Christopher Ledtke

Cleveland Clinic, Cleveland, OH, United States

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Publications (3)7 Total impact

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    ABSTRACT: Endovascular infection is an uncommon but devastating manifestation of histoplasmosis, which is often diagnosed late in disease. To evaluate the clinical and pathologic characteristics of patients with endovascular infections caused by Histoplasma capsulatum. All cases of patients with documented endovascular histoplasmosis at a single tertiary care center in an endemic region during the period 1993-2010 were reviewed. Patients presented with a subacute febrile illness and a history of endovascular devices. All patients had positive Histoplasma serology. Routine bacterial culture results were negative for all patients. In addition to yeast forms typical of histoplasmosis, pathologic findings also revealed mycelial forms in 4 of 5 patients. Inflammation was scant. Urinary antigen detection was positive in 4 of 5 patients and Histoplasma blood culture results were positive for 3 of 5 patients. Four patients were treated with a combination of surgical and medical therapy, which consisted of amphotericin B followed by itraconazole; these 4 patients had complete resolution of symptoms and no documented relapse. One patient died before planned surgery. Histoplasma capsulatum endovascular infections are clinically characterized by a subacute febrile illness with negative bacterial cultures in patients with prosthetic endografts or valves. Noninvasive diagnostics are often the initial clue to the diagnosis. Combined medical and surgical treatment is associated with survival. On histopathologic examination both mycelial and yeast forms are often observed, with absent to minimal tissue inflammatory reaction.
    Archives of pathology & laboratory medicine 06/2012; 136(6):640-5. · 2.78 Impact Factor
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    ABSTRACT: To describe the influence of age on clinical features of histoplasmosis. Retrospective single-center cohort study. Large tertiary care center. All individuals who met criteria for probable or proven histoplasmosis between 1998 and 2008. Participants were divided into the following categories of histoplasmosis: acute pulmonary, chronic pulmonary, asymptomatic, disseminated, and other. Correcting for immune status, the influence of age at diagnosis on presentation, diagnosis, imaging, treatment, and all-cause mortality was evaluated. In 347 participants with histoplasmosis, a number of characteristics were associated with age when evaluating participants according to diagnostic category. An age-associated increase in asymptomatic histoplasmosis was observed (P < .001). In symptomatic pulmonary histoplasmosis, older adults were less likely to present with chest pain (P < .001) and less likely to have hilar lymphadenopathy on imaging (P = .04). Lower rates of seropositivity with older age were seen in asymptomatic (P = .04) but not other forms of histoplasmosis. Cavitary disease was associated with older age in chronic pulmonary histoplasmosis (P = .05). Treatment did not change with age. All-cause mortality at 6 months was 4% and was associated with older age (P = .02). Although most studied characteristics of histoplasmosis were similar, notable age-related differences were present. Chronic cavitary disease and asymptomatic histoplasmosis were more common with older age. In acute histoplasmosis, the lack of chest pain and hilar lymphadenopathy may hinder diagnosis in older adults.
    Journal of the American Geriatrics Society 02/2012; 60(2):265-70. · 4.22 Impact Factor
  • Christopher Ledtke, J. Walton Tomford
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    ABSTRACT: Background: Histoplasmosis is an important endemic mycosis. Here we describe the influence of age on the diagnosis of histoplasmosis in a large single center cohort. Methods: The electronic medical record was reviewed for patients diagnosed with histoplasmosis at the Cleveland Clinic from 1998 to 2008. Positive pathology specimens, serology, urine antigen, or cultures were required for inclusion. We compared patients younger than 50 years old (group I) with those 50 years old or older (group II) at the time of presentation. JMP software (SAS, Cary, NC) was used for statistical analysis. Results: A total of 361 patients were included in this study. Median age at presentation was 53 years (range 7-84, 7 patients <18 years old). In group I (n=152) vs. group II (n=209), 52% vs. 60% were male (NS), 87% vs. 96% were white (p<0.01), 26% vs. 20% were immunocompromised (NS). Older patients were more likely to have malignancy (13% vs. 30%, p<0.001), COPD (3% vs. 22%, p<0.001), or DM (7% vs. 15%, p=0.03). Significant differences were found in diagnostic category, serology in asymptomatic patients, the presence of non-necrotizing granulomas, mean SUV on PET scans, and hilar lymphadenopathy on CXR in acute pulmonary histoplasmosis (see table, *p value for distribution of categories). In acute pulmonary histoplasmosis a trend towards less necrotizing granulomas in older adults was seen (30/35 [86%] vs. 25/38 [66%] in I vs. II, p=0.06). No differences were seen in urinary antigen positivity (overall positive in 39/148 [26%]), CT (single or multiple nodules seen in 197/300 [66%]), and other CXR manifestations. n=361 Age<50 (n=152) Ageā‰„50 (n=209) p Asymptomatic pulmonary 55 (36) 115 (55) <0.01* Serology positive/sent (%) 30/43 (70) 36/77 (47) 0.012 Non-necrotizing granuloma positive/sent (%) 9/32 (28) 11/93 (12) 0.048 Acute pulmonary, n (%) 51 (33) 53 (25) Non-necrotizing granuloma positive/sent (%) 5/35 (14) 14/38 (37) 0.035 SUV in PET positive, Mean (n, SD) 7.7 (10, 4.7) 4.8 (15, 3.1) 0.039 CXR hilar LAD positive/sent (%) 16/51 (31) 4/53 (8) <0.01 Chronic pulmonary, n (%) 10 (6) 21 (10) Disseminated or Other, n (%) 36 (24) 20 (10) Conclusions: In this large, single center cohort of patients with histoplasmosis, patients aged 50 years or older were more likely to present with asymptomatic or chronic histoplasmosis. Establishing the diagnosis in older patients may be more difficult, as asymptomatic older patients are less likely to have positive serology, and symptomatic older patients are less likely to have hilar LAD on CXR.
    Infectious Diseases Society of America 2009 Annual Meeting; 10/2009