Formerly Fungal disease in Five cases

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Of mycetomas and men

• Formerly Fungal disease in Five cases
• William Kelly, Pulmonary/CCM

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Fungal infection

• Most often asymptomatic
• Disease when immunocompromised and/or large
  exposure
• ANY organ (lung, CNS)
• Treatment often not rigorously defined
• If severe gt amphotericin (liposomal)
• Relapse common (if disseminated)

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Case 8

• 59 y.o. presenting to ALVA with eye pain.
  Promptly Transferred to MAMC ICU because of
  diabetic ketoacidosis on screening labs.

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Zygomycosis

• NOT mucormycosis
• Absidia, Rhizomucor, Rhizopus
• Severely immunocompromized (cancer therapy),
  diabetics, malnourished, burns
• Rhino-facial-cranial area
• Arterial emboli/necrosis
• Devastating/fatal? Debride liposomal ampho
  growth factors

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Aspergillus
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Aspergilloma/ fungus ball
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Aspergilloma/ fungus ball
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Aspergilloma

• Occurs in preformed cavities
• 11 of tuberculosis cavities
• Others sarcoid, bronchiectasis, cysts, CA,
  bullae, ankylosing spondylitis, infarction
• Most remain stable
• 10 shrink/resolve
• Rarely enlarges

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Aspergilloma

• May be asymptomatic for years
• Cough, dyspnea withOUT fever
• Hemoptysis, usually mild
• 2-14 mortality
• Poor prognosis severe underlying dz,
  steroids/immunosuppression, increasing IgG
  aspergillus titers, large volume hemoptysis, hx
  sarcoid or HIV

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Aspergilloma Diagnosis

• Crescent sign
• dependent positioning
• Diff dx hematoma, neoplasm, hydatid cyst,
  Wegeners
• Sputum (50)
• Serum IgG to fumigatus
• Rare false neg. if steroids or other species
• Skin test usually negative

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Aspergilloma Treatment

• None
• ? Antifungal therapy
• Embolization (temporizing)
• Resection
• 7-23 procedural mortality!
• 1.5 young, post TB patients

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Chronic necrotizing (CNA)

• Clinical diagnosis of exclusion
• Middle-aged, underlying lung disease
• Immunosuppression (mild)
• Infiltrate, thick pleura fungus ball (50)
• Aspergillus by sputum/ aspirate
• Serum ASP IgG, skin test positive
• Rx azolegtgtsurgery 73 alive_at_1-2 yrs

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Invasive pulmonary (IPA)

• NOT uncommon in certain populations
• 5 BMT patients
• 7.5 post induction for AML
• 1 per day of neutropenia
• (4 per day after 3 wks)
• 2 have no risk factors

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IPA Diagnosis

• Sputum (BMT patients)
• 90 positive predictive value
• 70 false negative rate
• Early CT/HRCT (85)
• Bronchoscopy (lt50 sens, 97 spec)
• Open lung biopsy
• Gold standard (still missed 3/15 cases)

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CT halo sign
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Infarcts/perfusion defects
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Infarcts/perfusion defects
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Aspergillus septate hyphae (2.5-4.5 um),
approx. 45 degree branching
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Aspergillus septate hyphae (2.5-4.5 um),
approx. 45 degree branching
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Zygomycosis (Mucormyosis) NON-septate,
irregular or 90 degrees
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Galactomannan antigen

• FDA approved 16MAY03
• Serum, BAL, other
• 80.7 sensitivity, 89.2 specificity
• False positives
• X-reactivity (Penicillium)
• Antigenemia (food stuffs, Zosyn)
• Titer decreases with treatment
• Except echinocandins (like Capsofungin)

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Aspergillus treatment

• Amphotericin
• Voriconazole
• Capsofungin
• Investigational
• Posaconazole, ravuconazole, FK463, anidulafungin
  (LY303366)
• Prophylaxis HEPA filters, avoidance, Rx

? Better for zygomycosis
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ABPA treatment

• Oral corticosteroids
• Inhaled corticosteroids
• Itraconazole (46 significant response)
• 50 reduction in steroid dose
• 25 decrease in IgE
• 25 increase in PFTs or exercise tolerance
• Resolved infiltrates

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Resources

• ID Clinics SEP 2006!
• http//www.doctorfungus.org
• http//www.idsociety.org
• http//www.aspergillus.man.ac.uk
• Dr. Lick CHEST 2002, editorial
• and others