Raymond L W, Donaldson J C, Elliott R C, Stoop D R, Benjamin S, Blair T, Humphries T J
Crit Rev Diagn Imaging. 1980;14(1):37-72.
This short series represents a spectrum of histoplasmosis usually described only in places where the infection is nearly universal. In fact, most of the patients in this series were born in such places (17 of 19 patients with complicated presentations; 2 had recent suspicious exposures). As young adults, they had moved away to pursue military life, usually in coastal areas where the evidence of infection with H. capsulatum is a statistical rarity. The implications of these observations are straightforward. At the clinical level, they focus on histoplasmosis as a possible cause of pulmonary, mediastinal, or other lesions of obscure etiology, whether or not the patient has recently lived in "the endemic area". The simple determination of CF gamma titers may heighten the index of suspicion, especially when not confounded by skin testing with histoplasmin, a practice which rarely provides useful information. [Table: see text] With regard to pathogenesis, it seems noteworthy that common form of histoplasmosis was not seen in this brief experience. That is the "marching cavity" described by Goodwin and Des Prez, and other forms of chronic cavitary disease. The absence of such lesions is consonant with the view that they require continuous exogenous infection for their development. As for the forms of histoplasmosis which were seen in this series, it appears that most of the illnesses developed outside of what is usually considered endemic areas. The term endemic, as construed medically, has been defined as "restricted to and constantly present in a particular country or locality". Such a construction is unduly pedantic and rigid for clinicians. A more probabilistic view is needed, with attention to the possible role of inapparent infection early in life and of environmental foci of infection in places where the organism is not notoriously present. The mobile nature of our society makes it likely that the radiographic manifestations of once-regional diseases such as this one will be encountered more generally than in the past.
这个简短的系列病例展现了一组组织胞浆菌病的情况，通常这种情况只在感染几乎普遍存在的地区才会被描述。事实上，该系列中的大多数患者都出生在这样的地区（19例有复杂临床表现的患者中有17例；2例近期有可疑接触史）。成年后，他们通常搬到沿海地区追求军旅生活，而在沿海地区，荚膜组织胞浆菌感染的证据在统计学上是罕见的。这些观察结果的意义很直接。在临床层面，它们将重点放在组织胞浆菌病上，认为其可能是肺部、纵隔或其他病因不明病变的原因，无论患者近期是否居住在“流行地区”。简单测定CFγ滴度可能会提高怀疑指数，尤其是在未被组织胞浆菌素皮肤试验干扰时，因为这种试验很少能提供有用信息。[表格：见原文]关于发病机制，值得注意的是，在这段简短的经历中未见到常见形式的组织胞浆菌病。即古德温和德斯普雷兹描述的“进行性空洞”以及其他形式的慢性空洞性疾病。此类病变的缺失与它们需要持续外源性感染才能发展的观点一致。至于本系列中所见的组织胞浆菌病形式，似乎大多数疾病是在通常不被认为是流行地区的地方发生的。从医学角度来看，“地方病”一词被定义为“局限于并持续存在于特定国家或地区”。这种定义对临床医生来说过于学究和死板。需要一种更具概率性的观点，关注早年隐性感染以及在该病原体并非广为人知存在的地方的环境感染源的可能作用。我们社会的流动性使得像这样曾经局限于特定地区的疾病的影像学表现比过去更可能被普遍遇到。
