Edit concept Question Editor Create issue ticket

Pulmonary Fungal Infection

Fungal Lung Disease

Pulmonary fungal infection manifests as bronchitis or pneumonia and may disseminate to other organs as well. Opportunistic fungal organisms pose a threat to individuals with weakened immune systems.


Presentation

Respiratory infections are attributed to a wide range of pathogens, of which fungi are responsible for a minority of cases. However, fungal organisms present a threat in immunosuppressed patients [1]. Moreover, predisposing factors include AIDS, hematological malignancy, organ transplantation, neutropenia, chronic use of corticosteroids and other immunosuppressive therapy, congenital immune deficiency syndromes, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), and other underlying lung conditions [2].

Fungal pulmonary infection manifests as bronchitis or pneumonia. In the former, cough is the predominant symptom. Moreover, a cough that continues for more than 5 days is indicative of acute bronchitis [3]. Additionally, nearly half of patients with acute bronchitis produce sputum that may be clear, green or yellow, and occasionally streaked with blood. Patients will also report malaise, sore throat, headache, dyspnea, chest pain, hoarseness, and runny/stuffy nose.

Among the manifestations of pneumonia are fever, chills, malaise, cough, hemoptysis, worsening dyspnea, pleuritic chest pain, night sweats, and weight loss [4].

Pulmonary fungal infections may be accompanied by extrapulmonary manifestations. Associated manifestations, for example, will include arthritis, arthralgia, and skin conditions such as erythema nodosum and erythema multiforme. Moreover, fungal infections may disseminate to the brain, blood, bone marrow, kidneys, liver, spleen, sinuses, eye, and muscle.

Also, hypersensitivity reactions such as allergic bronchial asthma and allergic bronchopulmonary aspergillosis (ABPA) may develop secondary to Candida or Aspergillus or species [5]. There are numerous types of other allergic reactions as well.

Complications

Disseminated disease caused by opportunistic infections such as aspergillosis, candidal infection, and cryptococcal meningoencephalitis are common causes of death in immunocompromised patients [6].

Physical exam

Notable signs of acute bronchitis include tachypnea, wheezing, rhonchi, rales and prolonged expiration [7] [8].

In cases of pneumonia, persistent fever is one of the initial symptoms. Other vital signs changes include tachycardia and tachypnea. Further manifestations may include pleural rub, pericardial rub, consolidation, rales, and other adventitious sounds. Also, patients often exhibit signs of distress.

If skin and rheumatologic syndromes are present, then appropriate clinical findings will be observed. Furthermore, patients with meningitis will demonstrate nuchal rigidity and altered mental status.

Malaise
  • Patients will also report malaise, sore throat, headache, dyspnea, chest pain, hoarseness, and runny/stuffy nose.[symptoma.com]
  • Symptomatic infection is associated with cough, chest pain, fevers, malaise, sputum production, and hemoptysis.[clinicaladvisor.com]
  • General symptoms associated with this form of aspergillosis include fever, night sweats, a cough that brings up sputum, fatigue, a general feeling of poor health (malaise), and unintended weight loss.[rarediseases.org]
  • Symptoms of Valley Fever Around 30%-35% of individuals develop flu-like symptoms, including a cough, fever, chills, and malaise that can get resolved more than two to six weeks without getting treated.[valley-fever.org]
  • A case report • A 71-year-old Chinese male was admitted with complaint of chronic cough and malaise for two months. He had been in Tucson, Arizona, USA, visiting for four months right before the symptoms occurred.[slideshare.net]
Intermittent Fever
  • The patient was hospitalized following a 2-month history of haemoptysis and a 1-month history of intermittent fever. Examination and pathology results confirmed a diagnosis of WG with associated pulmonary fungal infection.[ncbi.nlm.nih.gov]
Pallor
  • On examination, he was febrile and had severe pallor; his general condition was poor. Severe thrush was seen over the soft palate and oropharynx.[pmj.bmj.com]
Soft Tissue Mass
  • Figure 3 Left hilar soft tissue mass. (A) Chest X-ray showing left hilar soft tissue mass; (B) HRCT showing consolidation in the lingular segment and left upper lobe of lung. HRCT, high-resolution computed tomographic.[jtd.amegroups.com]
Pneumonia
  • In cases of pneumonia, persistent fever is one of the initial symptoms. Other vital signs changes include tachycardia and tachypnea.[symptoma.com]
  • The radiographic findings in aspergillus and mucoraceae pneumonia are also non-specific.[pmj.bmj.com]
  • It should be taken into consideration for differential diagnosis of community-acquired pneumonia.[ncbi.nlm.nih.gov]
  • Pulmonary Manifestations: Acute pneumonia – patients present with symptoms similar to community-acquired pneumonia with productive cough, fevers, weight loss, shortness of breath, and night sweats.[clinicaladvisor.com]
  • Fungal pneumonia can be treated with antifungal drugs and sometimes by surgical debridement. Pneumonia Coccidioidomycosis[en.wikipedia.org]
Cough
  • In the former, cough is the predominant symptom. Moreover, a cough that continues for more than 5 days is indicative of acute bronchitis.[symptoma.com]
  • Aspergillomas are often asymptomatic but may present with cough and rarely life threatening hemoptysis.[clinicaladvisor.com]
  • Case 2 A 60-year-old diabetic female presented with history of cough and fever for one month. She had taken multiple antibiotics without any improvement. Crackles were audible in left middle to lower part of chest.[jtd.amegroups.com]
  • Sputum smear or culture: The particular test takes the sample of a matter that is released in times of coughing or sputum in the presence of coccidioides organisms.[valley-fever.org]
  • Lung symptoms include fever, wheezing, and coughing. Patients may cough up blood or mucous plugs. Sinus symptoms include facial pressure, headache, blocked nose, yellow or green discharge from the nose, and cough.[dermnetnz.org]
Hemoptysis
  • In these nine patients, seven presented massive hemoptysis and all died of that; other two patients presented severe hemoptysis.[ncbi.nlm.nih.gov]
  • Among the manifestations of pneumonia are fever, chills, malaise, cough, hemoptysis, worsening dyspnea, pleuritic chest pain, night sweats, and weight loss. Pulmonary fungal infections may be accompanied by extrapulmonary manifestations.[symptoma.com]
  • Aspergillomas are often asymptomatic but may present with cough and rarely life threatening hemoptysis.[clinicaladvisor.com]
Dyspnea
  • Patients will also report malaise, sore throat, headache, dyspnea, chest pain, hoarseness, and runny/stuffy nose.[symptoma.com]
  • PCP in HIV usually presents with an insidious onset of dry cough, progressive dyspnea, weight loss, and fever. Acute dyspnea and chest pain should raise suspicion for a pneumothorax.[clinicaladvisor.com]
  • One of the following symptoms of lower respiratory tract infection: new sputum secretions, dyspnea, or hemoptysis; pleuritic chest pain; or physical finding of pleural rub in the background of host factor and microbiological criteria.[ejbronchology.eg.net]
  • Coughing that does not produce mucus; difficulty breathing, also called dyspnea; or abnormally fast breathing, known as tachypnea, are additional frequent symptoms of Candida pneumonia.[livestrong.com]
  • N Engl J Med 2017; 377:2580 A 29-year-old man presented with 2 months of fever, cough, dyspnea, and weight loss. Biopsy of extensive cutaneous lesions revealed Talaromyces marneffei.[nejm.org]
Chronic Cough
  • Ogawa H, Fujimura M, Takeuchi Y, Makimura K (2009) Efficacy of itraconazole in the treatment of patients with chronic cough whose sputa yield basidiomycetous fungi-Fungus-associated chronic cough (FACC).[journals.plos.org]
  • Chronic cough, dyspnea, wheezes, and cyanosis were present in both groups. Chest pain and hemoptysis were present in a small percentage of both groups (11.6 vs. 8.3 and 6.2 vs. 5.2) in COPD patients with and without comorbidities, respectively.[ejbronchology.eg.net]
  • They can experience unintended weight loss, a chronic cough that produces mucus, the coughing up of blood, fatigue, and shortness of breath. Less often, fever or night sweats can occur.[rarediseases.org]
  • A case report • A 71-year-old Chinese male was admitted with complaint of chronic cough and malaise for two months. He had been in Tucson, Arizona, USA, visiting for four months right before the symptoms occurred.[slideshare.net]
Cyanosis
  • Chronic cough, dyspnea, wheezes, and cyanosis were present in both groups. Chest pain and hemoptysis were present in a small percentage of both groups (11.6 vs. 8.3 and 6.2 vs. 5.2) in COPD patients with and without comorbidities, respectively.[ejbronchology.eg.net]
Oral Ulcers
  • The patient improved on treatment. leukaemia pulmonary infiltrate haemorrhage Statistics from Altmetric.com leukaemia pulmonary infiltrate haemorrhage A 52 year old man presented with the complaints of fever, cough, weakness, oral ulcers, painful swallowing[pmj.bmj.com]
Erythema of the Chest
  • 1. fever 2. arthralgias 3. erythema nodosum 4. erythema multiforme 5. chest pain[brainscape.com]
Altered Mental Status
  • Furthermore, patients with meningitis will demonstrate nuchal rigidity and altered mental status.[symptoma.com]

Workup

The workup of a pulmonary infection includes evaluation of the patient's medical history, risk factors, and exposures as well as any recent travel to regions of endemic fungal infection. Furthermore, the patient warrants a complete physical exam and diagnostic studies.

Laboratory tests

A complete blood count (CBC) with differential will reveal leukocytosis in immunocompetent patients with endemic infection whereas it shows leukopenia or neutropenia in those with an opportunistic infection. Moreover, eosinophilia is suggestive of aspergillosis [9].

To determine the etiology of the infection, cultures of sputum, blood, and bronchoalveolar lavage (BAL) fluid are obtained. Another important diagnostic technique is the microscopic analysis of respiratory secretions with specific stains and potassium hydroxide (KOH) preparation [2].

Depending on the pathogen, certain antigen detection studies with polymerase chain reaction (PCR) [10] and enzyme-linked immunosorbent assay (ELISA) [11] are available. Other nonculture methods include galactomannan assays for Aspergillus or Histoplasma [12] [13].

Imaging

Chest radiography in patients with a pulmonary fungal disease may demonstrate consolidation, nodules, and cavitation. Hilar or mediastinal adenopathy also develop in those with fungal infection [2].

Computed tomography (CT) scans are helpful in the assessment of pulmonary lesions found in immunocompromised individuals. Specifically, this imaging modality reveals the "halo sign'" in those with invasive aspergillosis [14].

Other

Procedures used in the diagnosis of pulmonary masses include fiberoptic bronchoscopy and percutaneous CT-guided fine-needle aspiration [15] [16].

Pulmonary Infiltrate
  • The usual causes of pulmonary infiltrates in patients with leukaemia are infection and haemorrhage.[pmj.bmj.com]
  • Hence, IA should be suspected in COPD patients receiving steroid treatment who have extensive pulmonary infiltrates [24].[ejbronchology.eg.net]
  • Miliary-pattern pulmonary infiltration in extensive disease. Blood cultures (may require specific fungal culture bottles).[patient.info]
  • Despite treatment with antibiotics, a repeat imaging study performed 8 weeks later showed a persistent pulmonary infiltrate. Images in Clinical Medicine Dec 08, 2016 Tinea Imbricata Burns C. and Valentine J.[nejm.org]
  • ARDS – In rare cases, patients may present with diffuse pulmonary infiltrates and ARDS, associated with a very high mortality. It is unclear whether this form occurs due to high fungal burden or poor host immune response.[clinicaladvisor.com]
Alveolar Consolidation
  • consolidation on chest radiography strongly suggests DPH. 1 4 5 As haemorrhages occur distal to the mucociliary escalator mechanism, many patients with DPH do not have haemoptysis. 4 5 Even in absence of haemoptysis, DPH should be suspected on the basis[pmj.bmj.com]

Treatment

  • Special attention for IPFI treatment should be prophylaxis, early management as well as sufficient and a whole course administration of effective broad-spectrum antifungal agents.[ncbi.nlm.nih.gov]
  • Selection criteria: Published or unpublished randomised controlled trials, where antifungal treatments have been compared to either placebo or no treatment, or where different doses of the same treatment have been used in the treatment of ABPA in people[cochrane.org]
  • […] time and plan, to establish China's own optimal antifungal treatment options, are reduced in patients with severe fungal infection harm and increase the rate of successful treatment with evidence-based medical evidence.[clinicaltrials.gov]

Prognosis

  • The prognosis of IPFI patients with massive hemoptysis is very poor. Special attention for IPFI treatment should be prophylaxis, early management as well as sufficient and a whole course administration of effective broad-spectrum antifungal agents.[ncbi.nlm.nih.gov]
  • The prognosis varies widely depending on the organism, adequacy of treatment, and the ability of the host to restore their immune system.[clinicaladvisor.com]
  • Serology may be useful for diagnosis (and prognosis) of some mycotic diseases such as coccidioidomycosis, pythiosis, and lagenidiosis.[merckvetmanual.com]
  • Hence early institution of antifungal therapy based primarily on clinical grounds is recommended. 9 Candida pneumonia is usually a part of disseminated candidiasis and has a poor prognosis.[pmj.bmj.com]

Etiology

  • To determine the etiology of the infection, cultures of sputum, blood, and bronchoalveolar lavage (BAL) fluid are obtained.[symptoma.com]
  • Typical fungal etiologies include aspergillosis, mucormycosis, and fusariosis.[cancertherapyadvisor.com]
  • EW The most common presentation of a leukemia patient with a fungal infection is a neutropenic fever of unexplained etiology. Typically, patients who develop a neutropenic fever will initially begin treatment with broad-spectrum antibiotics.[hematologyandoncology.net]
  • Pulmonary infiltrates in patients receiving long-term glucocorticoid treatment: etiology, prognostic factors, and associated inflammatory response. Chest 2003; 123 :488–498. 26. Guinea J, Torres-Narbona M, Gijón P, Muñoz P, Pozo F, Peláez T et al.[ejbronchology.eg.net]
  • Fungal bloodstream infections had among the highest rates of inappropriate initial treatment and hospital mortality for all etiologic agents of bloodstream infections examined ( 12 ).[doi.org]

Epidemiology

  • The following data was assessed: Epidemiology, laboratory and radiological features, microbiology, treatment and risk factors. Results : The medical sample consisted of 62 patients, 30 ICT and 32 ICP.[erj.ersjournals.com]
  • In epidemiological review of 929 patients with zygomycosis by Roden et al., the incidence of Mucor sinus infection was more common followed by pulmonary and cutaneous.[jtd.amegroups.com]
  • Trends in postmortem epidemiology of invasive fungal infections at a university hospital. J Infect. 1996;33:23–32. doi: 10.1016/S0163-4453(96)92700-0. CrossRef PubMed Google Scholar 4. Myers JD. Fungal infections in bone marrow transplant patients.[link.springer.com]
  • Nosocomial acquisition of Candida albicans : an epidemiologic study. J. Infect. Dis. 168 : 195 -201. Weinstein, M. P., S. Mirrett, M. L. Wilson, L. G. Reimer, and L. B. Reller. 1994.[doi.org]
  • […] populations Under-diagnosed and mistaken for tuberculosis Severe asthma with fungal sensitisation (SAFS) 6,500,000 350,000 – 489,000 asthma deaths 50% related to SAFS Uncertain Total 13,000,000 1,600,000 Probably a significant underestimate View all Epidemiological[gaffi.org]
Sex distribution
Age distribution

Pathophysiology

  • The present review addresses the epidemiology and pathophysiology of IPA in COPD patients.[erj.ersjournals.com]
  • Novel perspectives on mucormycosis: pathophysiology, presentation, and management. Clin Microbiol Rev. 2005;18:556-569. 16. Harris JR, Balajee SA, Park BJ. Pneumocystis jirovecii pneumonia: current knowledge and outstanding public health issues.[uspharmacist.com]
  • Moreover, new pathophysiological associations hitherto unknown, such as fungal sensitization and ABPM in patients with chronic obstructive pulmonary disease (COPD), are unfolding [ 11, 12 ].[journals.plos.org]

Prevention

  • Optimal prevention strategies require additional study. 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.[ncbi.nlm.nih.gov]
  • Centers for Disease Control and Prevention (November 21, 2015 updated.) Histoplasmosis. Available online at . Accessed August 27, 2016. Centers for Disease Control and Prevention (February 13, 2014 updated.) Pneumocystis Pneumonia.[labtestsonline.it]
  • Surgical resection of persistent pulmonary fungus nodules and secondary prophylaxis are effective in preventing fungal relapse in patients receiving chemotherapy or bone marrow transplantation for leukemia.[link.springer.com]
  • Centers for Disease Control and Prevention (December 4, 2015 updated.) Ringworm. Available online at . Accessed August 27, 2016. Centers for Disease Control and Prevention (February 13, 2014 updated.) Sporotrichosis. Available online at .[labtestsonline.org]

Summary



References

Article

  1. Lamoth F, Alexander BD. Nonmolecular methods for the diagnosis of respiratory fungal infections. Clin Lab Med. 2014; 34(2):315-336.
  2. Limper AH. The changing spectrum of fungal infections in pulmonary and critical care practice: clinical approach to diagnosis. Proc Am Thorac Soc. 2010;7(3):163–168.
  3. Wenzel RP, Fowler AA 3rd. Clinical practice. Acute bronchitis. N Engl J Med. 2006; 355(20):2125-2130.
  4. Centers for Disease Control and Prevention (CDC). Increase in Coccidioidomycosis - California, 2000-2007. MMWR Morb Mortal Wkly Rep. 2009; 58(5):105-109.
  5. Denning DW, Pashley C, Hartl D, et al. Fungal allergy in asthma–state of the art and research needs. ClinTransl Allergy. 2014;4:14.
  6. Segal BH, Walsh TJ. Current approaches to diagnosis and treatment of invasive aspergillosis. Am J Respir Crit Care Med. 2006;173(7):707-717.
  7. Mufson MA. Viral pharyngitis, laryngitis, croup and bronchitis. In: Goldman L, Bennett JC, eds. Cecil Textbook of medicine. 21st ed. Philadelphia: Saunders, 2000:1793–1794.
  8. Knutson D, Braun C. Diagnosis and Management of Acute Bronchitis. Am Fam Physician. 2002;65(10):2039-2045.
  9. Agarwal R, Gupta D, Aggarwal AN, et al. Clinical significance of hyperattenuating mucoid impaction in allergic bronchopulmonary aspergillosis: an analysis of 155 patients. Chest. 2007; 132(4): 1183–1190.
  10. Wheat LJ. Antigen detection, serology, and molecular diagnosis of invasive mycoses in the immunocompromised host. Transpl Infect Dis. 2006;8(3):128–139.
  11. Löffler J, Hebart H, Sepe S, Schumcher U, Klingebiel T, Einsele H. Detection of PCR-amplified fungal DNA by using a PCR-ELISA system. Med. Mycol. 1998;36(5):275-279.
  12. Husain S, Paterson DL, Studer SM, et al. Aspergillus galactomannan antigen in the bronchoalveolar lavage fluid for the diagnosis of invasive aspergillosis in lung transplant recipients. Transplantation. 2007;83(10):1330–1336.
  13. Hage CA, Davis TE, Egan L, et al. Diagnosis of pulmonary histoplasmosis and blastomycosis by detection of antigen in bronchoalveolar lavage fluid using an improved second-generation enzyme-linked immunoassay. Respir Med. 2007;101(1):43–47.
  14. Greene RE, Schlamm HT, Oestmann JW, et al. Imaging findings in acute invasive pulmonary aspergillosis: clinical significance of the halo sign. Clin Infect Dis. 2007; 44(3):373-379.
  15. Shannon VR, Andersson BS, Lei X, Champlin RE, Kontoyiannis DP. The changing spectrum of fungal infections in pulmonary and critical care practice: clinical approach to diagnosis. Bone Marrow Transplant. 2010;45(4):647-655.
  16. Nosari A, Anghilieri M, Carrafiello G, et al. Utility of percutaneous lung biopsy for diagnosing filamentous fungal infections in hematologic malignancies. Haematologica. 2003;88(12):1405-1409.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2019-07-11 20:25