Invasive fungal infection: Difference between revisions

Revision as of 21:00, 22 September 2019

Microbiology

Epidemiology

Among patients on posaconazole for a hematologic malignancy or bone marrow transplant, there is an approximately 2% rate of breakthrough infection 1

Classification

The classification is based on a combination of patient risk factors (host factors), imaging, and mycology 2
Host factors:
- Recent history of neutropenia (<0.5 × 109 neutrophils/L [<500 neutrophils/mm3] for >10 days) temporally related to the onset of fungal disease
- Receipt of an allogeneic stem cell transplant
- Prolonged use of corticosteroids (excluding among patients with allergic bronchopulmonary aspergillosis) at a mean minimum dose of 0.3 mg/kg/day of prednisone equivalent for >3 weeks
- Treatment with other recognized T cell immunosuppressants, such as cyclosporine, TNF-α blockers, specific monoclonal antibodies (such as alemtuzumab), or nucleoside analogues during the past 90 days
- Inherited severe immunodeficiency (such as chronic granulomatous disease or severe combined immunodeficiency)
Clinical criteria:
- Lower respiratory tract fungal disease
  - The presence of 1 of the following 3 signs on CT:
    - Dense, well-circumscribed lesions(s) with or without a halo sign
    - Air-crescent sign
    - Cavity
- Tracheobronchitis
  - Tracheobronchial ulceration, nodule, pseudomembrane, plaque, or eschar seen on bronchoscopic analysis
- Sinonasal infection
  - Imaging showing sinusitis plus at least 1 of the following 3 signs:
    - Acute localized pain (including pain radiating to the eye)
    - Nasal ulcer with black eschar
    - Extension from the paranasal sinus across bony barriers, including into the orbit
- CNS infection
  - 1 of the following 2 signs:
    - Focal lesions on imaging
    - Meningeal enhancement on MRI or CT
- Disseminated candidiasis
  - At least 1 of the following 2 entities after an episode of candidemia within the previous 2 weeks:
    - Small, target-like abscesses (bull's-eye lesions) in liver or spleen
    - Progressive retinal exudates on ophthalmologic examination
Mycological criteria
- Direct test (cytology, direct microscopy, or culture)
  - Mold in sputum, bronchoalveolar lavage fluid, bronchial brush, or sinus aspirate samples, indicated by 1 of the following:
  - Presence of fungal elements indicating a mold
  - Recovery by culture of a mold (e.g., Aspergillus, Fusarium, Zygomycetes, or Scedosporium species)
- Indirect tests (detection of antigen or cell-wall constituents)
  - Aspergillosis
    - Galactomannan antigen detected in plasma, serum, bronchoalveolar lavage fluid, or CSF
  - Invasive fungal disease other than cryptococcosis and zygomycoses
    - β-d-glucan detected in serum

Proven

Fungal elements in biopsy of diseased tissue, or highly specific indirect assays
Includes:
- Aspergillus in culture
- Histoplasma capsulatum: intracellular budding yeasts
- Coccidioides species: spherules
- Paracoccidioides brasiliensis: large yeasts with multiple daughter yeasts in a “pilot-wheel configuration”
- Blastomyces dermatitidis: thick-walled, broad-based budding yeasts
Can include Coccidioides antibodies in CSF, or Cryptococcus capsular antigen in CSF
Does not include urine antigens

Probable

Requires a susceptible host, clinical/radiographic features, and mycological evidence

Possible

Only cases with the appropriate host factors and with sufficient clinical/radiographic evidence without supporting mycological evidence
Not used for endemic fungi

References

^ Oliver A. Cornely, Johan Maertens, Drew J. Winston, John Perfect, Andrew J. Ullmann, Thomas J. Walsh, David Helfgott, Jerzy Holowiecki, Dick Stockelberg, Yeow-Tee Goh, Mario Petrini, Cathy Hardalo, Ramachandran Suresh, David Angulo-Gonzalez. Posaconazole vs. Fluconazole or Itraconazole Prophylaxis in Patients with Neutropenia. New England Journal of Medicine. 2007;356(4):348-359. doi:10.1056/nejmoa061094.
^ Ben De Pauw, Thomas J. Walsh, J. Peter Donnelly, David A. Stevens, John E. Edwards, Thierry Calandra, Peter G. Pappas, Johan Maertens, Olivier Lortholary, Carol A. Kauffman, David W. Denning, Thomas F. Patterson, Georg Maschmeyer, Jacques Bille, William E. Dismukes, Raoul Herbrecht, William W. Hope, Christopher C. Kibbler, Bart Jan Kullberg, Kieren A. Marr, Patricia Muñoz, Frank C. Odds, John R. Perfect, Angela Restrepo, Markus Ruhnke, Brahm H. Segal, Jack D. Sobel, Tania C. Sorrell, Claudio Viscoli, John R. Wingard, Theoklis Zaoutis, John E. Bennett. Revised Definitions of Invasive Fungal Disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clinical Infectious Diseases. 2008;46(12):1813-1821. doi:10.1086/588660.

@@ Line 1: / Line 1: @@
-== Organisms ==
+== Microbiology ==
 * [[Aspergillus species]]
@@ Line 10: / Line 10: @@
 * Among patients on posaconazole for a hematologic malignancy or bone marrow transplant, there is an approximately 2% rate of breakthrough infection [[CiteRef::cornely2007po]]
+== Classification ==
+* The classification is based on a combination of patient risk factors (host factors), imaging, and mycology [[CiteRef::de pauw2008re]]
+* Host factors:
+** Recent history of neutropenia (<0.5 × 109 neutrophils/L [<500 neutrophils/mm3] for >10 days) temporally related to the onset of fungal disease
+** Receipt of an allogeneic stem cell transplant
+** Prolonged use of corticosteroids (excluding among patients with allergic bronchopulmonary aspergillosis) at a mean minimum dose of 0.3 mg/kg/day of prednisone equivalent for >3 weeks
+** Treatment with other recognized T cell immunosuppressants, such as cyclosporine, TNF-α blockers, specific monoclonal antibodies (such as alemtuzumab), or nucleoside analogues during the past 90 days
+** Inherited severe immunodeficiency (such as chronic granulomatous disease or severe combined immunodeficiency)
+* Clinical criteria:
+** Lower respiratory tract fungal disease
+*** The presence of 1 of the following 3 signs on CT:
+**** Dense, well-circumscribed lesions(s) with or without a halo sign
+**** Air-crescent sign
+**** Cavity
+** Tracheobronchitis
+*** Tracheobronchial ulceration, nodule, pseudomembrane, plaque, or eschar seen on bronchoscopic analysis
+** Sinonasal infection
+*** Imaging showing sinusitis plus at least 1 of the following 3 signs:
+**** Acute localized pain (including pain radiating to the eye)
+**** Nasal ulcer with black eschar
+**** Extension from the paranasal sinus across bony barriers, including into the orbit
+** CNS infection
+*** 1 of the following 2 signs:
+**** Focal lesions on imaging
+**** Meningeal enhancement on MRI or CT
+** Disseminated candidiasis
+*** At least 1 of the following 2 entities after an episode of candidemia within the previous 2 weeks:
+**** Small, target-like abscesses (bull's-eye lesions) in liver or spleen
+**** Progressive retinal exudates on ophthalmologic examination
+* Mycological criteria
+** Direct test (cytology, direct microscopy, or culture)
+*** Mold in sputum, bronchoalveolar lavage fluid, bronchial brush, or sinus aspirate samples, indicated by 1 of the following:
+*** Presence of fungal elements indicating a mold
+*** Recovery by culture of a mold (e.g., Aspergillus, Fusarium, Zygomycetes, or Scedosporium species)
+** Indirect tests (detection of antigen or cell-wall constituents)
+*** Aspergillosis
+**** Galactomannan antigen detected in plasma, serum, bronchoalveolar lavage fluid, or CSF
+*** Invasive fungal disease other than cryptococcosis and zygomycoses
+**** β-d-glucan detected in serum
+=== Proven ===
+* Fungal elements in biopsy of diseased tissue, or highly specific indirect assays
+* Includes:
+** [[Aspergillus]] in culture
+** [[Histoplasma capsulatum]]: intracellular budding yeasts
+** [[Coccidioides species]]: spherules
+** [[Paracoccidioides brasiliensis]]: large yeasts with multiple daughter yeasts in a “pilot-wheel configuration”
+** [[Blastomyces dermatitidis]]: thick-walled, broad-based budding yeasts
+* Can include [[Coccidioides]] antibodies in CSF, or [[Cryptococcus]] capsular antigen in CSF
+* Does ''not'' include urine antigens
+=== Probable ===
+* Requires a susceptible host, clinical/radiographic features, and mycological evidence
+=== Possible ===
+* Only cases with the appropriate host factors and with sufficient clinical/radiographic evidence ''without'' supporting mycological evidence
+* Not used for endemic fungi
 [[Category:Infectious syndromes]]