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  • • Infection occurs after inhalation of sporangiospores, germination in a hyphal form

    • Pulmonary infection occurs in immunocompromised persons, follows a fulminant pattern

    • Distinct clinical syndromes:

    • -Rhinocerebral infection: Direct extension in CNS from paranasal sinus infection

      -Cutaneous infection: Burn patients

      -GI infection: Children with protein-calorie malnutrition

      -Disseminated infection: Uremic patients receiving deferoxamine therapy

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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

    Rhizopus arrhizus (most common), absidia species, rhizomucor species

    • -Infection occurs in patients with diabetes, leukemia, immunosuppression

      -Common in decaying fruit, vegetables, soil, and manure

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Symptoms and Signs

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  • • Pulmonary infection: Fever, cough, pleuritic chest pain, hemoptysis

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Imaging Findings

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  • Chest film: 3 distinct patterns

    • 1. Limited disease with involvement of single lobe

      2. Diffuse or disseminated disease

      3. Endobronchial disease with obstruction and secondary bacterial infection

    Chest CT scan: Characteristic halo sign, ring enhancement, and air-crescent sign

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  • • Demonstrating organism in symptomatic patients

    • No skin or serologic test

    • Fungi grow in culture as broad irregular nonseptate hyphae branch at 90-degree angles

    • Diagnosis most commonly made by histology

    • Sine qua non: Hyphal vascular invasion between internal elastic membrane and media of blood vessels causing thrombosis and infarction

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  • • Chest x-ray

    • Chest CT scan

    • Sputum microscopy and culture

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  • • Amphotericin B is standard treatment

    • Small group of patients have limited disease: Aggressive surgical resection + amphotericin B

    • Endobronchial form: Successful treatment with transbronchoscopic resection using laser therapy

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Prognosis

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  • • Mortality is 90% despite best treatment; death from fungal sepsis, pulmonary dysfunction, and hemoptysis

    • Those surgically treatable: Mortality 50%

    • Endobronchial treatment is generally successful

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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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