Leo Kaufman

Isolation of Blastomyces dermatitidis in Soil Associated with a Large Outbreak of Blastomycosis in Wisconsin

In investigating six cases of blastomycosis in two school groups that had separately visited an environmental camp in northern Wisconsin in June 1984, we identified a large outbreak of the disease and isolated Blastomyces dermatitidis from soil at a beaver pond near the camp. Of 89 elementary-school children and 10 adults from the two groups, 48 (51 percent) of the 95 evaluated in September had blastomycosis. Of the cases, 26 (54 percent) were symptomatic (the median incubation period was 45 days; range, 21 to 106 days). No cases were identified in 10 groups that visited the camp two weeks before or after these two groups. A review of camp itineraries, a questionnaire survey, and environmental investigation showed that blastomycosis occurred in two of four groups that visited a beaver pond and in none of eight groups that did not. Walking on the beaver lodge (P = 0.008) and picking up items from its soil (P = 0.05) were associated with illness. Cultures of soil from the beaver lodge and decomposed wood near the beaver dam yielded B. dermatitidis. We conclude that B. dermatitidis in the soil can be a reservoir for human infection.

Successful Medical Therapy for Deeply Invasive Facial Infection Due to Pythium insidiosum in a Child

Pythiosis occurs in animals and humans who encounter aquatic habitats that harbor Pythium insidiosum. Drug therapy for deeply invasive infections with this organism has been ineffective in humans and animals; patients have been cured only by radical surgical debridement. A 2-year-old boy developed periorbital cellulitis unresponsive to antibiotic and antifungal therapy. The cellulitis extended to the nasopharynx, compromising the airway and necessitating a gastrostomy for feeding. P. insidiosum was isolated from surgical biopsy specimens of the affected tissue. On the basis of in vitro susceptibility studies of the isolate, the patient was treated with a combination of terbinafine and itraconazole. The infection resolved over a period of a few months. The patient remained well 1.5 years after completing a 1-year course of therapy. Cure of deep P. insidiosum infection is feasible with drug therapy.

Outbreak of coccidioidomycosis in Washington state residents returning from Mexico.

In July 1996 the Washington State Department of Health (Seattle) was notified of a cluster of a flulike, rash-associated illness in a 126-member church group, many of whom were adolescents. The group had recently returned from Tecate, Mexico, where members had assisted with construction projects at an orphanage. After 1 member was diagnosed with coccidioidomycosis, we initiated a study to identify further cases. We identified 21 serologically confirmed cases of coccidioidomycosis (minimum attack rate, 17%). Twenty cases (95%) occurred in adolescents, and 13 patients (62%) had rash. Sixteen symptomatic patients saw 19 health care providers; 1 health care provider correctly diagnosed coccidioidomycosis. Coccidioides immitis was isolated from soil samples from Tecate by use of the intraperitoneal mouse inoculation method. Trip organizers were unaware of the potential for C. immitis infection. Travelers visiting regions where C. immitis is endemic should be made aware of the risk of acquiring coccidioidomycosis, and health care providers should be familiar with coccidioidomycosis and its diagnosis.

Investigation of an outbreak of endemic coccidioidomycosis in Brazil's Northeastern State of Piauí with a review of the occurrence and distribution of Coccidioides immitis in three other Brazilian states

An outbreak of coccidioidomycosis is described that involved three individuals and eight of their dogs, who had engaged in a successful hunt for nine-banded armadillos (Dasypus novemcinctus) in the environs of Oeiras, a community in Brazils north eastern state of Piauí.Diagnosis was based on clinical, serological and cultural findings. Four of 24 soil samples collected in and around the burrow of an armadillo yielded cultures of Coccidioides immitis, thus establishing the endemicity of that mould in the state of Piauí. A literature review revealed that C. immitis, aside from that state, is endemic in three other Brazilian states — Bahia, Ceará and Maranhão. These four contiguous states have semi-arid regions where climatic conditions and their flora are similar to those that exist in C. immitiss endemic regions in North, Central and South America.

Outbreak of histoplasmosis associated with the 1970 earth day activities

Abstract An outbreak of histoplasmosis occurred in early May 1970 at a junior high school in Delaware, Ohio; clinical illness occurred in 384 (40 per cent) of the students and faculty, with probably an equal number of subclinical cases. The mode of spread was airborne and was shown epidemiologically to be related to activities on Earth Day, April 22, 1970, when the courtyard in the center of the school, an old bird roost, was raked and swept. Contamination of the entire school building with courtyard air occurred via the schools forced air ventilation system with intakes in the courtyard. Soil samples from the courtyard were positive for Histoplasma capsulatum, but random samples from other areas around the building were negative. In two persons in the building only on April 22, the typical illness developed. Features of the outbreak have important implications for clinicians and public health officials.

Outbreak of Sporotrichosis among Tree Nursery Workers

In spring 1994, an outbreak of sporotrichosis occurred at a tree nursery in Florida; 9 (14%) of 65 workers involved in production of sphagnum moss topiaries developed lymphocutaneous sporotrichosis. A cohort study of all 65 employees was conducted to identify risk factors for sporotrichosis, and an environmental investigation was done. The risk of sporotrichosis increased significantly with the duration of working with sphagnum moss (P < .05), in particular with filling topiaries (P < .05), and with having less gardening experience (P < .05). Wearing gloves was protective (P < .005). Sporothrix schenckii was cultured from patients and sphagnum moss used in topiary production. Use of restriction fragment length polymorphism revealed an identical pattern for patient isolates that was different from the patterns of environmental isolates. Physicians should be aware of sporotrichosis in patients with ulcerative skin lesions who have a history of occupational or recreational exposure to sphagnum moss.

Acute histoplasmosis: Clinical, epidemiologic and serologic findings of an outbreak associated with exposure to a fallen tree

Abstract An outbreak of acute histoplasmosis occurred among 42 people who gathered for two days in May 1977 to cut and clear a fallen oak tree near Nashville (Williamson County), Tennessee. Thirty-two (76 per cent) of the participants had serologic evidence of infection; 20 (48 per cent) had acute pulmonary disease and of these, three required hospitalization. Frequent symptoms of acute pulmonary disease included fever, malaise, chest pain, headache, cough, myalgia, weight loss (≥ 5 pounds) and stomach cramps. Chest roentgenograms revealed abnormalities in 87 per cent of the ill participants. The disease developed in two dogs that were also present at the activities. Illness began an average of 14 days after exposure. Risk of illness was associated with sawing the tree, and loading wood and bark into a truck, as well as the length of the time spent near the tree. Tests for fungal antibodies in serum obtained from the participants and community controls, (those who lived in the county but did not have symptoms of respiratory illness) were used to establish criteria for serologic diagnosis. Immunodiffusion tests with initial serum samples were most useful for diagnosis; the presence of an M precipitin band was 75 per cent sensitive and was 97 per cent specific as judged by data from community controls. Similarly, the mycelial form antigen Histoplasma capsulatum complement fixation test at a titer ≥ 1:8 was 55 per cent sensitive and 97 per cent specific, and the yeast-form antigen complement fixation test at a titer of ⩾ 1:16 was 75 per cent sensitive and 77 per cent specific. When serum obtained four weeks after exposure (one to two weeks after onset of symptoms) was compared with serum obtained eight weeks after exposure, a fourfold increase in complement fixation antibodies was detected in 28 per cent of those infected.

Penicilliosis marneffei and pythiosis: emerging tropical diseases.

Penicilliosis marneffei and pythiosis insidiosi are emerging infections in subtropical, tropical, and temperate areas of the world. Penicilliosis marneffei is endemic in several Southeast Asian countries and may be carried to other areas of the world by residents of these countries or visitors. Pythiosis occurs in humans and animals who frequent the aquatic habitats that harbor Pythium insidiosum. Although early diagnosis is important because of the high morbidity or mortality associated with these two diseases, the diagnosis of these infections can be difficult because their clinical and histologic features are not pathognomonic. Prompt diagnosis is a prerequisite to their appropriate treatment. Laboratory testing, involving cultural, histologic and immunologic methods, is necessary to establish an unequivocal diagnosis. The clinical presentation, epidemiology, diagnosis and treatment of these diseases are discussed.

A natural focus ofHistoplasma capsulatum var.duboisii is a bat cave

The natural reservoir ofHistoplasma capsulatum var.duboisii, the etiological agent of histoplasmosis duboisii (African histoplasmosis) is not yet known. We report the isolation ofH. capsulatum var.duboisii from soil admixed with bat guano and from the intestinal contents of a bat in a sandstone cave in a rural area, Ogbunike in Anambra State of Nigeria. Eight of 45 samples of soil admixed with bat guano yieldedH. capsulatum var.duboisii. Of the 35 bats belonging to the speciesNycteris hispida andTadirida pumila examined, only one (N. hispida) yielded this fungus from its intestinal contents. Identification of the isolates asHistoplasma was confirmed by exoantigen tests and by mating with tester strains ofH. capsulatum. In vitro conversion to large yeast from suggestive ofH. capsulatum var.duboisii was obtained on brain heart infusion agar supplemented with sheep blood and glutamine or cysteine. Pathogenicity tests with mice for all the isolates confirmed their identity by the demonstration of large yeast forms (8–15 µm in diameter) within giant cells in the infected tissues. Investigations on the possible occurrence of human infections in the area are in progress.

Oral histoplasmosis in a patient infected with HIV. A case report

Histoplasmosis is a frequent complication of HIV infection and is usually the result of reactivation. In the immunocompromised host, histoplasmosis may cause a chronic pulmonary infection or disseminated disease. In the setting of disseminated disease, oral lesions are present in 30% to 50% of patients and may occur in almost every part of the oral mucosa. The most common sites are the tongue, palate, and buccal mucosa. In some cases, oral lesions appear to be the primary or only manifestation of disease. We have been able to find only five case reports in the literature of histoplasmosis in HIV infection with oral lesions. In two of the cases, histoplasmosis was apparently localized to the oral cavity, whereas two cases also had evidence of disseminated disease, the fifth was undetermined. We report one such case of apparently localized oral histoplasmosis in a patient with HIV infection.