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HIV-Associated Disseminated Emmonsiosis, Johannesburg, South Africa LETTERS and vesical veins, as well as in the 2. Berry A, Moné H, Iriart X, Mouahid order mammals (1). Although emmon- liver and the portal system. G, Abbo O, Boissier J, et al. Schistoso- sia rarely infect humans, the fungi can miasis haematobium, Corsica, France In a more comprehensive study [letter]. Emerg Infect Dis. 2014;20:1595–7. cause localized granulomatous pul- (9), Bulinus snails were found in all http://dx.doi.org/10.3201/eid2009.140928. monary disease (adiaspiromycosis) in of Corsica’s coastal rivers, except for 3. Brumpt E. Cycle évolutif du Schistosoma immunocompetent persons (1–4). Be- those in the northwestern-most part of bovis (Bilharzia crassa); infection spon- fore 2013, no association was known tanée de Bulinus contortus en Corse C.-R. the island. However, of the 55 bod- Acad. Sci. 1929;CLXXXXI:879. between emmonsia and HIV, and there ies of water where Bulinus snails were 4. Brumpt E. Cycle évolutif complet de was no indication that emmonsia were found, only 1 contained gastropods Schistosoma bovis. Infection naturelle en endemic to sub-Saharan Africa. with Schistosoma cercariae, and re- Corse et infection expérimentale de Buli- In 2013 a novel Emmonsia sp. nus contortus. Ann Parasitol Hum Comp. sults of a search for blood flukes in 220 1930;VIII:17–50. that is closely related to E. pasteuriana small rodents (known for being sus- 5. Pandey VS, Ziam H. Helminthoses cir- was described. The fungus caused dis- ceptible to S. bovis and captured near culatoires. In: Lefèvre P-C, Blancou J, seminated disease in 13 HIV-infected bodies of water where Bulinus snails Charmette R, editors. Principales mala- persons in South Africa (12 in Cape dies infectieuses et parasitaires du bétail, had been observed) were negative. Europe et régions chaudes. Paris: Tec & Town, 1 in Bloemfontein) (5). Two We have found no other docu- Doc Editions Lavoisier; 2003. p. 1485–99. additional cases of disseminated em- mentation on bovine schistosomiasis 6. Dollfus PH. Sur la présence en France et monsiosis caused by this novel species in Corsica between 1966 and the pres- en Corse du Bullinus contortus (Michaud), were identified in HIV-uninfected per- hôte intermédiaire de Schistosoma hæma- ent time. Has this disease disappeared tobium (Bilharz): note préliminaire. Bull sons (1 immunocompetent, the other since the 1960s? Is it still present as an Soc Pathol Exot. 1922;15:208–12. immunosuppressed for renal trans- enzootic disease with silent transmis- 7. Arfaa F, Massoud J, Chu KY. Suscepti- plantation) in Cape Town (6). Because sion? It should be noted that the disease bility of Portuguese Bulinus contortus to these cases clustered geographically, it Iranian strains of Schistosoma haematobi- produces few or no clinical signs and um and S. bovis. Bull World Health Organ. was suggested that this novel Emmon- that slaughterhouse detection requires 1967;37:165–6. sia sp. occupies a microenvironment dissection of the circulatory system of 8. Gretillat S. Epidémiologie de certaines around Cape Town (7). We report 3 the abdominal cavity. In any case, the affections à trématodes des animaux do- additional cases of disseminated em- mestiques en Corse (bilharziose bovine discovery of human cases of schisto- et distomatose bovine et ovine). Ann Para- monsiosis from Johannesburg, South somiasis proves that a human–Bulinus sitol Hum Comp. 1963;38:471–81. Africa, 403 km from Bloemfontein parasitic cycle exists in Corsica, and 9. Doby J-M, Rault S, Deblock S, Chabaud A. and 1,400 km from Cape Town. All therefore an animal–Bulinus cycle may Bulins et bilharzioses en Corse. Réparti- patients were HIV-infected and re- tion, fréquence et biologie de “Bulinus exist as well. For the sake of scientific truncates” [in French]. Annal. Parasitol. ported no travel to Bloemfontein or interest, an investigation into the pres- 1966;4:337–49. Cape Town. ence of S. bovis in ruminants in Cor- The 3 patients were admitted to sica would be worthwhile. Moreover, Address for correspondence: Paul M.V. Martin, Helen Joseph Hospital between Au- the fact that both Schistosoma species Anses - Lab de Lyon, 31, ave Tony Garnier, Lyon gust 2012 and August 2014; all pa- use the same intermediate host, Bulinus 69009, France; email: [email protected] tients were male and had CD4 counts contortus snails, could cause problems of ≤5 cells/µL at admission. Patient 1 with differential diagnosis. had never received antiretroviral thera- py; patients 2 and 3 had defaulted anti- Didier Calavas and retroviral treatment for several months Paul M.V. Martin before admission. All patients had Author affiliation: Agence Nationale de disseminated skin rash, pneumonia, Sécurité Sanitaire, Lyon Laboratory, anemia, and substantial weight loss; Lyon, France HIV-Associated chest radiographs suggested pulmo- DOI: http://dx.doi.org/10.3201/eid2012.141474 Disseminated nary tuberculosis. The rash appeared Emmonsiosis, as disseminated hyperpigmented scaly References papules and plaques (online Techni- Johannesburg, cal Appendix Figure 1, http://wwwnc. 1. Holtfreter MC, Moné H, Müller-Stöver I, South Africa cdc.gov/EID/article/20/12/14-0902- Mouahid G, Richter J. Schistosoma haemato- Techapp1.pdf). Patients 1 and 2 also bium infections acquired in Corsica, France, August 2013. Euro Surveill. 2014;19:20821 To the Editor: Emmonsia spp., had diarrhea and exhibited delirium. http://www.eurosurveillance.org/View dimorphic fungi found worldwide, Laboratory investigations for pa- Article.aspx?ArticleId=20821. cause disease mainly among lower- tient 1 showed normocytic anemia, 2164 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 20, No. 12, December 2014 LETTERS hyponatremia, renal insufficiency, and and chest radiographs compatible with wide surveillance program is needed elevated liver enzyme levels. Patients pulmonary tuberculosis. to enhance disease identification with- 2 and 3 had pancytopenia, hyponatre- The patients in our study received in South Africa and to determine the mia, metabolic acidosis, and elevated an initial misdiagnosis. Kenyon et al. environmental presence of this organ- liver enzyme levels. Lumbar puncture (5) also encountered diagnostic am- ism beyond South Africa’s borders. results were unremarkable for patients biguity in invasive fungal infection 1 and 3; patient 2 had normal lumbar cases: over an 8-year period in South Acknowledgments puncture results during a previous ad- Africa, 39 cases were diagnosed as We acknowledge Tsidiso Maphan- mission (online Technical Appendix histoplasmosis on the basis of histo- ga for technical assistance and Sarolda Table 1). Automated laboratory identi- logic findings, and only 1 was con- Keresztes for assistance in retrieving the fication systems initially misidentified firmed by using molecular techniques. laboratory samples. the Emmonsia sp. on blood culture as Because laboratory services in Africa Trichosporon spp. (patients 1 and 3) are generally weak (8), this trend of This work was supported by the Fog- and Histoplasma capsulatum (patient misdiagnosis could continue. The high arty International Center; the National 2). Co-infection with Mycobacterium death rate among patients with HIV- Cancer Institute; the National Heart, Lung, avium (patients 1 and 2) and M. tu- associated emmonsiosis (31%, 5/16 and Blood Institute; the Office of the Di- berculosis (patient 2) was observed patients) may partly be explained by rector Office of Research on Women’s (online Technical Appendix Table 2). misdiagnoses (5), and it also raises Health, National Institutes of Health; and Subsequent histologic examination questions regarding optimal treatment. the Office of the Director Office of AIDS of skin biopsy specimens from all pa- Amphotericin B will likely remain the Research, National Institutes of Health tients showed granulomas and yeast- optimal empiric induction therapy (grant no. R25 TW009340 to C.K.L.). like organisms. for suspected cases of disseminated Antifungal drug therapy con- fungal infection among HIV-infected Wesley G. van sisted of fluconazole for patient 1 persons in sub-Saharan Africa, given Hougenhouck-Tulleken, and conventional amphotericin B for the phylogenetic proximity of Em- Nectarios S. Papavarnavas, patients 2 and 3; itraconazole was monsia spp. to Histoplasma spp., the Jeremy S. Nel, co-administered to patient 2 (online antifungal minimum inhibitory con- Lauren Y. Blackburn, Technical Appendix Table 3). Clinical centrations of emmonsia reported thus Nelesh P. Govender, and biochemical parameters improved far (5), and the potential for labora- David C. Spencer, and for all patients during the first 2 weeks tory misdiagnosis of fungal infection Christopher K. Lippincott of hospitalization. However, hospital- cases. Supplementary itraconazole Author affiliations: Helen Joseph Hospi- acquired pneumonia developed in may be beneficial if dimorphic fungal tal, Johannesburg, South Africa (W.G. van patient 1, who subsequently died on infection, specifically emmonsia, is Hougenhouck-Tulleken, N.S. Papavarna- hospitalization day 21, and patient 2 clinically suspected. Regardless, early vas, J.S. Nel. D.C. Spencer); University of died of an unknown cause on day 17. confirmatory diagnoses based on cul- the Witwatersrand, Johannesburg (W.G. Permission for autopsy was not grant- ture and histopathologic results should van Hougenhouck-Tulleken, N.P. Goven- ed for either patient. At the time of this be aggressively pursued. der); Right to Care, Johannesburg (N.S. report, patient 3 was recovering well. Although HIV-associated em- Papavarnavas,
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