J. K. Staszak1, P. Zmijewski1, B. Bagga2, S. Arnold2, R. Williams1 1University of Tennessee Health Science Center,Pediatric Surgery,Memphis, TN, USA 2University of Tennessee Health Science Center,Pediatric Infectious Disease,Memphis, TN, USA
Introduction: Mediastinal lymphadenopathy (ML) in children can arise from malignancy, infection, or rheumatic illness among others, and may be found incidentally on imaging or during work-up for a variety of symptoms. Our aim was to describe the presentation and natural history of histoplasmosis in children who present to a tertiary care center with ML in an endemic area of the country. We hypothesized there would be no evidence to support serial imaging or treatment with anti-fungal or other medications.
Methods: After IRB approval, a retrospective study of all children (age < 21 years) presenting with proven (positive serologies) or suspected histoplasmosis (negative serologies, negative tuberculosis testing, benign outcomes in follow-up) over a 5-year period was done. Seventy-four patients were tested; those with another diagnosis (n=6) or without ML (n=22) were excluded, for a cohort of 46 patients. Demographics, clinical presentation, symptoms, laboratory data, treatment course, radiography studies, and in- and out-patient visits were examined.
Results: Of the 46 patients with ML, 27 were proven and 19 were suspected to have histoplasmosis. Median follow-up by imaging or clinical exam was 6.9 months (0.3 – 73.2 months), with 8 children lost to follow up after hospital discharge. Sixteen patients received antifungal therapy with itraconazole and 15 patients received at least one course of steroids; 11 patients (24%) received both. There was no difference in readmission rate (n=5 versus 2), p=0.7) or recurrence (n=2 versus 5, p=0.4) between patients who received an antifungal and those that did not. Patients who received steroid therapy were more likely to have airway narrowing on their CT scan (p=0.003) and present with at least one respiratory symptom (n=14, p=0.004). Receiving steroid therapy was associated with a higher readmission rate (6 patients versus 2 not treated with steroids, p=0.04), but not with disease recurrence. Nine patients underwent biopsy of a lymph node; and pathology was non-diagnostic in all. Twenty-seven patients had at least one positive confirmatory lab test for histoplasmosis; 23 complement fixation antibody titers, 14 immunodiffusion assays, 1 urine antigen and 2 serum antigen. Only those with negative lab studies had complete resolution of ML on imaging (n=2). Thirty-nine patients (84%) with a diagnosis of histoplasmosis (proven or suspected) were asymptomatic by 1-2 month follow up, with the remainder having intermittent chest pain or reactive airway disease.
Conclusion: Mediastinal lymphadenopathy due to proven or suspected histoplasmosis is usually a self-limiting disease that can be managed with symptomatic treatment. Antifungals and steroids are of unclear benefit and may not alter the natural course of the disease. Biopsies are rarely diagnostic in the setting of mediastinal lymphadenopathy and invasive procedures should be avoided. Associated lymphadenopathy is very slow to resolve even after symptoms improve.