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histoplasmosis/fatigue
Jan 31, 2002

HELLO Dr. BOB!

I wish you were my Doc. 1 year ago i started having high fevers, was treated with antibiotics, tested for everything, and was released. The test for histo came back negative.

5 months ago i started having very high fevers again, was tested and treated for MAC, and spleen was removed. Histo was a suspect again (I am from Ohio valley area) but test came back negative. The byopsy came back positive for granuals, and docs suspected it had spread to my liver (it was enlarged too)

I was put on antibiotics and Prednisone, and fevers finally went away and I am feeling better.

In the last 5 months CD-4 dropped from 89 to 54 last week, and I still get tired easily eventhough i eat great and excersise. My viral load is still undetectable. I am still off work.

Last week, I finally tested positive for Histoplasmosis. (VERY high numbers). Why would it take so long to show up? Is this whats causing the granuals on my organs?

And is this the cause of fatigue and lower CD-4?

My doctor anticipated that after my splenectomy that CD-4 would rise to the 150 mark or so, and it has dropped instead.

once again, i ask your counsel on my issues.

thanks for everything.....

Response from Dr. Frascino

Hi!

I wish I were your doctor as well. We could talk about the Ohio Valley areas; I spent 4 years there! Histoplasmosis is endemic in the central and south central regions of the U.S. (including the Ohio Valley). It is a systemic fungal infection that is usually not a problem for people with normal immune systems. We, however, have anything but "normal" immune systems. It really becomes a problem when CD4 counts are low, i.e. less than 50-100. If your CD4 counts are low when you contract histoplasmosis, your immune system can't fight it off properly. Another possibility is to have a "reactivation" type of problem. This occurs when a person is exposed to histoplasmosis and their immune system initially controls it. But then, sometime in the future their immune system becomes deficient, as it does with AIDS, and the histoplasmosis becomes active again. Histoplasmosis is not the easiest opportunistic infection to diagnose due to technical reasons. The good news is that it usually does respond to medications - "antifungals" such as itraconazole, amphotericin B, or AmBisome.

Is this what's causing the "granuals?" Well, I assume you mean "granulomas." Yes, it's possible, but MAC can cause these as well. Is this causing your CD4 count to fall? Probably. Remember, CD4 cells are part of the body's immune system and are designed to help fight infections - lots of infections, not just HIV. Chances are some of your CD4s are quite busy battling histoplasmosis, others are trying to control MAC, and still others are targeting HIV. Will your CD4 count go up? Hopefully. The goal here is to successfully treat all your opportunistic infections and your HIV. Luckily, your HIV viral load is undetectable. Hopefully, your MAC responded to treatment and your histoplasmosis will soon be under control as well. For the histoplasmosis, you may want to follow a blood test called HPA (histoplasma antigen test). It can be useful in documenting your response to therapy. Are there other potential causes for your fatigue? Sure. You should check for anemia (hemoglobin less than 14 for men, or 12 for women). You should also check for hormonal imbalances - low testosterone in men, adrenal insufficiency, low thyroid hormone. In addition, since your counts are low, you should be checked for other potential opportunistic infections such as PCP, CMV, etc. Try not to get discouraged by all these possibilities. That your HIV is under control is encouraging. Just continue to work with your AIDS specialist to optimally address the other issues I mentioned above. Remember the importance of diet, rest, exercise, decreased stress, and a positive attitude. Don't rush back to work. Focus on your health. Write back if you have additional problems or if things aren't getting better.

Good luck.

Dr. Bob


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