20

AmericAn JournAl

of

clinicAl medicine Winter 2010 Volume SeVen, number one

Core CompetenCies

CHEST X-RAY

Food Handler with Cough

Manoj Mazumder, MD

A 21-year-old African-American food handler from Memphis, who works in a nursing home facility, has experienced increasingly severe nausea and vomiting over the past six days. During the last day he has complained of chest pain, slight nonproductive cough, and a fever. e denies a previous history of allergy, surgery, or hospitali!ation. e smoked for two years "ut #uit several years ago. e denies $% exposure, hemoptysis, headache, night sweats, and weight loss. e denies cave explo- ration and exotic pets. is vital signs are unremarka"le& "lood pressure 1'()*+, pulse ,- "eats per minute, oral temperature ...'/ 0ahrenheit, respiratory rate 1, per minute and unla"ored. is physical examination is unremarka"le. $he lungs are clear to auscultation and percussion. 1ulse oximeter documents 2a3 2 of ..4. $he peak flow is -(' 5)minute. An electrocardiogram is normal, and the hemogram is normal with a white "lood cell count of -.' x1'.)5, and the hemoglo"in is 1(.1 gms)dl. $he following chest radiogram is o"tained, and clinical #uestions follow. 0irst, there is a postero-anterior view and then a lateral image. 1. $he "est interpretation of this image is& a. Acute pneumonia ". 2econdary tu"erculosis c. 1rimary tu"erculosis d. Diffuse "ilateral a"normalities of unknown etiology 2. $he "est management plan would include& a. ospitali!ation ". 6mmediate referral to the pu"lic health department c. A 11D skin test with reading in -7-*2 hours d. %ronchoscopy following A6Ds precautions

Core Competencies Chest X-ray

AmericAn JournAl number one

of

clinicAl medicine Winter 2010 Volume SeVen,

21
nated with "at or "ird droppings, including poultry. 2pores "ecome air"orne when contaminated soil is distur"ed. %reathing the spores causes infection. $he disease is not transmitted from an infected person to someone else.1 Histoplasma capsulatum may infect anyone. 1ositive histoplasmin skin tests occur in as many as 7'4 of the people living in areas where H. capsulatum is common, such as the midwestern >nited 2tates, in the 3hio and Mississippi valleys. Among the endemic mycoses it is the most common cause for hospitali!ation.2 6ts symptoms vary greatly, "ut the disease primarily affects the lungs. Most indi- viduals with histoplasmosis are asymptomatic. 2ince person-to-person transmission of histoplasma is not known, the patient can continue working as a food handler. $ransmis- sion "y organ transplantation has "een reported, however.+,Distinct patterns may "e seen on a chest x-ray. istoplasmo- mas are healed pulmonary lesions that appear as residual nod- ules on chest radiography. $hese are seen here, "ut his disease has not reactivated. $his military pattern of histoplasmosis is fre#uently accompanied "y calcified hilar adenopathy, "ut that is not seen here. ;hronic histoplasmosis can resem"le tu"erculosis and can worsen over months or years. $hose who develop clinical manifestations are usually immunocompromised or are exposed to a high #uantity of inoculum. 6nfants, young children, and older persons, in particular those with chronic lung disease, are at increased risk for severe disease. $he acute respiratory disease is characteri!ed "y respiratory symptoms, a general ill feeling, fever, chest pains, and a dry or nonproductive cough. $he disseminated form is fatal unless treated.

$he patient returns from the hospital where his 68 and "ronchoscopy examinations were 9normal.: A 11D was placed, and two days later the induration was noted to "e . mm. A lateral image from the first day is reviewed.

+. $he lateral image is most consistent with& a. Acute pneumonia ". 2econdary tu"erculosis c. 1rimary tu"erculosis d. Diffuse "ilateral a"normalities of unknown etiology -. $his radiograph, present illness, and physical examination are most consistent with& a. %lastomycosis ". $u"erculosis c. istoplasmosis d. 1neumocystis ;arinii (. Management of this case should include& a. 6mmediate termination as a food handler ". <uarantine with pu"lic health department c. ;ourse of medication as outpatient d. =outine care with o"servation for changes

Treatment for Pulmonary Histoplasmosis

;linical practice guidelines for the management of patients with histoplasmosis were updated in 2''* "y the 6nfectious Disease 2ociety of America.( $he therapeutic approach to pulmonary istoplasmosis varies according to the specific disease process, namely& 1. Acute pulmonary istoplasmosis 2. ;hronic pulmonary istoplasmosis +. Mediastinal granulomas -. 0i"rosing mediastinitis (. %roncholithiasis ,. 1ulmonary nodules $his patient has asymptomatic pulmonary nodules. 2ites of healed Histoplasma capsulatum lung infection can evolve into pulmonary nodules that can persist long term. (,, $hey are typi- cally asymptomatic and are identified incidentally on chest x rays or ;$ imaging. 6n the setting of isolated nodules, there is no evidence that antifungal therapy is "eneficial.(,* Antifungal medications are used to treat severe cases of acute histoplas- mosis and all cases of chronic and

Discussion
6n the radiograph "oth lung fields have multiple scattered small nodules. $hese were uniformly small, less than 2 mm each. Although there are several differential diagnoses for this pat- tern, this most likely represents a fungal infection known as histoplasmosis. $u"erculosis and 68 should "e excluded, and they were. 6npatient workup was not necessary. istoplasmosis is a disease caused "y the fungus Histoplasma capsulatum. H. capsulatum grows in soil and material contami-

disseminated disease. Mild Core Competencies Chest X-ray

22

AmericAn JournAl

of

clinicAl medicine Winter 2010 Volume SeVen, number one

disease usually resolves without treatment. 1ast infection results in partial protection against ill effects if reinfected.( His- toplasma species may remain latent in healed granulomas and recur due to su"se#uent cell-mediated immunity impairment.

"otential Financial #onflicts of $nterest% &y A'#M policy, all aut(ors are re)uired to disclose any and all commercial, financial, and ot(er relations(ips in any *ay related to t(e su+ject of t(is article t(at mi,(t create any potential conflict of interest. -(e aut(or (as stated t(at no suc( relations(ips e.ist.

Diagnosis
;ulture of Histoplasma capsulatum from "one marrow, "lood, sputum, and tissue specimens is the definitive method of diagnosis. Demonstration of the typical intracellular yeast forms "y microscopic examination strongly supports the diagnosis of histoplasmosis when clinical, epidemiologic, and other la"oratory studies are compati"le. An antigen detection test used on urine and serum is a rapid, commercially availa"le diagnostic test. Antigen detection is most sensitive for severe, acute pulmonary infections and for progressive disseminated infections. 6t often is transiently posi- tive early in the course of acute, self-limited pulmonary infec- tions. A negative test does not exclude infection. 6n this case, these healed pulmonary nodules will re#uire no further investigations. 0urther, nothing will "e gained from an- tigen tests or skin tests at this time. 2urveillance at six to twelve months and as new symptoms arise seems reasona"le. Manoj Mazumder, Department of Family Medicine, University of Arkansas Medical Sciences, ittle !ock.

References
1.

http://www.cdc.gov/niosh/hi97146.html&))www.cdc.
gov)niosh)hi.*1-,.html D 2 ?@632 A 1u"lication @o. .*-1-, 2eptem"er 1..*. 2. +. ;hu B , 0eudtner ;, eydon C, et al. ospitali!ations for endemic mycoses, a population "ased study. #lin $nfect Dis. 2'',D-2&722-72(. 5imaye A1, ;onnolly 1A, 2ager M, et al. $ransmission of istoplasma ;apsulatum "y organ transmission. /e* 0n,l ' Med. 2'''D+-+&11,+11,,. http&))neEm.highwire.org)cgi)reprint)+-+)1,)11,+.pdfA. Fong 2G, Allen DM. $ransmission of disseminated histoplasmosis via cadaveric renal transplantation& ;ase report. #lin $nfect Dis. 1..2D1-&2+2--. Fheat B, 0reifeld AH, Cleiman M%, et al. ;linical practice guidelines for the management of patients with histoplasmosis& 2''* update "y the 6nfectious Diseases 2ociety of America. #lin $nfect Dis. 2''*D-(?*A&7'*I 2(. Hoodwin =A Br, 2nell BD Br. $he enlarging istoplasma. ;oncept of a tumor-like phenomenon encompassing the tu"erculoma and coccidiodyoma. Am !ev Dis. 1.,.,1''&1. %enson ;A, Caplan BJ, Masur , et al. $reating opportunistic infections among 68-infected adults and adolescents& =ecommendations from ;D;, the @ational 6nstitutes of ealth, and the 68 Medicine Association) 6nfectious Diseases 2ociety of America. MMF= =ecomm =epD 2''-D 8ol. (+D pp. 1-112D 622@& 1(-(-7,'1D 1>%MJD& 1(7-1',.

-. (.

,.

*.

Answers 1-aD 2-cD +-dD --cD (-d

Core Competencies Chest X-ray