5-61
Lab: Eosinophils may be seen on blood smear. Gram stain or KOH of sputum for spherules (10-80 μm round
structures with 2-5 μm round endospores inside)
Assessment:
Differential Diagnosis
Acute pulmonary disease - influenza, “atypical” pneumonia, histoplasmosis, blastomycosis (see respective
topics)
Meningitis - tuberculosis, syphilis, cryptococcosis (see respective topics); and CNS tumors (see Neurology:
Seizure Disorders and Epilepsy)
Plan:
Treatment
Primary: Observation is the treatment of choice for acute pulmonary infection and for asymptomatic cavitary
disease in patients not at increased risk for dissemination or chronic disease. Amphotericin B 0.5-1 mg/kg IV
daily should be used in acute life-threatening infection. This can be followed with fluconazole 400-800 mg/day
to complete 3-6 months of therapy. Meningeal infection is treated with fluconazole, 400-800 mg daily for life.
All other forms of coccidioidomycosis are treated with long-term fluconazole.
Alternative: Itraconazole (400-600 mg/day) may be used in non-meningeal infections. Some authorities add
intrathecal amphotericin B in the initial therapy of meningeal disease.
Patient Education
General: Acute pulmonary disease will likely resolve untreated in 6-8 weeks. Meningeal disease requires
lifelong therapy.
Medications: See Candidiasis section for adverse effects of intravenous amphotericin B and azole antifun-
gals.
Prevention and Hygiene: No human-to-human spread. Others should avoid inhaling dust where patient
was exposed.
Follow-up Actions
Return evaluation: Patients should be evaluated frequently for progressive disease.
Evacuation/Consultation Criteria: Evacuate and refer all patients to a specialist for care.
ID: Histoplasmosis (Darling’s Disease)
LTC Duane Hospenthal, MC, USAIntroduction: Histoplasma capsulatum is a dimorphic fungus that can cause disease ranging from asymptom-
atic pulmonary infection to life-threatening disseminated infection. Acute infection occurs 3-21 days after
exposure. Most infection is asymptomatic or self-limiting pulmonary disease. Severity is dependent on
patient’s immunity and intensity of exposure. Chronic pulmonary disease, mediastinitis and disseminated
disease are rare. Geographic Associations: Found worldwide, this infection is most common in the central US
(Mississippi and Ohio River basins). Risk Factors: Outbreaks may occur with the removal of debris containing
contaminated bird or bat droppings. Outbreaks in military personnel have been documented after clearing
barracks and bunkers. Immunocompromised persons are at higher to develop disseminated disease.
Subjective: Symptoms
Acute (days): Malaise, fever, chills, anorexia, myalgias, cough, pleuritic chest pain. Chronic (months):
cough
Focused History: Have you traveled to the Midwest US recently? (endemic in Ohio and Mississippi River
valleys) Have you been in caves or been near bird droppings lately? (The fungus is found in debris and soil
contaminated with bat or bird guano.)
Objective: Signs
Using Basic Tools: Inspection: Fever, weight loss; hypotension and shock in immunocompromised patient