1. Fungal Infections Slackers Facts by Mike Ori

2. Disclaimer The information represents my understanding only so errors and omissions are probably rampant. It has not been vetted or reviewed by faculty. The source is our class notes. The document can mostly be used forward and backward. I tried to mark questionable stuff with (?). If you want it to look pretty, steal some crayons and go to town. Finally… If you’re a gunner, buck up and do your own work.

3. What is a tinea

4. A superficial fungal infection defined by its anatomical location

5. List common tinea locations and names

6. NameLocation CapitisHead BarbaeBeard/face FacieiFace CorpusBody (ringworm) CrurisInguinal (Jock itch, usually not scrotum/penis) PedisFoot (Athletes foot) ManuumHands – expect pedis to be present too UnguiumNails/nail bed (onychomycosis)

7. Etiologic agent: Itchy scrotum

8. Candida

9. Vaginal candidiasis predisposing factors

10. Diabetes Antibiotic use Pregnancy HIV

11. What is a woods lamp and why is it used

12. It is a UV lamp that causes some fungal infections to fluoresce and hence serves as a diagnostic tool.

13. What is the slide mount prep for fungal infections

14. KOH prep

15. Etiologic agent: Angular chelitis

16. Candida

17. Etiologic agent: Erythematous depapillation in midline of lingua

18. Candida

19. Etiologic agent: pseudomembranous plaques in mouth

20. Candida

21. Candida treatment

22. Topicals - Nystatin rinse (swish and swallow), OTC azoles Systemics – Triazoles or amphotericin B

23. Onychomycosis sx

24. Opaque, yellow, thickened, chalky nails with debris accumulation

25. Onychomycosis tx

26. Usually long term systemic anti-fungals like fluconazole, itraconazole, terbinafine.

27. Aspergilla source

28. Environment - soil

29. Aspergillosis categories

30. Non-invasive Allergic reaction Aspergilloma Invasive Chronic necrotizing aspergillosis Invasive pulmonary aspergillosis

31. Aspergilloma tx

32. Surgical removal if aspergilloma is problematic. Medical tx cannot adequately penetrate the ball.

33. Chronic necrotizing aspergilloma features

34. Invades lung parenchyma but does not invade vasculature

35. Chronic necrotizing aspergilloma epidemiology

36. Lung disease accompanied by “some” immune suppression

37. Invasive pulmonary aspergillosis characterization

38. Destruction of the lung parenchyma with invasion into the vasculature (angio invasive)

39. Invasive pulmonary aspergillosis epidemiology

40. Prolonged neutropenia as in cancer tx

41. Fusariosis characterization

42. Commensal organism on many grains that causes keratitis in contact lens users. Infection occurs by direct inoculation and may spread systemically in immunocompromised hosts.

43. Fusariosis risk factors

44. Prolonged neutropenia or immune suppression due to allograft transplants

45. Bioterror potential of Fusariosis

46. Mycotoxins have been weaponized

47. Scedosporis characterization

48. Dimorphic fungus with clinical disease similar to Fusariosis.

49. Scedosporiosis risk factors

50. Prolonged neutropenia, immune suppression due to allograft transplants, diabetes.

51. Zygomycosis chracterization. AKA: Mucormycosis

52. Nasal sinus infection extending into the brain or orbit as a result of Mucorales species.

53. Zygomycosis epidemiology

54. Immune compromised hosts with acidemia as occurs in diabetes. Also occurs in poor nutrition, burns, and neutropenia.

55. Zygomycosis tx

56. Aggressive surgical debridement

57. Identify Etiology: A patient complains of dry cough, dyspnea, and fevers. CXR shows diffuse bilateral interstitial infiltrate. ABG shows hypoxemia and hypocarbia. HX includes treatment for rheumatoid arthritis.

58. Pneumocystis jirovecii

59. Is it likely the PT above is HIV +?

60. While PJP is most commonly associated with HIV, it can occur in situations of depressed cellular immunity independent of HIV status.

61. What is the tx for PJP?

62. TMP-SMX both for TX and prophylaxis.

63. What is the likely illness of an HIV + with a CD4 < 100 individual that cleans chicken coops?

64. Cryptococcus neoformans meningitis

65. Cryptococcal DX tests

66. India ink stains showing encapsulated yeast. Serology

67. Cryptococcus TX

68. Amphotericin B followed by fluconazole

69. A 30 year old female presents to your clinic with complaining of a yeast infection that “won’t go away”. She has tried OTC treatment. She has not been sexually active for the last 4 years. She is has never used IV drugs. What tests would you recommend?

70. HIV test. Recurrent or intractable yeast infections can be a sign of HIV. Remember HIV can take years to develop. (Not sure if you would culture the infection)

71. What are the signs of thrush.

72. Angular chelitis Midline lingual erythema Psuedomembranes Dysphagia Odynophagia

73. A patient in the ICU suffered a traumatic laceration to their bowel. They are receiving TPN and antibiotics. They are currently tachycardic, hypotensive, and febrile. Three blood cultures drawn 4 hours apart are negative for bacteremia. What is the likely agent.

74. Candida fungemia

75. Lab tests identify Candida krusei. What possible agent would you administer to resolve the fungemia.

76. Triazoles amphotericin B echinocandins

77. You administer triazoles but the patient does not improve. Why?

78. Candida krusei is increasingly resistant to triazoles through a Ca++ dependent efflux pump.

79. What are the major endemic mycoses?

80. Histoplasmosis Blastomycosis Coccidioidomycosis Paracoccidioidomycosis Sporotrichosis Penicillosis

81. Describe the endemic mycoses morphology

82. They are dimorphic and exist as yeast forms at body temperature.

83. Histoplasmosis epidemiology

84. Worldwide distribution with concentrations in the Mississippi and Ohio river valleys. In particular areas with high nitrogen content such as bat caves. I am the bat!!

85. Histoplasmosis histology

86. Macrophages with intracellular yeast that may be confused for ingested RBC’s

87. Histoplasmosis DX

88. Histology Serology

89. Histoplasmosis treatment caveats

90. Primary pneumonia usually does not require tx. Disseminated disease usually responds to intraconazole or amphotericin B if severe

91. Blastomycosis epidemiology

92. South and north central US in outdoorsy people with exposure to wooded areas. Hunters and nudists (?).

93. Blastomycosis histology

94. Broad based budding yeast

95. Blastomycosis serology caveats

96. Serology is not useful as cross reactions to other common pathogens occurs.

97. Coccidioidomycosis epidemiology

98. Endemic in the soils of the San Joquin valley and parts of the southwestern US and northern Mexico.

99. Coccidioidomycosis histology

100. Endospore containing spherule forms

101. Coccidioidomycosis sx

102. Pneumonia Eosinophilia Hilar and mediastinal lymphadenopathy Night sweats Fatigue Weight loss Meningitis

103. Coccidioidomycosis meningitis prognosis and TX

104. Universally fatal if not treated. TX with lifelong Fluconazole or itraconazole

105. Describe role of anti-fungals in cocci

106. Most primary cocci pneumonia resolves without TX so TX is reserved for prolonged disease with high IgG titer and significant weight loss.

107. Describe the utility of delayed type sensitivity testing in cocci diagnosis

108. Not particularly useful as most people are seropositive. IgG titers are used to follow course of disseminated disease.

109. Compare the culture growth rate of Cocci, hist, blasto.

110. Cocci – fast (days) Hist – slow (weeks) Blasto – slow (weeks)

111. Paracoccidioidomycosis epidemiology

112. Endemic to Brazil

113. Paracoccidioidomycosis sx

114. Ulcerating skin, nasal, and oral lesions in middle aged and older males. Associated with EtOH and tobacco use

115. Paracoccidiodomycosis histology

116. Steering wheel yeast forms

117. Sporotrichosis epidemiology

118. Occupational or recreational exposure to fungus living trees, shrubs, and soil. Commonly associated with punctures from rose thorns.

119. Sporotrichosis sx

120. Lymphocutaneous disease with pustules, ulcers, and lymphangitic spread moving away from site of injury.

121. Clsssic sporotrichosis tx

122. Potassium Iodide