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  • • Most common sites of infection are lungs and CNS

    • Predilection for lower lobes of lungs

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Epidemiology

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  • • Pulmonary fungal infections are rising due to widespread use of broad-spectrum antibiotics, immunosuppressive drugs, and HIV infection

    • Occur anywhere in world, some with characteristic endemic areas

    Cryptococcus neoformans: Found in pigeon excreta, grasses, trees, plants, fruits, insects, birds, dairy products

    • -Exists also on skin and in nasopharynx, GI tract, and vagina

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Symptoms and Signs

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Pulmonary Infection

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  • • Many asymptomatic

    • If symptoms, cough, pleuritic chest pain, fever

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CNS Infection

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  • • Usually follows asymptomatic pulmonary infection

    • Symptoms vary since many patients are immunocompromised

    • Many do not manifest usual signs of meningitis or cerebritis

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Laboratory Findings

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  • • Elevated serum antigen (via complement fixation tests)

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Imaging Findings

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  • • Chest film: Can appear as 3-10 cm pleural-based mass without smooth borders, areas of consolidation, or as disseminated miliary nodular infiltrate

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  • • Elevated serum antigen (via complement fixation tests)

    • Histology: India ink stain

    • Culture is extremely time consuming

    • No skin test exists

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  • • Chest x-ray

    • Chest CT scan

    • Sputum microscopy and culture

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  • • Medical therapy warranted in most cases of pulmonary infection even if asymptomatic

    • Surgical resection rarely necessary

    • Open lung biopsy if diagnosis is equivocal

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Surgery

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Indications

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  • • To exclude malignancy

    • Determine etiology of undiagnosed diffuse pulmonary infiltrate

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Medications

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  • • Amphotericin B is treatment of choice combined with flucytosine

    • Fluconazole and itraconazole are useful for long-term maintenance therapy

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References

Piarrouz R et al: Assessment of preemptive treatment to prevent severe candidiasis in critically ill surgical patients. Crit Care Med 2004;32:2443.
Walsh TJ et al: Voriconazole compared with liposomal amphotericin B for empirical antifungal therapy in patients with neutropenia and persistent fever. NEJM 2002;346:225.  [PubMed: 11807146]

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