Fungal Infections. Fungal Infections

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1 Fungal Infection in the Immune Competent Host Steven L. Primack, MD Fungal Infection in the Immune Competent Host Steven L. Primack, MD Department of Radiology Oregon Health & Science University Fungal Infections Endemic fungi -Soil of certain regions -Residence or travel history -Healthy individual or immune suppressed Ubiquitous -Found worldwide -Immune suppressed or underlying lung dz Fungal Infections Endemic fungi -Histoplasma capsulatum -Blastomyces dermatitidis -Coccidioides immitis - Ubiquitous - Aspergillus -Candida -Cryptococcus neoformans -Zygomycetes (mucor) From: Robbins & Cotran Fungal Infections Immune competent host Endemic fungi focus of this presentation Histoplasmosis Histoplasma capsulatum Ohio, Mississippi, St. Lawrence River valleys Asymptomatic or flu-like illness Aspergillus -? Immune competent - Chronic necrotizing aspergillosis (COPD, diabetes, steroids, malnutrition) - Mycetoma (underlying lung dz cavity) - ABPA (asthma, hypersensitivity) 164

2 Histoplasmosis North American Blastomycosis Acute histoplasmosis Histoplasmoma incidental nodule Chronic pulmonary histoplasmosis Fibrosing mediastinitis Broncholithiasis Histoplasmosis will be covered in the next presentation Blastomyces dermatitidis Central, southeastern US - Ohio, Mississippi, Missouri River valleys - Wisconsin, Minnesota, Mississippi, Louisiana, Kentucky, Arkansas Quebec, Ontario, Manitoba Fungus proliferates in warm, moist soil - usually wooded areas North American Blastomycosis North American Blastomycosis Mild flu-like symptoms or acute pneumonia Skin pustules, subcut abscesses (head and neck, extremities) Arthralgias, myalgias Chronic mimics lung CA North American Blastomycosis Diagnosis Cytology: Broad based budding organism from sputum, BAL or tissue biopsy Culture: slow growing North American Blastomycosis Thoracic Imaging Consolidation patchy, confluent Mass solitary or multiple Cavitation more common in chronic Lymphadenopathy occasionally Miliary pattern - immunocompromised 165

3 166

4 Coccidioidomycosis Coccidioides immitis Endemic in southwest US, northern Mexico Symptoms present in 20-40%, usually mild Coccidioidomycosis Coccidioidomycosis Histology Two phases - Mycelial: mold in dry desert soil, growing in branching hyphae, wind disperses, then inhaled - Inhaled mycelia form endospores in lung of affected host proliferate to form spherules Proliferating endospores form spherules in necrotizing granuloma Spherule Silver stain 167

5 Coccidioidomycosis Primary/Acute Coccidioidomycosis Diagnosis Coccidioidal spherules in cytology or biopsy specimen Culture from any body fluid positive for Coccidioides Serologic test positive for organism Spherule with endospore blow-out Primary/Acute Coccidioidomycosis Asymptomatic or flu-like symptoms Symptoms 1 to 4 weeks after exposure Valley fever -toxic erythema or erythema nodosum, arthralgias, conjuctivitis Primary/Acute Coccidioidomycosis Imaging Consolidation focal or multifocal Nodules, may cavitate Lymphadenopathy in 20% Small pleural effusion in 10 to 20% Rad findings usually resolve within 2 months Subacute or persistent cocci 168

6 Courtesy of Loren Ketai 44F, moved from Arizona last week 44F, moved from Arizona last week Courtesy of Loren Ketai Chronic Pulmonary Coccidioidomycosis Thoracentesis lymphocyte predominant, o/w negative. CT biopsy positive for cocci Usually found incidentally Approx 5% of cases become chronic Lung nodule(s) Cavities (10-15%) -Solitary, thin walled, lung periphery Upper lobe fibrocavitary disease (<1%) 169

7 44M, dx by TTNA 65f, h/o NSIP, new lung nodule Emerging fungal infection in Pacific Northwest First diagnosed in North America in East coast of Vancouver Island, then mainland BC - Oregon Willamette Valley - Washington San Juan Islands 170 presentation 1 month f/u 69M, dx by resection 2 month f/u

8 British Columbia CDC reported infxns. 9% fatality rate U.S. CDC Oregon 43, Wash 15, Idaho 1, Calif 1 (60 infxns) 20% fatality rate Incidence likely higher: may not be reported or presumed C neoformans Ecology Temperate climate - warm, dry summer and mild, wet winter Previously only tropical and subtropical climates - Australia, New Zealand, SE Asia, Latin America, Central and South America, Hawaii Strongly associated with eucalyptus tree early 1990s Pacific NW fungus most likely from Australia Isolated from >10 native tree species on Vanc Island and in soil, air, sea water, fresh water - Mostly Douglas Fir and Western Hemlock Why thriving in new environment? -? global climate change -? pathogen adapting to new climate niche Inhalation of yeast spores leads to pneumonia Disturbing colonized soil increased fungal burden. Cough, SOB, fevers, chills Meningitis or focal CNS lesions in 20% (more than in C neformans) If underlying lung dz, steroids, immunocompromised: Affected at lower concentration of fungus, more severe symptoms Diagnosis Culture Detection of cryptococcal antigen in body fluid Yeast forms from BAL, biopsy CT guided biopsy C gattii v. C neoformans - Divided based on specific antigen with determinants on polysaccharide capsule - Capsular serotypes B and C both C gattii (usually B) - Capsular serotypes A and D are C neoformans Distinguishing C neoformans from C gattii: plating on differential media not routinely available in labs Aggregate yeast forms with thick capsules 171

9 Imaging Pulmonary nodules and masses most common Consolidation focal or patchy Cavitation occurs CNS masses frequently occur 1 month f/u 172 Presentation 1 month f/u 3 month f/u 8 month f/u

10 Fungal Infection in the Immune Competent Host Summary Travel history or living in endemic region In ddx for nodules/masses, often cavitary Consolidation not responding to standard antibiotics Cocci: high incidence, usually mild or no symptoms Blasto: low incidence, but more aggressive Crypto gattii: emerging fungal infxn in Pacific NW, can be very aggressive, meningitis/cns masses References Wheat et al. State-of-the-art review of pulmonary fungal infections. Semin Respir Infect 2002; 17: Fang et al. Imaging manifestations of blastomycosis: a pulmonary infection with potential dissemination. RadioGraphics 2007; 27: Batra P et al. Thoracic coccidioidomycosis. Semin Roentgenol 1996; 31: Fox DL et al. Pulmonary crytococcosis in immunocompetent patients: CT findings in 12 patients. AJR 2005; 185: Dewar GJ et al. : An emerging cause of pulmonary nodules. Can Respir J 2008; 15: MacDougall et al. Spread of in British Columbia, Canada, and detection in the Pacific Northwest, USA. Emerging Infectious Diseases. Vol 13, No. 1. January Histo covered in detail in next presentation 173

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