ID: Fungal Infections

Disease Candidiasis: Candida spp, esp albicans Transmission/Reservoir 1.Oval budding yeast that form hyphae & long pseudohyphae 2.Normally colonize humans but overgrowth causes disease 3.RFs abx, DM, immunosuppressive therapy, immunocompromised hosts (at risk for mucocutaneous & systemic types) Clinical Findings 1.Mucocutaneous growth (typical) a.vagina (yeast infection) thick white cottage cheese like discharge; painless but itchy b.mouth, oropharynx (thrush) thick white plaques that adhere to oral mucosa, painless, if unexplained think about HIV c.cutaneous erythematous eroded patches w/satellite lesions; MC in DM; appears in skin folds, underneath breasts & in macerated skin areas d.GIT (esophagus) can cause odynophagia, can be asx 2.Disseminated or invasive in immunocompromised hosts; sepsis/septic shock, meningitis, multiple abscesses in various organs Diagnosis 1..Mucocutaneous clinical; KOH prep shows yeast 2.Invasive blood or tissue culture Treatment 1.Remove indwelling catheters or central lines 2.Oropharyngeal a.clotrimazole troches 5x/day b.nystatin mouthwash 35x/day (oral type) c.oral ketoconazole or fluconazole (esophageal type) 3.Vaginal miconazole or clotrimazole cream 4.Cutaneous oral nystatin powder, keep skin dry 5.Systemic ampho B or fluconazole; new alt agents include voriconazole & caspofungin 1.ABPA avoid exposure to Aspergillus, corticosteroids may help 2.Pulm aspergilloma lung lobectomy if massive hemoptysis 3.Invasive aspergillosis IV ampho B, voriconazole or caspofungin 4.Suspect head or brain involvement imaging studies; may need surgery

Aspergillosis: Aspergillus spp

1.Spores are everywhere in environment 2.Invasive type limited to severely immunocompromised pts consider in immunocompromised pt w/fever & resp distress despite use of broadspectrum abx

1.Allergic bronchopulmonary aspergillosis a.type 1 HSR to Aspergillus b.asthma & eosinophilia; recurrent exacerbations are common 2.Pulmonary aspergilloma a.due to inhalation of spores into lung b.RFs hx of sarcoidosis, histoplasmosis, TB, bronchiectasis c.chronic cough, some hemoptysis d.can resolve spontaneously or invade locally 3.Invasive aspergillosis a.hyphae invade lung vasc thrombosis & infarction b.hosts at-risk pts w/acute leukemia, transplant recipients, pts w/advanced AIDS c.acute onset of fever, cough, resp distress, diffuse bilat pulm infiltrates d.transmitted via hematogenous dissemination; can invade sinuses, orbits & brain

1.CXR dense pulm consolidation, fungus ball 2.Def dx tissue bx 3.Presumed when fungus is isolated from sputum of severely immunocompromised /neutropenic pt w/clinical sx 4.Blood cultures not helpful b/c rarely +

ID: Fungal Infections

Cryptococcosi s: C. neoformans 1.Budding round yeast w/thick PS capsue 2.Assoc. w/pigeon droppings 3.MC in pts w/advanced AIDS 4.Infection due to inhalation of fungus into lungs; hematogenous spread may involve brain & meninges 1.Inhalation of spores from environment 1.CNS disease meningitis, meningoencephalitis or brain abscess a.fever, headache, irritability, dizziness, confusion, seizures; insidious onset 2.Isolated pulmonary infection 1.If meningitis is suspected LP a.latex agglutination cryptococcal Ag in CSF b.India ink smear encapsulated yeasts 2.Tissue bx no inflammatory response 3.Bug can be in urine & blood 1.Culture from urine, sputum, body fluids 1.Ampho B w/flucytosine for 2 wks fluconazole 2.Duration depends on follow-up CSF cultures

Blastomycosis : B. dermatidis (dimorphic fungus) Histoplasmosi s: H. capsuatum (dimorphic fungus w/septate hyphae) Coccidioidom ycosis: C. immitis (dimorphic fungus) Sporotrichosi s: S. schenckii (dimorphic cigar-shaped yeasts)

1.Disseminated infection chronic indolent disease 2.Constitutional sx, lymphadenopathy, pneumonia

1.PO itraconazole for 6-12 mos 2.Ampho B for meningitis

1.Exposure to bird/bat droppings 2.Endemic in Ohio & Mississippi River valleys

1.Flu-like sx, erythema nodosum, hepatosplenomegaly

1.Demonstration of yeast in body fluids or skin

1.PO itraconazole 2.Ampho B for severe infection or immunocompromised host

1.Inhalation of spores

1.Asx or non-specific resp sx 2.Dissemination focal CNS findings

1.Visualization of fungus in fluids or skin

1.Invasion of skin by thorn or other plant material

1.Lymphocutaneous hard subcutaneous nodules ulcerate & drain 2.Disseminated pneumonia, meningitis

1.Visualization of yeast in tissue or body fluids or serology

1.PO fluconazole or itraconazole 6 mo 2.IV ampho B for severe infections or immunocompromised host 1.KI for 1-2 mos or itraconazole for 3-6 mos 2.Disseminated ampho B