Disseminated Histoplasmosis Post-IL6 Inhibitor Use in A COVID-19 Patient

Abstract

We report a case of a 40-year-old male patient who developed a fever one week after recovering from severe COVID-19 illness that had needed treatment with injectable corticosteroids and Tocilizumab. The patient had had maculopapular lesions on his trunk months before contracting COVID-19, but the skin lesions progressed along with the post-covid fever. Detailed workup and biopsy from skin lesions on the face, trunk, and bone marrow revealed Histoplasmosis. This case highlights the possibility of flaring up of Histoplasmosis in COVID-19 patients who have been treated with immunosuppressants. In our case, the plausible reason for reactivation and growth of Histoplasma may be the suppression of IL6 action by Tocilizumab. It may be prudent to screen patients for Histoplasma and other fungal infections like aspergillus before administering an immune-suppressive regimen in patients with a moderate or severe COVID-19 illness. Urinary Histoplasma antigen may be used for screening in these patients. J Microbiol Infect Dis 2021; 11(3):170-173.

Keywords

• COVID-19
• IL6 inhibitor
• Histoplasmosis

Kaynakça

1. 1. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395:507-513.
2. 2. Garcia-Vidal C, Sanjuan G, Moreno-García E, et al. COVID-19 Researchers Group. Incidence of coinfections and superinfections in hospitalized patients with COVID-19: a retrospective cohort study. Clin Microbiol Infect. 2021; 27(1):83-88.
3. 3. Arastehfar A, Carvalho A, van de Veerdonk FL, et al. COVID-19 Associated Pulmonary Aspergillosis (CAPA)-From Immunology to Treatment. J Fungi 2020; 6(2):91.
4. 4. Wheat LJ. Diagnosis and management of Histoplasmosis. Eur J ClinMicrobiol Infect Dis 1989; 8:480-490.
5. 5. Minamoto GY, Rosenberg AS. Fungal Infections in patients with acquired immunodeficiency syndrome. Med Clin North Am 1997; 81:389-409.
6. 6. Cirillo-Hyland VA, Gross P. Disseminated histoplasmosis in a patient with acquired immunodeficiency syndrome. Cutis 1995;55(3):161-164.
7. 7. Adenis AA, Aznar C, Couppié P. Histoplasmosis in HIV-Infected Patients: A Review of New Developments and Remaining Gaps. Curr Trop Med Rep 2014;1(2):119-128.
8. 8. Sayal S K, Prasad PS, Mehta A, Sanghi S. Disseminated Histoplasmosis: cutaneous presentation. Indian J Dermatol Venereol Leprol 2003; 69 (S1):90-91.

9. 9. Antinori S, Bonazzetti C, Gubertini G, et al. Tocilizumab for cytokine storm syndrome in COVID-19 pneumonia: an increased risk for candidemia? AutoimmunRev 2020; 19(7):102564.
10. 10. Guaraldi G, Meschiari M, Cozzi-Lepri A, et al. Tocilizumab in patients with severe COVID-19: a retrospective cohort study. Lancet Rheumatol 2020; 2(8):474-484.
11. 11. Bertolini M, Mutti MF, Barletta JA, et al. COVID-19 associated with AIDS-related disseminated Histoplasmosis: a case report. Int J STD AIDS 2020;31(12):1222-1224.
12. 12. Messina FA, Marin E, Caceres DH, et al. Coronavirus Disease 2019 (COVID-19) in a Patient with Disseminated Histoplasmosis and HIV-A Case Report from Argentina and Literature Review. J Fungi 2020; 6(4):275.
13. 13. Lane TE, Otero GC, Wu-Hsieh BA, Howard DH. Expression of inducible nitric oxide synthase by stimulated macrophages correlates with their antihistoplasma activity. Infect Immun 1994; 62(4):1478-9.
14. 14. Ranque S, Pelletier R, Michel-Nguyen A, Dromer F. Platelia Aspergillus assay for diagnosis of disseminated histoplasmosis. Eur J ClinMicrobiol Infect Dis. 2007; 26(12):941-943.
15. 15. Wheat LJ, Hackett E, Durkin M, et al. Histoplasmosis-associated cross-reactivity in the BioRadPlatelia Aspergillus enzymeimmunoassay. Clin Vaccine Immunol 2007; 14:638-640.