dehydrogenase activity (2 110 I.U.) was seen in four patients before treatment and in one who was on Pentamidine. Alkaline phospha- tase (213.0 Bodansky units) was elevated in two patients, and serum glutamic pyruvic transaminase (2 35 I.U.) in two (performed only in three patients). Minimal increase in total serum bilirubin (21.0 mg/l00 ml) was present transiently in two patients. Total serum protein, albumin, and globulin were diminished minimally in five patients and se- verely in Patient 6, resulting in peripheral edema and ascites in the latter.

Percutaneous needle aspirate of the lung was performed in the three children with pneumonia. No organisms could be demon-

FIG. 1 . Yeast forms of H . capsulatuni seen with Wright's stain in bone marrow histio- cytes of Patient 6 (xlo00). Numerous ov- oid organisms, sur- rounded by a clear zone, are apparent in the cytoplasm.

strated on smear or culture. H. capsulatunt was grown from bone marrow cultures in all six children, blood cultures in three, and a rectal culture in one. Yeast forms of the organism were seen in bone marrow macrophages using Wright's stain (Fig. 1) in two of the six patients (5 and 6), while cultures of the marrow done on the same days were positive for H . capsulatum.

Roentgenograms of the chest in patients with pneumonia showed bilateral, diffuse alveolar disease in a miliary, granular, or con- fluent pattern. This showed complete or par- tial resolution in Patients 1 and 4, respec- tively, before treatment was begun. Patient 4 also had hilar adenopathy. Patient 3 had mul- tiple, hilar and apical, calcific densities present on chest roentgenogram at the time of diagnosis of her leukemia (Fig. 2A). She subsequently developed bilateral pneumonitis 27 months later complicated by concomitant Pn,eumocystis carinii infection and bilateral pleural effusions. Intradermal histoplasmin and tuberculin skin tests were nonreactive at

1130 CANCER April 1974 VOl. 33

FIG. 2A (top). Chest roentgenogram (9/10/68) on Patient 3 at diagnosis of leukemia. Mul- tiple calcific densities are apparent in right hilum and apex indicating previous infection. FIG. 2B (bottom). Chest roentgenogram (12/24/70) on Patient 3 during pneumonia (day 26) demonstrating bilateral alveolar disease obscuring the cardiac borders. Pneumocystis carinii infection had been diagnosed on day 7 and treated with pentamidine.

this time and 1 month later. The effusions re- solved spontaneously in 2 weeks, but roentgenographic evidence of alveolar disease persisted for 6 months (Fig. 2B).

Complement fixation tests for yeast and/or mycelial phase antigens for H . capsulatum were 1 : 8 or greater in five children. The histoplasmin latex agglutination test" did not cor- relate with the complement fixation test, and both false-negative and false-positive results occurred. The histoplasmin skin test was reactive in Patient 4 before treatment and in Patient 2 after 5 days of therapy. Immuno- globulins were done on four patients and were normal in Patients 3, 4, and 6. Patient 5 showed a moderate elevation of IgG and a minimal elevation of IgM in the peripheral blood on one occasion, but the test was not repeated.

All patients were treated with amphotericin B at a dose of 1.0 mg/kg/day, administered intravenously over a 6-hour period. Dosage was sequentially increased from an initial dose of 0.25 mg/kg/day over the first 3 days so that the first full dose was administered on the 4th day. Treatment was for 1 month with 2 weeks of daily therapy followed by 2 weeks of alternate-day therapy.

All six patients recovered from their disease. Fever was absent after 2 to 5 days of therapy in five patients and absent at the onset of treatment in the sixth. Liver and spleen size returned to normal in 12 to 36 days in four children, while one (Patient 1) died from other causes before complete resolution of the hepatosplenomegaly; one did not have organ enlargement at the onset.

Superficial thrombophlebitis developed in two patients, one of whom developed generalized seizures as a result of the inadvertent infusion of amphotericin B at an excessively rapid rate. In a third patient infiltration of the drug into subcutaneous tissues resulted in severe, local, chemical cellulitis with bullae formation on the skin. These complications were treated by temporary cessation of therapy, changing the infusion sites and sympto- matic measures as applicable. In an attempt to prevent chills, fever, and local pain in two individuals, hydrocortisone (25 to 50 mg) was administered intravenously, just prior to infusion of the drug.

Transient azotemia (BUN 2 20 mg/lOO ml) occurred in five patients and was controlled by

No. 4 HISTOPLASMOSIS IN LEUKEMIA Cox and Hughes 1131

omitting a drug dose for 24 to 48 hours if the level rose to 240 mg/100 ml. Omission of a drug dose in the 1st week of therapy resulted in return of fever in 24 to 48 hours, but no other deleterious effects were noted. Hypokalemia (53.0 mEq/L) occurred in two patients and was treated with supplemental potassium. In- termittent elevation of the SGOT was seen in one child only during therapy. In a second child this began after 5 weeks of symptoms coincident with initiation of therapy and therefore could not be definitely related to treatment. Eosinophilia of 8-280/, was observed transiently in two patients, and lasted for 6 days in Patient 3 and 34 days in Patient 2, with persistence for 10 days after comple- tion of therapy in the latter. Thrombocyto- penia ( I 50,000/mm3) was apparently related to therapy in Patient 5 since the platelet count diminished on therapy and returned to normal after the drug was stopped. No effects were noted from this, and no therapy was given. Patient 1 received sulfadiazine at a dose of 100 mg/kg/day for 6 weeks, during which time two separate bone marrow cultures remained positive for H . capsulatum. Subsequent therapy with amphotericin B. 3 weeks later, eradicated the organism.

Three patients died from causes unrelated to their histoplasmosis. Postmortem examina- tion was performed on two. Patient 1 showed no evidence of residual disease, but focal, healed granulomas were found in the lung and kidney of Patient 3. N o organisms were observed with methenamine silver stain. The three surviving patients have been followed from 5 to 33 months, and, at the present time, no evidence of recurrence has been noted.

Consolidated Laboratories, Chicago Heights, Ill.

CASE REPORT

Patient 4. A 29/12-year-old Caucasian male from Tennessee was admitted to S JCRH in August of 1969, where a diagnosis of acute lymphocytic leukemia was made. On October 5, 1971, he developed fever, rhinorrhea, cough, tachypnea, and splenomegaly. Labora- tory studies revealed a white blood count (WBC) of 3,70O/mm3 with 2% polymorphonuclear cells, 3% band forms, 44% lymphocytes, 49% monocytes, and 2% eosinophils; hemoglobin 11.8 mg/100 ml; and estimated platelet count 184,00O/mm3. By October 12, 1971, the WBC was 10,60O/mrn3 with 60% polymorphonuclear cells, 11% band forms, 13% lymphocytes, 8% monocytes, and 8% eosinophils. Signs and symptoms persisted and on November 8, 1971, a bone marrow culture

1132 CANCER April 1974 Vol. 33

was taken which was subsequently positive for H . cnpszdaturn. On November 9, 1971, a chest roentgenogram revealed bilateral, miliary, alveolar disease and hilar adenopathy. The WBC was 2,lOO/mm3 with 87% polymorphonuclear cells, 10% lymphocytes, 1 monocytes, and 2% eosinophils; hemoglobin 11.5 g m / l O O ml; and an estimated platelet count of 180,000/mm3. Serum immunoglobu- lin levels were: IgG, 1,100 mg/100 ml; IgA, 55 mg/l00 ml; and IgM, 85 mg/100 ml. Leuke- mia chemotherapy at this time consisted of methotrexate, cyclophosphamide, and 6-mercaptopurine. Pulmonary needle aspirate showed no fungal organisms on smear or culture. The histoplasmin skin test was reactive, but was nonreactive 10 days later on Novem- ber 19, 1971. However, the complement fixing (CF) antibody titer for H . capsulatum was I 1:8 on November 9 but positive at a 1:s dilu- tion with yeast phase antigen on November 22, 1971. Mycelial phase antigen was negative on both occasions.

Therapy with intravenous am hotericin B

ond bone marrow culture and a blood culture grew H . capsulatum. Treatment was con tinued until December 22, 1971 at a total dose of 22.9 mg/kg. Fever was absent after 2 days of therapy, and the hepatosplenomegaly was not present after 13 days. Transient elevation of the SGOT up to 86 I.U. occurred for 5 days prior to and for 9 days after amphotericin B. Complications of therapy included elevation of the BUN to 28 mg/lOOml for 1 day, transient hypokalemia to 3.2 mEq/L, and a grand ma1 seizure. On the 9th day of therapy total serum protein was 6.0 gm/100 ml, with the albumin 3.5 gm/IOO ml and globulin 2.5 gm/100 ml. The chest roentgenogram revealed no pneumonia after 5 days of therapy. During the last week of treatment the peripheral WBC increased to 10,000/mm3 with a shift to the left. Recovery was uneventful.

was begun November 19, at whic K time a see

DISCUSSION

Disseminated histoplasmosis in childhood leukemia may present a clinical pattern difficult to differentiate from that observed in the primary malignant disease. The infection occurs after prolonged immunosuppression and presents with nonspecific signs and symptoms. In our patients with acute lymphocytic leukemia, the only finding consistently present was fever. Hepatosplenomegaly, the hall- mark of the disseminated form of the disease in infants, was a frequent finding. Only four case reports of disease in leukemic children have appeared in the literature during the

past decade. In one the infection occurred during relapse,4 in another during remission,l and in the other two cases the hematologic status was not described.l5J6

The occurrence of disseminated histoplasmosis is an uncommon event and the true prevalence is not known. In an epidemic in the Midwest in 1964, 1 case of disseminated disease occurred among 6,000 persons in- fected.12 At SJCRH, 6 cases occurred over a 10-year period among 792 children treated for leukemia. Thus, although the prevalence of disseminated disease is unknown in the general population, it is obviously more frequent in children with leukemia.

At this hospital, histoplasmosis is encountered most commonly during remission. The patients were chronically ill with persistent signs and symptoms but did not appear toxic. Respiratory distress was not a prominent fea- ture with pneumonitis, and rales were not usually present. The absence of these features and the absence of roentgenographic evidence of pulmonary disease in half the patients made diagnosis difficult.

The laboratory data provided some assist- ance but seldom consistently. Ikukopenia and/or neutropenia were commonly encountered, but anemia, usually present in infants with disseminated disease at hemoglobin levels of 5 to 7 gm/100 rnI,l4 was seldom encountered. The significance of this observation is difficult to evaluate due to the frequent blood transfusions these patients receive for their leukemia. Abnormal liver function was difficult to evaluate due to an inconstant pattern of involvement with any oE the commonly ern- ployed tests and possible elevation from the antileukemia chemotherapy. The histoplasmin skin test was unreliable since it was more commonly nonreactive. The complement fixation test for histoplasmosis was a more accurate in- dex of disease, with five of six patients having titers 2 1 : s at the time of cultural isolation or subsequent seroconversion. The seronega- tive individual (Patient 1) was histoplasmin skin test negative and was the only patient receiving prednisone every other day through- out his disease, but it cannot be determined if this was contributory.

It is of interest that the "immunosuppressed" host is capable of huinoral antibody response to H . cnpsulattirn. In one patient (Patient 3) a baseline chest roentgenogram taken at the time of initial admission for leukemia revealed healed, calcified lesions in the

lung characteristic of inactive pulmonary histoplasmosis. Disseminated histoplasmosis occurred 26 months after onset of immunosuppressive chemotherapy and radiation. This implies re-activation of a dormant mycotic infection, although the possibility of exogenous reinfection also e ~ i s t s . 1 ~

Pulmonary needle aspiration was not useful in diagnosis in any of the three patients in the presence of diffuse, bilateral pulmonary disease. The reasons for this are speculative, but perhaps are related to the intracellular presence of this parasite in macrophages with relatively fewer organisms lying free in the alveolar spaces, or to the fact that active lesions were not present at the aspiration site. The presence of a positive bone marrow culture for H . capsulatum confirmed the diagnosis in each patient. A search for organisms on a Wright's stained smear of the marrow was also done and provided the diagnosis before the cultures revealed growth in two patients in this series.

The therapy with amphotericin B was re-

No. 4 HISTOPLASMOSIS IN LEUKEMIA * Cox and Hughes 1133

markably effective in these patients as evi- denced by their complete recovery and the absence of organisms at autopsy. Therapy should be instituted as soon as cultural isolation occurs or when the organims are seen in the marrow aspirate. Recovery with treatment has occurred in adults in remission1 and in children relapse.4 A full course of 1 month of intravenous therapy is suggested, the last 2 weeks of which may be done on an outpatient basis if the course of the disease or therapy does not indicate otherwise. The usual complications of this drug, including thrombe phlebitis, azotemia, hypokalemia, chills, fever, seizures, and local tissue damage with inadvertent subcutaneous administration, were all observed and treated successfully in a symp- tomatic manner or by discontinuing the drug temporarily. Sulfonamides were ineffective in the one patient treated. This is similar to the experience of Utzl6 and Bodey,l where par- tial suppression of disease occurred on sulfonamides, but hepatosplenomegaly persisted, in one case for 18 months1

REFERENCES

1. Bodey, G. P.: Fungal infections complicating acute leukemia. J. Chronic Dis. 19:667-687, 1966.

2. Cooperberg, A. A., and Schwartz, J.: The diagnosis of disseminated histoplasmosis from marrow aspiration. Ann. Intern. M e d . 61:289-295, 1964.

3. Davis, P. L., and Ripka, J. W.: Pancytopenia with leukemia-like picture-Effects of histo,plasmosis.

4. Drewinko, B., Lichtiger, B., and Thomson, S.: Bone marrow histoplasmosis associated with acute lymphocytic leukemia. Beitr. Pathol. Bd. 147:293-299, 1972.

5 . Ende, N., Pizzolato, P., and Ziskind, J.: Hodgkin's disease associated with histoplasmosis. Cancer 5:763- 769, 1952.

6. Furcolow, M. L.: Opportunism in histoplasmosis. Lab. Invest. 2:1134-1139, 1962.

7. Hood, A. B., IngIis, F. G., Lowenstein, L., Dos- setor, J . B., and MacLean, L. D.: Histoplasmosis and thrombocytopenic purpura-Transmission by renal homotransplantation. Can. M e d . Assoc. J. 93:587-592, 1965.

8. Hughes, W. T.: Leukemia monitoring with fungal bone manow cultures. fAMA 218:441-443, 1971.

9. Murray, P. J. S., and Sladden, R. A.: Dissemi- nated histoplasmosis following long-term steroid therapy for reticulosarcoma. Br. M e d . J. 2:631-632, 1965.

JAMA 188:176-177, 1964.

10. Reyes, F. M., Medina, M. A., and Corrada, R. M.: Disseminated histoplasmosis complicating granulocytic leukemia. Bol. Asoc. Med. P . R. 58:380-385, 1966.

11. Rifkind, D., Marchiaro, T. L., Schneck, S. A,, and Hill, R. B.: Systemic fungal infections complicating renal transplantation and immunosuppressive therapy. Am. J. Med. 43:28-38, 1967.

12. Sarosi, G. A., Voth, D. W., Dahl, B. A., Doto, I. L., and Tosh, F. E.: Disseminated histoplasmosis- Results of long-term followup. A Center for Disease Control cooperative mycoses study. Ann. Intern. Med. 75:511-516, 1971.

13. Schwarz, J., and Baum, G. L.: Reinfection in histoplasmosis. Arch. Pnthol. 75:475-479, 1963.

14. Silverman, F. N., Schwarz, J., Lahey, M. E., and Carson, R. P.: Histoplasmosis. Am. J. Med. 19:410- 459, 1955.

15. Smith, J. W., and Utz, J. P.: Progressive disseminated histoplasmosis-A prospective study of 26 patients. Ann. Intern. Med. 56:557-565, 1972.

16. Utz, J. P.: The spectrum of opportunistic fungus infections. Lab. Invest. 2:1018-1025, 1962.

17. Watson, J. I., Mandl, M. A. J., and Rose, B.: Dis- seminated histoplasmosis occurring in association with systemic lupus erythematosus. Can. Med. Assoc. J. 99: 958-962, 1968.

disseminated histoplasmosis and childhood leukemia

Documents