sign in sign up
<<
Home , Aspergilloma, Fungal pneumonia, Sporothrix schenckii

CHAPTER Fungal in the

52 Udas Chandra Ghosh, Kaushik Hazra

INTRODUCTION The following risk factors may predispose to develop is the leading infectious cause of death in fungal in the 6 1, 2 developed countries . Though the fungal cause of 1. Acute leukemia or lymphoma during myeloablative pneumonia occupies a minor portion in the immune- chemotherapy competent patients, but it causes a major role in immune- deficient populations. 2. Bone marrow or peripheral blood stem cell transplantation Fungi may colonize body sites without producing disease or they may be a true pathogen, generating a broad variety 3. Solid organ transplantation on immunosuppressive of clinical syndromes. treatment Fungal infections of the lung are less common than 4. Prolonged corticosteroid therapy bacterial and viral infections and very difficult for 5. Acquired syndrome diagnosis and treatment purposes. Their virulence varies from causing no symptoms to death. Out of more than 1 6. Prolonged neutropenia from various causes lakh only few fungi cause human infection and 7. Congenital immune deficiency syndromes the most vulnerable organs are skin and lungs3, 4. 8. Postsplenectomy state RISK FACTORS 9. Genetic predisposition Workers or farmers with heavy exposure to bird, bat, or rodent droppings or other animal excreta in endemic EPIDEMIOLOGY OF FUNGAL PNEUMONIA areas are predisposed to any of the endemic fungal The incidences of invasive fungal infections have , such as , in which the increased during recent decades, largely because of the environmental exposure to avian or bat feces encourages increasing size of the population at risk. This population the growth of the organism. In addition, farmers and includes the patients of cancers of immune cells of the gardeners are at higher risk of acquiring blood, bone marrow, and lymph nodes, and those with because of their chance of cuts or puncture wounds while human immunodeficiency virus (HIV) infection, as they working with soil. are immunosupressed. With advances in critical care medicine and introduction The basic pulmonary pathologic process again can be of broad-spectrum antibiotics, the incidence of invasive broadly classified as (a) allergic manifestation or (b) actual fungal infections in intensive care is on the rise, especially infection 5, 7 in patients with immunosuppression 5. TLR1 (Toll like receptors) and TLR6 polymorphisms in the recipient have been associated with susceptibility Table 1: Fungi causing Pneumonia to invasive after allogeneic stem cell transplantation.5 Endemic fungal pneumonia pathogen The invasive fungal infections (termed mycoses) can be causing histoplamosis. divided into two broad categories: endemic mycoses and immitis causing . opportunistic mycoses (Table 1). Blastomyces dermatitidis causing . True pathogenic or endemic fungi Paracoccidioides brasiliensis causing The endemic pathogens that most frequently infect healthy individuals. True pathogenic fungi produce a different Opportunistic fungal pneumonia pathogen form in tissue or at 37°C in contrast to mycelial form in Candida spp. causing culture at 25-30°C. These fungi are referred to as dimorphic fungi and include Histoplasma capsulatum, Blastomyces spp. causing aspergillosis dermatitidis, , Paracoccidioides Mucor spp. causing brasiliensis, Penicillium marneffei and causing schenckii. Fortunately, they are not commonly found in the Indian subcontinent and are natural inhabitants Zygomycetes CHAPTER 52 233 4 11 4,16-18 16,19,20 4,13-15 acute stage stage of remission stage of exacerbation stage of steroid dependent stage of fibrosis Allergic alveolitis - by inhalation of high density of high of by inhalation - Allergic alveolitis aspergillosis (ABPA). Allergic broncho pulmonary Colonisation in damaged lung - parenchyma. Invasive Aspergillosis individuals. - in immunodeficient Mixed syndromes RADIOLOGICAL PICTURERADIOLOGICAL PULMONARY ASPERGILLOSIS PULMONARY ABPA CT scan bronchogram: Hallmark is proximal with distal sparing. Management of ABPA ). ( or Steroid and Steroid is used in acute phase with tapering dose till the resolution. Diagnostic of ABPA criteria favor the we validated, Although not prospectively by following diagnostic criteria proposed the International Mycology (ISHAM) Animal Society for Human and that simplify prior diagnostic ABPA working group for 2): schema (Table Stages of ABPA 1. 2. 3. 4. 5. Chest Xray areas of consolidation Massive Inflamed vascular andshadows) bronchial walls (Trampaste shadows) bronchi with fungal debris (Tooth Blocked line finger appearance) & gloved Ring shadows (Bronchiectasis) appearance (Nodular shadows) Parenchymal Local areas of atelectesis & emphysema These are the are the These fungal most common in lung infections in our country- response of or allergic to the lung invasion According in pathogenic reactions the species, lung to aspergillus like can be varied human beings 1. 2. 3. 4. 5. bronchial pathology, mediated immune an is This manifested in susceptible individual. wheezing, episodic and are haemoptysis Manifestations mimicking acute asthmatic episode. . 7,8 . Along with 9,10 A. fumigatus H. capsulatum and B. Candida, Cryptococcus, Pneumocystis, Cryptococcus, Candida, is restricted to south-east Asia possibly Invasive pulmonary aspergillosis and aspergillosis pulmonary Invasive 6,11 Skin hypersensitivity test raised titre Serological evidence of Convincing demonstration of fungi from body fluids or tissue specimens. Table 2: ISHAM Diagnostic Criteria for ABPA Diagnostic 2: ISHAM for Criteria Table present): must be (one conditions Predisposing Asthma (CF) be present): criteria (both must Obligatory IgE levels positivity or detectable skin test Aspergillus against (typically total serum IgE concentration Elevated all other criteria, >1000 IU/mL, but if the patient meets <1000 IU/mL may be acceptable) an IgE value least two must be present): Other criteria (at to Precipitating serum Radiographic pulmonary opacities consistent with Radiographic pulmonary ABPA >500 cells/microL in Total eosinophil count historical) patients (may be glucocorticoid-naïve P. marneffei remaining with its habitat bamboo rats of North and South America. of North and South distribution. a worldwide dermatitidis have are reported blastomycosis and histoplasmosis In India, from different states,is only one report of restricted to Manipur state. There but Penicilliosis luriei and due to S. schenckii var. sporotrichosis systemic marneffei is Asian country an represents the only report from b. c. The diagnosis of this disease entity is based on indirect entity is based on of this disease diagnosis The evidences like a. Diagnosis of fungal infections emergence of AIDS in India, histoplasmosis is increasingly AIDS in India, histoplasmosis emergence of reported. Opportunistic fungal infections involve ubiquitous fungi whose immune and occur predominantly in individuals include species like systems are compromised. These and Zygomycetes Aspergillus, Candida, Cryptococcus (big four). systemic candidiasis are the most prevalent opportunistic are the most prevalent systemic candidiasis do not follow any fungal infections. These infections and are seen with particular geographic distribution increasing frequency worldwide. occurred, and newer have recently changes However, with especially pathogens are being recognized it is not just a Sometimes, AIDS. the emergence of single , but rather a combination of fungi i.e. under species zygomycetes, and Aspergillus Coccidioides, Histoplasma, and/or successive concomitant produce may which opportunistic systemic fungal infections. 234 Resolution Pneumocystis jiroveci Pneumonia23,24 Typically resolution has been defined as- Pneumocystis is a unicellular fungus. 1. Control of asthmatic attacks Pneumocystis jiroveci pneumonia (PJP), previously known as Pneumocystis carinii pneumonia (PCP), is still 2. Reduction of IGE level more than 35% with the most common in HIV positive reduction of peripheral eosinophilia patients, though the incidence is decreasing. 3. Disappearance of pulmonary opacities Before the widespread use of prophylaxis for P Aspergilloma4 jiroveci pneumonia (PJP), the frequency of Pneumocystis Growth of aspergillus fungal ball inside pre existing infection in lung transplant patients and HIV patients pulmonary cavities (e.g. TB, sarcoid, cavities in RA). before starting HAART was very high. Clinical features are characterised by- The taxonomic classification of the Pneumocystis genus Recurrent with recurrent was debated and previously thought to be a protozoan infection. but biochemical analysis of the nucleic acid composition of Pneumocystis rRNA and mitochondrial DNA identified Diagnosis: confirmed by

PULMONOLOGY it as a unicellular fungus rather than a protozoan. Chest X ray-mass within cavity with air cresent level on the top, especially in upper lobe (Monods sign) Symptoms of PJP includes progressive exertional dyspnea, fever, nonproductive cough, chest discomfort Positive precipitin test to Aspergillus The physical examination findings of PJP are nonspecific Demonstration of fungal hyphae in respiratory secretions and includes tachypnea, tachycardia, and pulmonary or from tissue specimen. symptoms are few mild crackles and rhonchi but Raised IgE levels. otherwise normal findings Treatment Diagnosis is done from chest x-ray CT scan thorax, Only observations for asymptomatic individuals and induced sputum by hypertonic saline, broncho alveolar interventions like bronchial artery embolisation & lavage or from tissue specimen. Sputum induction is the surgical resection, radiotherapy, systemic antifungal for quickest and least-invasive method rest of the patients. Though it is fungal pneumonia, P jiroveci pneumonia (PJP) Invasive Aspergillosis4, 16, 21 does not respond to antifungal treatment. The treatment of choice is TMP-SMX, with second-line agents including It is the dissemination of the fungus aspergillus especially pentamidine, dapsone, pyrimethamine, or atovaquone. in immune-compromised host by invasion into viable tissue or blood vessels. Clinically characterized by Pulmonary mucormycosis4 , and pneumonia. Occurs specially in immunocompromised and diabetic Diagnosis is confirmed by Chest X-ray (round pneumonia, patients by granulomatous invasion into upper airways cavitations) & by broncho alveolar lavage. and sinuses with high mortality rate. 4 Treatment is systemic antifungal drugs (Amphotericin B). Pulmonary Cryptococcosis Invasive fungal pneumonia of immunocompromised Chronic necrotising Aspergillosis patients from avian excreta through aerosols. It is intermediate form of aspergillloma in immune- competent patients. Other invasive pulmonary mycoses which are not very common in our country are histoplasmosis, Pulmonary Candidiasis16,22 coccidioidomycosis and para coccidioidosis occurs mainly Opportunistic fungal infections especially in immune- in laboratory workers, diagnosed by compromised patients, like old mal nourished diabetic with demonstration fungi from broncho alveolar lavage patients or in patients with prolonged steroid therapy. or precipitin tests. Treatment is systemic . For last 2 decades, there is a change in the distribution of CONCLUSION Candida spp. causing Incidence of fungal pneumonia is increasing in not only nosocomial infections frequently a life threatening immune-deficient but also in immune- competent patients. complication in patients admitted in ICUs and emerging Though it is very difficult to diagnose fungal pneumonia species are C. tropicalis, C. glabrata, C. parapsilosis, by routine investigations, but it should be kept in mind C.krusei, and C. lusitaniae. that the known risk factors, history & clinical profile and early treatment may help to prevent significant morbidity Diagnosis is by demonstration of fungus by fibre optic and mortality also. bronchoscopy. Treatment is by systemic antifungals like ketoconazole, REFERENCES 1. Kisch B. Forgotten leaders in modern medicine: Valentin, and amphotericin B. CHAPTER 52 235 Ed. Ed. nd nd J Infect J Infect 1970; 21:366-375. 1970; WB Saunders & Co; Philadelphia: 1994; 332-54. WB Saunders & Co; Stringer really JR. Has the name been Cushion MT, most researchers. Clin Infect Dis 2005; changed? It has for 41:1756-8. pneumonia Pneumocystis A. Iwamoto T, Nakamura T, Fujii in patients with HIV laboratory infection: findings, clinical and manifestations, Chemother 2007; 13:1-7. radiological features. Clin Infect Dis aspergillosis. Invasive Denning DW. 1998; 26:781-805. Fraser RS, Pare JAP, Eraser RG, Chest 2 of Diseases of in Synopsis Lungs of Diseases Pare PD. In: Infectious 332-54. WB Saunders & Co; Philadelphia: 1994; JN. Pulmonary Mycotic Infections. Mohapatra LN, Pande Ahuja MMS, Ed. Progress in Clinical Medicine in India, In: A. New Delhi 1978; 235-39. Heinemann Stringer JR. Has the name really been Cushion MT, 2005; changed? It has for most researchers. Clin Infect Dis 41:1756-8 pneumonia A. Pneumocystis Iwamoto Nakamura T, Fujii T, in patients with HIV laboratory infection: findings, clinical and manifestations, Chemother 2007; 13:1-7. radiological features. Mc Carthy DS, Simon G, Hargreave E. Radiological E. Radiological G, Hargreave Simon DS, Mc Carthy Aspergillosis. Pulmonary Broncho Allergic in Appearance Radiology Clinical Davies SF, Saros GA. WB Medicine. Respiratory of Book edit Text JA, JG,Nadel In: Fungal Infection 1161-1170. Co. Philadelphia: 1994; Saunders in Murray Patterson R, Greenberger P, Radin RC, Robert M. Allergic as an aid to Aspergillosis - Staging Pulmonary Broncho 1982; 96:286-91. Management. Am J Med Fraser RS, Pare JAP, Eraser RG, Chest 2 of Diseases of in Synopsis Lungs of Diseases Pare PD. In: Infectious 18. 19. 20. 21. 22. 23. 24. 14. 15. 16. 17. Clin Contr Contr 1954; Clin Infect Dis 1998; 2004; 158:49-52. 2014; 3:14-25 Trans Am Philos Soc Am Philos Trans 1992; 30:2492-4. 1977; 3:2-6. 1977; 3:2-6. Microbiol Immunol Gruby, Remark, Auerback. Gruby, Auerback. Remark, 44:139-317. medicine. in modern mycoses Systemic L. Ajello B.N. Panda, Fungal infections of 2004; 51:63-69. scenario. Indian J Tuberc lungs : the emerging Sousa KC, de CC, de Fernandes OF, Mirande Kobayashi ED, Silva Mdo study. Mycopathologia R. prospective Candiduria in hospital patients: a Singh T, Kashyap AK, Ahluwalia G, Chinna D, Sidhu SS. G, Chinna D, Sidhu Ahluwalia AK, Kashyap Singh T, a of setting care critical in infections fungal of Epidemiology prospective a India: North in hospital teaching care tertiary study. J Clin Sci Res surveillance Chakrabarti A,microbiology of systemic fungal infections. A,microbiology Chakrabarti 1 J Postgrad Med 2005; 51 Suppl 1, page K, Singh TJ, et al. Disseminated Ranjana KH, Priyokumar Penicillium marneffei state, India. J Infect 2002; 45:268-71. patients in Manipur infection amonget al. Fatal pulmonary AA, Kaufman L, Durry E, Padhye HIV-infected luriei in by var. caused sporotrichosis India. J Clin Microbiol 26:781-805. Moore RD, Chaisson RE. Natural history of opportunistic cohort. Ann Intern in an HIV infected urban clinical disease Med 1996; 124:633-42. Allergic A, et al. A, Shah R, Chakrabarti Agarwal bronchopulmonary aspergillosis: review of literature and proposal of new diagnostic and classification criteria. Exp Allergy 2013; 43:850. PA, R,Patterson Holwig Greenberger M, Liotta JC,Roberts M. Allergic Broncho History and Classification Pulmonary of Early disease by Serological Aspergillosis:Natural 1986; 916-918. and Roentgenographic studies. Arch Int Med Actinomycotic Fungal and AG. Seaton 0, Leitch A, Seaton Diseases. In: Crofton and Douglas’s Respiratory Diseases Press Delhi 1989; 448-475. 4th Ed. Oxford University Denning DW. Invasive aspergillosis. 2. 5. 4. 3. 7. 8. 6. 10. 11. 12. 13. 9.