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Candidemia in Critically Ill Patients: Comparison in IC VS Histopathological diagnosis Arunaloke Chakrabarti 2017 Professor & Head Center for Advanced Research in Medical Mycology & WHO Collaborating Center Histopathological diagnosis Department of Medical Microbiology Postgraduate Institute of Medical EducationAUG & Research Professor Arunaloke Chakrabarti Chandigarh – 160012, India Head, Department of Medical Microbiology Postgraduate Institute of Medical Education and Research Chandigarh, India 5-6 Co-chair, ISHAM Asia Fungal Working Group SPEAKER CONFERENCE,OF MMTN Need of histopathological diagnosis Learning histopathological diagnosis • Fungi are ubiquitous & saprophyticAT • Learn tissue reaction to fungi • Usual laboratory contaminant COPYRIGHT • Commonly performed H & E stain in histopathology will help you to • Infection versus colonization - a frequent problem observe tissue reaction • Rapid & cost-effective means of providing a presumptive or • Difficult to identify fungi on H & E (except Histoplasma, Mucor etc.) definitive diagnosis of an invasive fungal infection • On H&E, all fungi show pink cytoplasm, blue nuclei & no colouration of • Help in knowing the load, tissue reaction, extent & invasion the wall. You may see unstained area in the position of fungi • Difficulty – to get samples from deep tissue • Go ahead performing PAS, GMS • Advances in diagnostic radiology & patient support (platelet • Other specific stains – Alcian blue, Mucicarmine, Fontana Masson etc. transfusions) have improved collection of tissue biopsy specimens PRESENTED • Need training…. 1 Other challenges • Morphological characteristics of fungi are specific in few occasions 2017 Tissue reaction depends on • Histopathology report - description fungus & the presence or absence of tissue invasion & the host reaction to the infection • Host immunity • Comment - most frequent fungi associated with the morphology, AUG other possible fungi considered in the differential diagnosis • Class of fungal pathogen • Alternate techniques - immunohistochemistry, in situ 5-6 hybridization, & PCR • Laser micro-dissection - detect dual fungal infections & the local environment in which this phenomenon occurs SPEAKER CONFERENCE,OF MMTN Superficial Candida infection AT • Low level tissue destruction & inflammation compared to dermatophytes COPYRIGHT • Pathogenic (vs. commensal) correlates with pro-inflammatory Superficial infections response & depends on fungal burden • Steps – colonization, adhesion, invasion, damage • Cell wall (mannan, glucan, chitin, protein) triggers host immune response (cytokines, antimicrobial molecule & attraction of immune effector cells) • But it is not best interest of commensal Candida, as host PRESENTED response would cause elimination 2 Chronic mucocutaneous candidiasis 2017 • Disease occurs in autoimmune polyendocrinopathy candidiasis ectodermal dystrophy syndrome (APECED), hypoparathyroidism, Addison disease or Hyper IgE syndrome • CMC can occur in defective pathogen recognitionAUG pathway • Low level of inflammation 5-6 SPEAKER CONFERENCE,OF MMTN Malassezia Dermatophyte AT infection infection COPYRIGHT • Host secretion of β- endorphins increase the production of Malssezia • Though dermatophytes alone have minimal capacity to damage phospholipases host, consistently high level of host tissue destruction observed in disrupt epithelial dermatophytosis barrier & provoke inflammation • However, for long-term survival - tissue reaction required (tinea PRESENTEDunguium – localized in nail & avoid host immune cells) Hube et al. J Mycol Med 2015; 25: e44 3 Tissue reaction in subcutaneous & systemic fungal infections Tissue reaction Tissue reactions Fungi can be suspected • Non-invasive colonization of pre-existing cavity – fungal ball Acute pyogenic or suppurative Candida, Aspergillus (paranasal sinus & pulmonary cavities) Suppurative with angio-invasion Aspergillus, Mucorales 2017 • Allergic, mucin-producing, non-invasive fungal disease –ABPA, AFRS Mixed suppurative inflammation Blastomyces, Coccidioides Mixed suppurative & granulomatous Blastomyces, Coccidioides, Talaromyces, • No reaction, gelatinous (Cryptococcus) Paracoccidioides, Sporothrix, Phaeohyphomycetes • Predominantly neutrophilic inflammatory response Predominantly granulomatous Cryptococcus, Histoplasma, Coccidioides AUG Granulomatous with various degree of Cryptococcus, Rhinosporidium, Chronic or Mild neutropenia – localized lesion (neutrophilic exudate) fibrosis sub-acute aspergillosis Severe neutropenia – disseminated (coagulative necrosis) Nodules having vascular necrosis, lympho- Histoplasma histiocytic vasculitis, rare granuloma • Granuloma vs. diffuse macrophage5-6 infiltration Granuloma with necrosis & calcification Histoplasma, Coccidioides Predominant fibrosis with granuloma, Entomophthorales • Mixed granulomatous & purulent inflammation (mixture of mixed eosinophilic inflammation Diffuse alveolar damage (ARDS) Blastomyces, Histoplasma, Aspergillus epithelioid macrophages & neutrophils) SPEAKER CONFERENCE,OF MMTN Mixed granulomatous & purulent inflammation Fungal ball • Localized controlled infection – granulomaAT predominates, organism scanty (chronic granulomatous FRS) • Fulminant infection – predominance of neutrophils,COPYRIGHT organism readily seen (dimorphic infection in AIDS) • Mixed purulent & granulomatous inflammation (sporotrichosis, chromoblastomycosis) . Usually unilateral . Involves the maxillary sinus . Well defined, high attenuation mass . Occasional flocculent Ca . Reactive sclerosis of sinus wall PRESENTED . No invasion 4 Aspergilloma 2017 • Fungus ball composed of Aspergillus hyphae & cellular debris within a pulmonary cavity AUG • Preexisting pulmonary cavities that have become colonized with Aspergillus spp. 5-6 • Fungal ball is single, cavity stable over months • Patient has few symptoms (mild cough only) and little evidence of systemic inflammation SPEAKER CONFERENCE,OF MMTN Allergic fungal rhinosinusitis •Type I hypersensitivity •Nasal polyposis AT •Characteristic CT findings •Allergic mucin without mucosal invasion •Positive fungal culture of sinus content COPYRIGHT Bent & Kuhn, Otolaryngol Head Neck Surg, 1994; 111: 580-8 PRESENTED 5 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT PRESENTED 6 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT Gelatinous inflammation PRESENTED 7 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT PRESENTED Acute pyogenic 8 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT PRESENTED PAS 9 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT PRESENTED 10 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT Acute TRICHOSPORONOSIS PRESENTED coccidioidal CANDIDA pneumonia ASPERGILLUS Mixed purulent & granulomatous 11 2017 AUG 5-6 SPEAKER Rhinosporidiosis CONFERENCE,OF MMTN AT COPYRIGHT Lobomycosis Chromoblastomycosis PRESENTED Granuloma of chromoblastomycosis 12 2017 AUG 5-6 SPEAKER Mycetoma CONFERENCE,OF MMTN AT COPYRIGHT PRESENTED Granulomatous pathology Granulomatous Invasive Granulomas chronic inflammatory infiltrate with few fungal hyphae 13 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT Coccidioidal nodule PRESENTED 14 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT PRESENTED 15 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT PRESENTED 16 Interaction of Aspergillus with host 2017 Frequency of aspergillosisFrequencyof Acute IA ABPA Allergic sinusitis Subacute IA aspergillosis TracheobronchitisAUG Aspergilloma Chronic cavitary Chronic fibrosing Frequency of Frequencyof 5-6 Immune dysfunction Normal Immune hyperactivity immune function www.aspergillus.org.uk SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT Acute invasive aspergillosis PRESENTED 17 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN Chronic pulmonary aspergillosis Clinical phenotypes of chronicATaspergillosis Single/simple aspergilloma COPYRIGHT Subacute Invasive aspergillosis Aspergillus (SAIA) or chronic necrotizing nodule(s) pulmonary aspergillosis (CNPA) Aspergilloma CFPA Chronic cavitary pulmonary CCPA aspergillosis (CCPA) Chronic fibrosing pulmonary aspergillosis (CFPA) PRESENTED Denning et al. Eur Respir J 2016; 47: 45 Aspergillus nodule Sub-acute invasive aspergillosis 18 2017 AUG 5-6 SPEAKER CONFERENCE,OF Aspergilloma MMTN AT COPYRIGHT PRESENTED Chronic necrotizing pulmonary aspergillosis 19 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN PM -22189 AT COPYRIGHT PRESENTED 20 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT PRESENTED Allergic aspergillosis - allergic fungal rhinosinusitis - allergic bronchopulmonary aspergillosis (ABPA) 21 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT PRESENTED 22 2017 Pneumocystosis AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT Wt-856g COPYRIGHT PRESENTEDPM-22153 PM-22153 23 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT PRESENTED 24 2017 AUG 5-6 SPEAKER CONFERENCE,OF MMTN AT COPYRIGHT PRESENTED 25.
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