Invasive fungal infection
From IDWiki
Microbiology
- Aspergillus species
- Mucormycosis
- Cryptococcus?
- Penicillium
- Others...
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 Ă 109 neutrophils/L for >10 days) temporally related to the onset of fungal disease
- Receipt of an allogeneic stem cell transplant
- Prolonged use of corticosteroids (excluding ABPA) at a mean minimum dose of 0.3 mg/kg/day of prednisone equivalent for >3 weeks
- âTreatment with other recognized T cell immunosuppressants, such as cyclosporine, TNF-Îą 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
- âLower 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
- âSinonasal infection: imaging showing sinusitis plus at least 1 of the following 3 signs:
- âAcute localized pain (including pain radiating to the eye)
- âNasal ulcer with black eschar
- âExtension from the paranasal sinus across bony barriers, including into the orbit
- âCNS infection: 1 of the following 2 signs
- âFocal lesions on imaging
- âMeningeal enhancement on MRI or CT
- âDisseminated candidiasis:âAt least 1 of the following 2 entities after an episode of candidemia within the previous 2 weeks:
- âSmall, target-like abscesses (bull's-eye lesions) in liver or spleen
- âProgressive retinal exudates on ophthalmologic examination
- âLower respiratory tract fungal disease: the presence of 1 of the following 3 signs on CT
- Mycological criteria
- âDirect test (cytology, direct microscopy, or culture)
- âMold in sputum, bronchoalveolar lavage fluid, bronchial brush, or sinus aspirate samples, indicated by 1 of the following:
- âPresence of fungal elements indicating a mold
- âRecovery by culture of a mold (e.g., Aspergillus, Fusarium, Zygomycetes, or Scedosporium species)
- âIndirect tests (detection of antigen or cell-wall constituents)
- âAspergillosis:âGalactomannan antigen detected in plasma, serum, bronchoalveolar lavage fluid, or CSF
- âInvasive fungal disease other than cryptococcosis and zygomycoses:âβ-d-glucan detected in serum
- âDirect test (cytology, direct microscopy, or culture)
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 âpilot-wheel configurationâ
- 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.