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daily In critically ill patients who are not responding to conventional antifungal treatment, there may be a role for the addition of caspofungin to amphotericin B or voriconazole therapy, although randomized trials are lacking Based on promising results in neutropenic patients with invasive pulmonary aspergillosis, surgical resection warrants further study The mortality rate of pulmonary or disseminated disease in the immunocompromised patient remains well above 50%, particularly in patients with refractory neutropenia This high mortality rate often leads clinicians to institute prophylactic therapy around the time of bone marrow transplantation with agents such as itraconazole
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Bart-Delabesse E et al Detection of Aspergillus galactomannan antigenemia to determine biological and clinical implications of beta-lactam treatments J Clin Microbiol 2005 Oct;43(10):5214 20 [PMID: 16207986] Hope WW et al Laboratory diagnosis of invasive aspergillosis Lancet Infect Dis 2005 Oct;5(10):609 22 [PMID: 16183515] Singh N et al Aspergillus infections in transplant recipients Clin Microbiol Rev 2005 Jan;18(1):44 69 [PMID: 15653818]
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Blastomycosis occurs most often in men infected during occupational or recreational activities out of doors and in a geographically limited area of the south central and midwestern United States and Canada Disease usually occurs in immunocompetent individuals Pulmonary infection is most common and may be asymptomatic When dissemination takes place, lesions are most frequently seen in the skin, bones, and urogenital system Cough, moderate fever, dyspnea, and chest pain are common These may resolve or progress, with bloody and purulent sputum production, pleurisy, fever, chills, loss of weight, and prostration Radiologic studies, either chest radiographs or CT scans, usually reveal pulmonary infiltrates and enlarged regional lymph nodes, though less commonly than in histoplasmosis or coccidioidomycosis Raised, verrucous cutaneous lesions that have an abrupt downward sloping border are usually present in disseminated blastomycosis Bones often the ribs and vertebrae are frequently involved Lesions appear to be both destructive and proliferative on radiography Epididymitis, prostatitis, and other involvement of the male urogenital system may occur Central nervous system involvement is uncommon Although they do not appear to be at greater risk for acquisition of disease, infection in HIV-infected persons may progress rapidly, with dissemination common Laboratory findings usually include leukocytosis and anemia, though these are not specific The organism is found in clinical specimens, such as expectorated sputum or tissue, as a thick-walled cell 5 20 mcm in diameter that may have a single broad-based bud It grows readily on culture Serologic tests are not well standardized A urinary antigen test is available, but it has some cross reactivity with Histoplasma; consequently, its usefulness in diagnosis and in assessing response to therapy is unclear Itraconazole, 100 200 mg/d orally for at least 2 3 months, is the therapy of choice for nonmeningeal disease, with a response rate of over 80% Amphotericin B, 03 06 mg/kg/d intravenously for a total dose of 15 25 g, is given for treatment failures or cases with central nervous system involvement Clinical follow-up for relapse should be made regularly for several years so that therapy may be resumed or another drug instituted
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Kauffman CA et al Endemic mycoses: Blastomycosis, histoplasmosis, and sporotrichosis Infect Dis Clin North Am 2006 Sep; 20(3):645 62 [PMID: 16984873]
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The term mucormycosis (zygomycosis, phycomycosis) is applied to opportunistic infections caused by members of the genera Rhizopus, Mucor, Absidia, and Cunninghamella Predisposing conditions include diabetic ketoacidosis, chronic renal failure, desferoxamine therapy, and treatment with corticosteroids or cytotoxic drugs These organisms appear in tissues as broad, branching nonseptate hyphae Biopsy with histologic examination is almost always required for diagnosis; cultures are frequently negative Invasive disease of the sinuses, orbits, and the lungs may occur Widely disseminated disease has been more commonly seen recently in patients who have received aggressive chemotherapy and broad-spectrum antifungal prophylaxis The diagnosis should be considered in immunocompromised patients with black necrotic lesions of the nose or sinuses or with new cranial nerve abnormalities Without treatment, cerebral invasion may ensue A prolonged course of high-dosage amphotericin B (1 15 mg/ kg/d intravenously) or a lipid preparation of amphotericin B should be started early Based on in vitro susceptibility and reports of successful salvage therapy, there may be a role for posaconazole in the treatment of these infections, but other azoles are likely to be ineffective Control of diabetes and other underlying conditions, along with extensive repeated surgical removal of necrotic, nonperfused tissue, is essential Even when these measures are introduced in a timely fashion, the prognosis is poor, with a 30 50% mortality rate for localized disease and higher rates in disseminated cases
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Kontoyiannis DP et al Zygomycosis in a tertiary-care cancer center in the era of Aspergillus-active antifungal therapy A case-control observational study of 27 recent cases J Infect Dis 2005 Apr 15;191(8):1350 60 [PMID: 15776383] Spellberg B et al Novel perspectives on mucormycosis: pathophysiology, presentation, and management Clin Micro Rev 2005 Jul;18(3):556 69 [PMID: 16020690]
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Paracoccidioides brasiliensis infections have been found only in patients who have resided in South or Central America or Mexico Long asymptomatic periods enable patients to travel far from the endemic areas before developing clinical problems Ulceration of the nasopharynx and oropharynx is usually the first symptom Papules ulcerate and enlarge both peripherally and deeper into the subcutaneous tissue Differential diagnosis includes muco-
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