Common Fungi Catherine Diamond MD MPH
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Clinically Common Fungi Yeast Mold Dermatophytes Candida Coccidioides Cryptococcus Histoplasma Blastomycosis Aspergillus Mucor Epidermophyton Trichophyton Microsporum
Fungus among Us: A Gross Simplification Serious Immunocompromised, hospitalized e.g. cryptococcal meningitis, pulmonary aspergillus Seen mainly by infectious disease specialists, oncologists, hospitalists, intensivists Increasing Annoying Community dwellers e.g. onychomycosis, vaginal candidiasis Seen mainly by primary care MDs (FP, IM, peds, gyn), dermatologists, podiatrists Always with us
Case One A 32 year old man was diagnosed with AIDS two years ago but did not return for care. He complains of a headache and blurred vision.
C. neoformans found in soil samples from around the world in areas frequented by birds, especially pigeons and chickens, and in association with rotting vegetation
Cryptococcus predominantly presents as meningitis in patients with AIDS, organ transplant or chronic corticosteroids Pulmonary and skin disease also occur Immunocompetent disease rare Presentation
Diagnosis Serum & CSF cryptococcal antigen CSF fungal culture CSF protein, glucose, cell count
Treatment Induction: amphotericin & flucytosine Suppression: oral fluconazole
Complications Increased intracranial pressure which can result in blindness Must check opening pressure! Abnormal defined as >20 cm H20 Immune reconstitution syndrome (IRIS) ART started 2-10 weeks after antifungal Rx initiated
Take Home In AIDS or transplant patient with meningitis, think cryptococcus Check CSF cryptococci antigen, fungal culture & opening pressure Treat cryptococcus with induction amphotericin & flucytosine then suppression fluconazole
Case Two A 42 year old woman with ALL received chemotherapy and become neutropenic. She developed a fever. Chest X-ray shows a right upper lobe cavity.
Presentation Invasive aspergillosis Pulmonary Rhinocerebral (r/o Mucor) Allergic bronchopulmonary aspergillosis(abpa)/sinusitis Chronic pulmonary aspergillosis Skin disease much less common
Diagnosis Culture Galactomannan serum & BAL Galactomannan is a polysaccharide that is a major constituent of Aspergillus cell walls May also be positive with fusarium, histoplama
Treatment Voriconazole Amphotericin Isavuconazole
Mucor vs Aspergillus Both aspergillus & mucor cause rhino orbital cerebral disease in immunocompromised (hematologic malignancies, neutropenic, corticosteroids) Mucor had a predilection for DM Voriconazole will not treat mucor; use amphotericin
Mucor Microbiology Mucor hyphae are broader with irregular branching & rare septation in comparison to aspergillus Rhizopus is a species in the order mucorales Mucor may not grow in culture BD glucan not positive in mucor
Take Home In immunocompromised patient with lung cavity or sinus disease, think aspergillus (or mucor) Check pathology, fungal culture and galactomannan serum and BAL Treat aspergillus with voriconazole and mucor with amphotericin
Case Four A 54 year old male truck driver with no PMH is admitted to the intensive care unit with severe bilateral pneumonia requiring intubation. Sputum cultures and legionella urinary antigen are negative and he is not responding to intravenous ceftriaxone and azithromycin
Coccidomycosis Spherule with Endospores
Presentation Primary Valley Fever (ranges from asymptomatic to severe and may be immunocompetent or immunocompromised) Pneumonia Skin Erythema nododosum Erythema multiforme Pulmonary sequelae Cavities Nodules Disseminated Bone & joint Meningitis Skin
Diagnosis Serology Enzyme Immunoassay screen Confirm and titer with complement fixation or immunodiffusion In contrast to histoplasma, antigen not used (insensitive) Characteristic pathology Cultures may be positive but are a hazard to lab personnel
Treatment Fluconazole Itraconazole for bone/joint Amphotericin
Case Five A 47 year old woman with poorly controlled inflammatory bowel disease is transferred from the colorectal service on piperacillin/tazobactam and TPN because of fever and hypotension.
Presentation Fungemia Line infection Hepatosplenic candidiasis Endophthalmitis Oral thrush Esophagitis Vaginitis
Diagnosis Fungal blood culture (may grow in routine culture as well) KOH stain Visual
Kondo T, Terada K. N Engl J Med 2017;376:1574-1574. Candida Esophagitis
Treatment None (funguria) Skin Nystatin or clotrimazole Thrush Fluconazole Nystatin or clotrimazole Esophagitis Fluconazole Candidemia Micafungin initially Fluconazole (krusei resistant, glabrata dose dependent) Amphotericin (lusitaniae resistant)
Take Home Use micafungin for empiric therapy of candidemia
Conclusions Mild fungal infections (tinea, onochomycosis) occur in immunocompromised and immunocompetent but mostly harmless Serious fungal infections (cryptococcus, aspergillus, mucor) tend to occur in immunocompromised hosts Endemic fungi (cocci, histo, blasto) and candida occur in immunocompromised and immunocompetent and vary in severity
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