Active histoplasmosis is rarely diagnosed in Great Britain. We present the illness records of three patients with disseminated histoplasmosis. In two patients the infection was discovered at necropsy and resulted in caseous destruction of the adrenal glands, and in one of these there was also fungal invasion of the liver and wall of the aorta. The third patient had Addison's disease and also a chronic tongue ulcer from which the fungus was cultured by biopsy.
The eight other patients with disseminated histoplasmosis and the six with active localized disease previously reported in Great Britain are reviewed.
The natural history of the disease, with emphasis on the prolonged incubation period of up to 18 years, is described. Granulomatous ulceration of the oropharynx and larynx and caseous destruction of the adrenal glands may be characteristic features.
Diagnosis usually requires a history of a stay in endemic regions. It is suggested by the clinical picture and positive complement fixation or precipitin tests and it is confirmed by culture of the fungus which may also be recognized in histological preparations. Histoplasmin skin tests are usually negative.
Standard treatment is with intravenous amphotericin B, but in our surviving patient a chronic tongue ulcer of nine years' duration showed considerable healing after 10 months' oral treatment with trimethoprim-sulphamethoxazole in combination.
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