Histoplasmosis Case Report Form

[NCEZID] Characteristics of Cases of Priority Fungal Diseases

Att 3c- Histoplasmosis Case Report Form

OMB: 0920-1385

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Form Approved

OMB No. 0920-1385

Exp. Date: 3/31/26


Histoplasmosis Case Report Form

Unique patient ID (State initials + unique state ID): ________________

NNDSS State ID: ___________________________________________________ □ Not applicable

NORS ID: _________________________________________________________ □ Not applicable

EIP laboratory ID: __________________________________________________ □ Not applicable

Form completion data

Name of person completing this form: _______________________

Institution: _______________________

Email: ____________________

Telephone: ___________________

Date form completed: _________________


Date reporting jurisdiction was first notified (if applicable): ______-______-___________ (mm-dd-yyyy)

Date reported to EIP site (if applicable): ______-______-___________ (mm-dd-yyyy)

Date chart abstraction completed (if applicable): ______-______-___________ (mm-dd-yyyy)

Date patient interview completed (if applicable): ______-______-___________ (mm-dd-yyyy)

CRF status: Complete Pending Chart unavailable


Date of incident specimen collection (DISC)*: ______-______-___________ (mm-dd-yyyy)

*This is the date of specimen collection for the patient’s first positive histoplasmosis test



A. Case Surveillance Information

Reporting state/jurisdiction: ______________

Reporting county: ____________

Case classification status: □ Confirmed □ Probable □ Suspect □ Not a case □ Unknown



CHART REVIEW

B. Patient Demographics

1. Age at DISC:

(use months or days if patient was aged <2 years)


________ □ Years □ Months □ Days □ Unknown

2. Assigned sex at birth


Male □ Female □ Unknown

3. Gender identity

Male □ Female □ Transgender, non-binary, or another gender

Prefer not to answer/Decline □ Unknown

4. Ethnic origin

Hispanic or Latino □ Not Hispanic or Latino □ Unknown

5. Race (select all that apply)

American Indian/Alaska Native □ Asian □ Black/African American

Native Hawaiian/Pacific Islander □ White □ Other (specify): _________________

Unknown


Please specify any additional details noted in the chart about race (e.g., nationality, ethnic group): _________________________

6. Patient’s country of primary residence (e.g., USA)


_________________________________________ □ Unknown

7. Patient’s state, jurisdiction, or territory of primary residence

_________________________________________ □ Unknown

8. Patient's county of primary residence (Please do not write the word “County”; for example, write “Cook” instead of “Cook County”):



_________________________________________ □ Unknown

9. Patient’s city of primary residence


_________________________________________ □ Unknown

10. Patient’s ZIP code of primary residence


_________________________________________ □ Unknown

11. Patient’s type of health insurance at DISC

Private □ Medicare □ Medicaid/state assistance program □ Military □ Indian Health Service □ Incarcerated □ Uninsured □ Other (specify): ____________________________________

Unknown



C. Patient underlying risk factors & medical conditions present during the 2 years before DISC (unless other timeframe specified)

1. Cancer □ Yes □ No □ Unknown

Hematologic malignancy

specify malignancy: _____________

Solid organ malignancy

specify organ:____________

Chemotherapy

If yes, specify therapy type: ________________

2. HIV infection □ Yes □ No □ Unknown

If yes, choose one of the below

Ever had CD4 < 200 cells/mm3 within past 6 months

Yes □ No □ Unknown


3. Chronic pulmonary diagnosis □ Yes □ No □ Unknown

Chronic obstructive pulmonary disease (COPD) or emphysema

Bronchiectasis

Cystic fibrosis

Allergic bronchopulmonary aspergillosis (ABPA)

Pulmonary fibrosis

Asthma

Interstitial Lung Disease

Other chronic pulmonary diagnosis (specify):____________

4. Any respiratory viral test in 120 days before or after DISC

Yes □ No □ Unknown


If yes, (select all that apply):

SARS-CoV-2 (PCR or antigen test)

Date of specimen collection (mm/dd/yyyy): ____________

Positive □ Negative □ Unknown

Influenza

Date of specimen collection (mm/dd/yyyy): ____________

Positive □ Negative □ Unknown□ Other respiratory virus (specify) ________________

Date of specimen collection (mm/dd/yyyy): ____________

Positive □ Negative □ Unknown

5. Transplant received within 2 years before DISC

Yes □ No □ Unknown

Solid organ transplant:

Lung Heart Kidney Pancreas Liver Skin graft Other:___________________________ □ Unknown


Hematopoietic stem cell transplant (HSCT)

6. Other selected conditions:

None

Cardiovascular disease

(specify): _________________

Diabetes mellitus

End stage renal disease/dialysis

Autoimmune disease(s) or inherited immunodeficiency(-ies)

(specify): _________________________

Medications/therapies that weaken the immune system

TNF-alpha inhibitors (e.g., infliximab, adalimumab, etanercept)

Other (specify): ____________________________________________

Cirrhosis

Liver disease without cirrhosis

Systemic lupus erythematosus

Active tuberculosis

Pregnant

Pregnant on DISC

Gestational age (weeks):_______ Unknown

Post-partum (gave birth within 6 weeks before DISC)

7. Please list any other potentially relevant clinical information: _____________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________





D. Social History

1. Smoking (select all that apply)



Tobacco, current □ Tobacco, previous □ E-nicotine delivery system, current □ E-nicotine delivery system, previous □ None □ Unknown

2. Documented alcohol use disorder


Yes □ No □ Unknown

3. Cannabis use

Yes, with documented use disorder

Yes, without documented use disorder

No

Unknown

4. Other illicit substance use

Yes, specify other illicit substance(s): _________ □ No □ Unknown





E. Laboratory data (specimen and testing data)


1. Specimen collection date: _____/_____/__________

2. Location of specimen collection:


Hospital inpatient

Intensive care unit

Surgery/OR

Radiology

Other inpatient _______________



Outpatient

Emergency room

Clinic/Provider’s office

Dialysis center

Surgery

Urgent care

Observational/clinical decision unit

Other outpatient ____________________




Long-term care facility (LTCF )

Long-term acute care hospital (LTACH)

Autopsy

Other ____________________

Unknown



Serology

Serum

ID IgG


ID IgM

CF IgG

EIA IgG

EIA IgM

Other: _________________

Unknown



CSF

ID IgG

ID IgM

CF IgG


EIA IgG


EIA IgM


Other: _________________


Unknown

Result:

Pos., titer: ____ □ Neg. □ Unclear □ Unk.


Pos., titer: ____ □ Neg. □ Unclear □ Unk.


Pos., titer: ____ □ Neg. □ Unclear □ Unk.


Pos. □ Neg. □ Unclear □ Unk.


Pos. □ Neg. □ Unclear □ Unk.


Pos. □ Neg. □ Unclear □ Unk.


Pos. □ Neg. □ Unclear □ Unk.




Pos., titer: ____ □ Neg. □ Unclear □ Unk.


Pos., titer: ____ □ Neg. □ Unclear □ Unk.


Pos., titer: ____ □ Neg. □ Unclear □ Unk.


Pos. □ Neg. □ Unclear □ Unk.


Pos. □ Neg. □ Unclear □ Unk.


Pos. □ Neg. □ Unclear □ Unk.


Pos. □ Neg. □ Unclear □ Unk.

Laboratory where testing was performed:

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.



ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.

Antigen


Serum



Urine

Result:

Pos., titer: ____ □ Neg. □ Unclear □ Unk.

Below limit of quantification?

Yes □ No □ Unk.

Pos., titer: ____ □ Neg. □ Unclear □ Unk.

Below limit of quantification?

Yes □ No □ Unk.

Laboratory:

ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.


ARUP □ MiraVista □ Mayo □ Quest □ LabCorp

Other_________________ □ Unk.




Other laboratory methods

Bronchial specimen

Culture

Direct smear/cytology

Molecular test (e.g., PCR)

Specify test: ________________________

Other _____________________________

Unknown

Result:

Pos. □ Neg. □ Unclear □ Unk.

H. capsulatum var. capsulatumH. capsulatum var. duboisii □ Pending □ Unk.

Pos. □ Neg. □ Unclear □ Unk.

Pos. □ Neg. □ Unclear □ Unk.


Pos. □ Neg. □ Unclear □ Unk.

Pos. □ Neg. □ Unclear □ Unk.

Sputum

Culture

Direct smear/cytology

Molecular test (e.g., PCR)

Specify test: ________________________

Other _____________________________

Unknown

Result:

Pos. □ Neg. □ Unclear □ Unk.

H. capsulatum var. capsulatumH. capsulatum var. duboisii □ Pending □ Unk.

Pos. □ Neg. □ Unclear □ Unk.

Pos. □ Neg. □ Unclear □ Unk.


Pos. □ Neg. □ Unclear □ Unk.

Pos. □ Neg. □ Unclear □ Unk.

Urine

Culture

Other _____________________________

Unknown

Result:

Pos. □ Neg. □ Unclear □ Unk.

H. capsulatum var. capsulatumH. capsulatum var. duboisii □ Pending □ Unk.

Pos. □ Neg. □ Unclear □ Unk.

Pos. □ Neg. □ Unclear □ Unk.

Lung tissue

Culture

Histopathology

Molecular test (e.g., PCR)

Specify test: ________________________

Other _____________________________

Unknown

Result:

Pos. □ Neg. □ Unclear □ Unk.

H. capsulatum var. capsulatumH. capsulatum var. duboisii □ Pending □ Unk.

Pos. □ Neg. □ Unclear □ Unk.

Pos. □ Neg. □ Unclear □ Unk.


Pos. □ Neg. □ Unclear □ Unk.

Pos. □ Neg. □ Unclear □ Unk.

Other specimen _________________________

Culture

Histopathology

Direct smear/cytology

Molecular test (e.g., PCR)

Specify test: ________________________

Other _____________________________

Unknown

Result:

Pos. □ Neg. □ Unclear □ Unk.

H. capsulatum var. capsulatumH. capsulatum var. duboisii □ Pending □ Unk.

Pos. □ Neg. □ Unclear □ Unk.

Pos. □ Neg. □ Unclear □ Unk.

Pos. □ Neg. □ Unclear □ Unk.


Pos. □ Neg. □ Unclear □ Unk.

Pos. □ Neg. □ Unclear □ Unk.







F. Antifungal susceptibility testing

Date of culture (mm/dd/yyyy)

Species

Drug

MIC

_____/_____/__________

H. capsulatum var. capsulatum

H. capsulatum var. duboisii

Unknown

Amphotericin B



Anidulafungin (Eraxis)



Caspofungin (Cancidas)



Fluconazole (Diflucan)



Flucytosine (5FC)



Ibrexafungerp (Brexafemme)


Isavuconazole (Cresemba)



Itraconazole (Sporanox)


Micafungin (Mycamine)


Posaconazole (Noxafil)


Voriconazole (Vfend)




G. Patient symptoms, diagnosis, and outcomes

1. Acute signs/symptoms on or within 60 days before DISC?

Yes □ No acute signs or symptoms □ Unknown

1a. Symptoms experienced on or within 60 days before DISC (select all that apply).

Pulmonary: □ Cough □ Hemoptysis □ Wheezing □ Shortness of Breath


Other respiratory infection symptoms: □ Sore throat □ Chest pain □ Chills □ Night Sweats □ Fever □ Fatigue □ Stiff neck □ Headache □ Joint or bone pain or body aches □ Weight loss without trying □ Muscle pain □ Nausea □ Vomiting


Dermal: □ Rash or other skin problems ((□ Erythema nodosum □ Erythema multiforme □ Other (specify) ________))


Neurologic: □ Confusion □ Seizures


Radiologic findings: □ Abnormal findings on chest imaging (e.g., pulmonary infiltrates, cavitation, nodules, or lesions) □ Peripheral lymphadenopathy □ Bone or joint abnormality (e.g., osteomyelitis, pathologic fracture) □ Meningitis, encephalitis, or focal brain lesion □ Abscess, granuloma, or lesion in other system


No acute signs/symptoms

Other (specify) _______

2. Date of earliest symptom onset?

______/______/___________ (mm/dd/yyyy)

If exact date unknown, approximate date of onset: ____________

No acute signs/symptoms

Unknown


3. Was the patient part of an outbreak of suspected fungal infections?

Yes □ No □ Unknown


4. Did the patient request to be tested for histoplasmosis?

Yes □ No □ Unknown


5. According to treating clinicians, which clinical syndrome(s) related to Histoplasma did the patient have on or within 60 days after DISC?

Acute pulmonary histoplasmosis

Subacute pulmonary histoplasmosis

Chronic pulmonary histoplasmosis

Progressive disseminated histoplasmosis

Histoplasmosis meningitis

Treated with a ventriculoperitoneal (VP) shunt? □ Yes □ No □ Unknown

Presumed ocular histoplasmosis syndrome (POHS)

Focal histoplasmosis (specify site): _________________

Unknown

6. What other clinical diagnoses did the patient have on or within 60 days before DISC? (select all that apply)

Blastomycosis

Coccidioidomycosis

Cryptococcosis

Other fungal infection (specify): __________

Community-acquired pneumonia

Bacterial pneumonia

Viral pneumonia

Cancer

Tuberculosis

Influenza

COVID-19

Other infection/disease not listed (specify): __________

None

Unknown

7. Site of Histoplasma infection based on clinical impression on or within 60 days after DISC (select all that apply)

Lung □ Skin □ Bone □ Joint □ Central nervous system □ No site identified

Other (specify) _____________________________ □ Unknown

8. Was the patient hospitalized at an acute care hospital in the 60 days before to 60 days after DISC?

Yes □ No □ Unknown

If yes, dates of admission of hospitalization most proximal to DISC,


Admission date: ______/______/___________ (mm/dd/yyyy)


Discharge date: ______/______/___________ (mm/dd/yyyy) □ Still hospitalized


If yes,


Received ICU-level care in the 14 days before DISC?: □ Yes □ No □ Unknown


Received ICU-level care in the 14 days after DISC?: □ Yes □ No □ Unknown


Discharge ICD-10 diagnosis code(s): _________________________________

9. Died within 60 days after DISC?


No


Yes, date of death _______ / _______/ ______________ (mm/dd/yyyy)

Cause(s) of death _________________

If yes, did death occur in hospital? □ Yes □ No □ Unknown


Unknown

10. Did the patient have any outpatient, urgent care, and/or emergency department visits in the 60 days before to 60 days after DISC?

Yes □ No □ Unknown

If yes, how many visits? ______ (if more than one, fill out information below for each visit)


Date of visit: ______/______/___________ (mm/dd/yyyy)

If date of visit is after DISC, was the visit related to histoplasmosis? □ Yes □ No □ Unknown

Setting: □ Primary care □ Urgent care □ Emergency department □ Specialty care: Pulmonology □ Specialty care: Infectious Disease □ Other (specify):

Chief complaint: _____________ □ Not listed □ Unknown

Was histoplasmosis noted as a possible diagnosis?

Yes □ No □ Unknown

Did the visit involve fever or recent onset of respiratory symptoms?

Yes □ No □ Unknown


11. Was a chest x-ray taken within 60 days before to 60 days after DISC?

Yes □ No □ Unknown

If yes, were any of the chest x-rays abnormal □ Yes □ No □ Unknown

Date of first abnormal chest x-ray: ______/______/___________ (mm/dd/yyyy)

For first abnormal chest x-ray, select all that apply;

Air space density Air space opacity Consolidation Cavitary lesions Granuloma Pulmonary infiltrate Interstitial infiltrate Lobar infiltrate Nodule Report not available Other (specify): ______________________ □ Unknown


12. Was a chest CT scan taken within 90 days before to 60 days after DISC?

Yes □ No □ Unknown

If yes, were any of the chest CT scans abnormal □ Yes □ No □ Unknown

Date of first abnormal chest CT scan: ______/______/__________ (mm/dd/yyyy)

For first abnormal chest CT scan, select all that apply;

Air space density Air space opacity Consolidation Cavitary lesions Granuloma Pulmonary infiltrate Interstitial infiltrate Lobar infiltrate Nodule Report not available Other (specify): ______________________ □ Unknown




H. Vital Status

1. Has the patient died?


No


Yes, date of death _______ / _______/______________ (mm/dd/yyyy)

Cause(s) of death _________________

If yes, did death occur in hospital? □ Yes □ No □ Unknown


Unknown



I. Antifungal Treatment

1. Did the patient receive antifungal drugs during the 90 days before to 60 days after the DISC? □ Yes □ No □ Unknown

(If yes, please complete the table below for each drug received)

Select one of the following to complete each row of the table:


Amphotericin B lipid complex (ABLC)

Liposomal Amphotericin B (L-AmB)

Amphotericin B coloidal dispersion (ABCD)

Anidulafungin (ANF)

Caspofungin (CAS)


Fluconazole (FLC)

Flucytosine (5FC)

Ibrexafungerp (IBR)

Isavuconazole (ISA)

Itraconazole (ITC)


Micafungin (MFG)

Posaconazole (PSC)

Voriconazole (VRC)

Other drug (OTH), specify:________________

Unknown drug (UNK)


Drug abbrev.

First date given (mm/dd/yyyy)

Last date given (mm/dd/yyyy)

Indication

Therapeutic Drug Monitoring (TDM)


__ __/__ __/__ __ __ __

__ __/__ __/__ __ __ __

Prophylaxis

Treatment for Histoplasma

Treatment for non-Histoplasma infection


Yes

Date of earliest TDM:

TDM level:


Date of second TDM:

TDM level:


No


__ __/__ __/__ __ __ __

__ __/__ __/__ __ __ __

Prophylaxis

Treatment for Histoplasma

Treatment for non-Histoplasma infection


Yes

Date of earliest TDM:

TDM level:


Date of second TDM:

TDM level:


No


__ __/__ __/__ __ __ __

__ __/__ __/__ __ __ __

Prophylaxis

Treatment for Histoplasma

Treatment for non-Histoplasma infection


Yes

Date of earliest TDM:

TDM level:


Date of second TDM:

TDM level:


No


__ __/__ __/__ __ __ __

__ __/__ __/__ __ __ __

Prophylaxis

Treatment for Histoplasma

Treatment for non-Histoplasma infection


Yes

Date of earliest TDM:

TDM level:


Date of second TDM:

TDM level:


No





PATIENT INTERVIEW

J. Supplemental Patient Interview Form

Note that the “you” in these questions refers to the patient.

1. Person interviewed

Patient □ Someone other than the patient, (specify relationship to patient): _______________

2. Were you told that you had a positive lab result for histoplasmosis before our call today?

Yes

If yes, what type of healthcare setting told you? □ Emergency room □ Urgent care

Primary care □ Hospital □ Pharmacy □ Public health official □ Other (specify): _________

No

If no, were you told that you had a negative lab result for histoplasmosis before our call today? □ Yes □ No □ Unsure

Unsure

If unsure, were you told that you had a negative lab result for histoplasmosis before our call today? □ Yes □ No □ Unsure

3. Is your home located in an urban, suburban, or rural area?

Urban □ Suburban □ Rural, wooded □ Rural, farmland □ Don’t know

4. In the four weeks before testing positive for histoplasmosis or symptom onset, did you travel out of your home county or state?

Yes, specify city/state/dates:

No

Don’t know

5. In the four weeks before testing positive for histoplasmosis or symptom onset, which of the following outdoor activities did you participate in within an area known to have the fungus that causes histoplasmosis (select all that apply)?


Dig in soil

Go in a barn

Go in a cave

Handle bird poop

Handle bat poop

Clean a chicken coop

Construction

Demolition/renovation

Excavation

Clean attic/chimney

Hiking

Hunting

Camping

Heating/air conditioning work

Gardening/landscaping

Other handling of plants/trees

Outdoor sports, specify

Other outdoor activity, specify

None

Don’t know

6. In the four weeks before testing positive for histoplasmosis, what kind of work did you do? If you did more than one type of job in the four weeks before you were tested, please tell us about each one:

____________________ □ Student □ Unemployed □ Retired □ Not applicable □ Unknown

7. In the four weeks before testing positive for histoplasmosis, what kind of industry did you work in? If you worked in more than one industry in the four weeks before you were tested, please tell us about each one:

____________________ □ Student □ Unemployed □ Retired □ Not applicable □ Unknown

8. How often did you work, travel, or volunteer outdoors in the four weeks before testing positive for histoplasmosis?

Every day

Most days

Some days

Rarely

Never

N/A

Don’t know

9. In the four weeks before testing positive for histoplasmosis, how often did you wear a respirator like an N95 or KN95 or a mask at work?


Every day

Most days

Some days

Rarely

Never

N/A

Don’t know

10. Did you miss school or work because of histoplasmosis?


Yes, number of days ________

No

N/A

Don’t know

13. Had you ever heard of histoplasmosis before you were diagnosed or told of your positive result?

Yes

If yes, where did you hear about it? (check all that apply) □ Healthcare provider □ Internet □ Family member, friend, coworker □ Radio □ Television □ Don’t know □ Other, specify

No

Don’t know

14. How do you think people get histoplasmosis? (check all that apply)


From another person □ From animals □ From food □ From bug bites □ From water □ From the environment □ Other, specify: _________________________________ □ Don’t know



Additional comments:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CDC estimates the average public reporting burden for this collection of information as 60 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1385).


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