Histoplasmosis is caused by infection with the dimorphic soil fungus Histoplasma capsulatum. Histoplasmosis is in any parts of the world with warm humid soil and large migratory bird populations. It is the most common pulmonary and systemic mycosis of humans. Even under the most adverse conditions, ordinary soil teems with life. One square meter — of plain dirt can contain more than 10,000 varieties of bacteria and fungi and up to 1,000 species of protozoa, nematodes and earthworms. Most soil organisms are highly beneficial, but a few can be dangerous, and some can even be deadly. One of these is the fungus Histoplasma capsulatum, which in humans and other animals causes a lung disease called histoplasmosis.

 It's transmitted through airborne spores that you breathe into your lungs when you work in or around soil that contains the fungus. Farmers, landscapers, construction workers and people who have contact with birds or bats are especially at risk.

Most people with histoplasmosis never develop signs and symptoms and aren't aware they have the disease. But for some people — primarily infants and those with compromised immune systems — histoplasmosis can be much more serious.

Fortunately, effective treatments are available for even the most severe forms of histoplasmosis. But these therapies often involve extensive hospital stays and can cause serious side effects, so it's best for people with compromised immune systems to do everything possible to avoid infection.

Signs and symptoms

Several types of histoplasmosis exist, ranging from mild to life-threatening. The most benign form produces no signs or symptoms, but severe infections may cause serious problems throughout your body. When signs and symptoms do occur, they usually appear three to 17 days after exposure.

Common types of histoplasmosis include:

• Asymptomatic primary histoplasmosis. This is the most common form of histoplasmosis and usually produces no signs and symptoms in otherwise healthy people who become infected. The only residual sign of infection may be a small scar in the lung. Although these scars are harmless, they sometimes show up as a suspicious nodule on a routine chest x-ray or computerized tomography (CT) scan. In that case, special radiologic testing can usually confirm that the nodule isn't cancerous.

• Acute symptomatic pulmonary histoplasmosis. This form of histoplasmosis tends to occur in otherwise healthy people who have had intense exposure to H. capsulatum. Because the severity of the disease depends on the number of fungus spores inhaled, reactions may range from a brief period of not feeling well to serious illness. Typical signs and symptoms may include fever, headache, dry cough, chills, chest pain, weight loss and sweats. In some cases, arthritis or pericarditis — an inflammation of the sac that surrounds the heart — may develop weeks or months after the initial infection. These problems aren't a sign that the infection has spread outside your lungs. Instead, they develop because your immune system responds to the fungus with an unusual amount of inflammation. Arthritis is much more likely to occur in women than in men and is often accompanied by erythema nodosum, a skin rash in the form of nodules that's usually found on the shins. The rash and arthritis frequently go away on their own or following treatment with nonsteroidal anti-inflammatory drugs.

• On the other end of the spectrum, people who have inhaled a large number of spores may develop severe acute pulmonary syndrome, a potentially life-threatening condition in which breathing becomes difficult and not enough oxygen reaches the lungs. Acute pulmonary syndrome is frequently referred to as spelunker's lung because it often occurs after intense exposure to bat excrement stirred up by explorers in caves.

• Chronic pulmonary histoplasmosis. This type of histoplasmosis usually affects people with an underlying lung disease such as emphysema. It's most common in white, middle-aged men. Signs and symptoms — including fatigue, fever, night sweats and a cough that may sometimes bring up blood — are similar to those of tuberculosis. The disease is long-term, and if left untreated may progress to disabling lung problems.

• Disseminated histoplasmosis. Occurring primarily in infants and people with compromised immune systems, disseminated histoplasmosis can affect nearly any part of your body, including your eyes, liver, bone marrow, skin, adrenal glands and intestinal tract. Depending on which organs are affected, people with this form of the disease may develop anemia, pneumonia, pericarditis, meninigitis, adrenal insufficiency or ulcers of the mouth, tongue or intestinal tract. Untreated disseminated histoplasmosis is usually fatal.

• Chest pain

• Emphysema

• Fatigue

• Headache

• Pneumonia

• Tuberculosis

Causes

Histoplasma capsulatum is primarily found in the temperate regions of the world.

The fungus thrives in damp soil that's rich in organic material, especially the droppings from birds and bats. For that reason, it's particularly common in chicken and pigeon coops, old barns, caves and parks.

Birds themselves aren't infected with histoplasmosis — their body temperature is too high — but they can carry H. capsulatum on their wings, and their droppings support the growth of the fungus. Birds commonly kept as pets, such as canaries and parakeets, aren't affected.

Although bats, which have a lower body temperature, can be infected, you can't contract histoplasmosis from a bat or from another person.

Instead, you develop histoplasmosis when you inhale the reproductive cells (spores) of the fungus. The spores are extremely light and float into the air when dirt or other contaminated material is disturbed. That's why a high number of cases occur in farmers, landscapers, construction workers and spelunkers. In one instance, an entire Boy Scout troop became infected after cleaning up an old park filled with roosting starlings.

Histoplasmosis and your lungs
Your lungs are two spongy organs, each surrounded by a moist membrane (the pleura). When you inhale, air is carried through the windpipe (trachea) to your lungs in two major airways called bronchi. Inside your lungs, the bronchi subdivide nearly 20 times into a million smaller airways (bronchioles), which finally end in clusters of tiny air sacs called alveoli.

Because the spores of H. capsulatum are no more than two-millionths of a meter in diameter, they can easily enter your lungs and settle in the small air sacs. There, the spores are trapped by macrophages — immune system cells that attack foreign organisms. The macrophages carry the spores to lymph nodes in your chest, where they continue to multiply. This may lead to inflammation, scarring and calcium deposits. In cases of heavy infection, the lymph nodes may become so enlarged that they obstruct your esophagus or your lungs' airways.

Most often, however, you're not likely to have noticeable signs and symptoms, and the infection clears on its own without treatment. But if your immune system isn't able to eliminate the spores, they can enter your bloodstream and travel to other parts of your body. In that case, you may develop a variety of severe problems that can be fatal if not diagnosed and treated quickly.

Risk factors

Anyone exposed to H. capsulatum is likely to become infected. People who inhale a huge number of spores — those who work with heavily infected soil or have close contact with bats, for example — are more likely to develop signs and symptoms.

Most at risk of infection are:

• Farmers

• Poultry keepers, especially when cleaning chicken coops, pigeon roosts and bat-infested barns or lofts

• Construction workers

• Landscapers and gardeners

• People involved in building roads

• People who monitor bird populations or who have contact with bats or bat caves

• Archeologists

• Geologists

Because their immune systems are weakened, the following people are most likely to develop disseminated histoplasmosis, the potentially fatal form of the disease:

• Infants and very young children.

• Older adults. The risk of disseminated histoplasmosis increases with age.

• HIV-positive people or those living with AIDS. People whose CD4 lymphocyte count is below 200 are especially vulnerable. CD4 lymphocytes are the white blood cells that coordinate your entire immune system.

• People receiving chemotherapy or long-term treatment with corticosteroid drugs such as prednisone.

• People who have had organ transplants and are taking anti-rejection medications.

• chemotherapy

Histoplasmosis > 1 > 2 > 3 > 4

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