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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
These are systemic fungal infections - either endemic or opportunistic, generally only infecting those who are immunocompromised.[1, 2]See also separate Fungal Lung Infections article.
Endemic fungal infections
Histoplasmosis is linked to exposure to bird and bat droppings especially along the Ohio and Mississippi river valleys in the USA. It usually occurs as an atypical pneumonia, in the acute form appearing in epidemics with prostration, fever and respiratory symptoms.
- Progressive disseminated histoplasmosis - fever, dyspnoea, cough, loss of weight and prostration with hepatosplenomegaly. Usually fatal within six weeks.
- Chronic progressive pulmonary histoplasmosis is usually seen in older patients with chronic obstructive pulmonary disease (COPD).
- Disseminated disease when seen in the immunocompromised is usually due to reactivation of prior infection often seen in HIV infection.
Itraconazole for mild-to-moderate cases; amphotericin in severe cases or for those who fail on itraconazole.
Coccidioidomycosis is caused by a mould that grows in the soil in Southwestern USA, Mexico and Central and South America. <1% of immunocompetent affected people suffer dissemination but in these cases mortality is high. 40% of primary infections are symptomatic, usually presenting with respiratory tract symptoms plus fever, with pleuritic pain. There may be arthralgia with swelling (often knees and ankles). Management: intravenous (IV) amphotericin for severe infections; in mild cases oral fluconazole or itraconazole continued for six months or longer.Surgery may be needed to drain cavities or abscesses or to resolve diagnostic dilemmas in nodular disease.
See separate Pneumocystis Jirovecii Pneumonia article. It is very rarely symptomatic in immunocompetent patients but, in immunocompromised patients (especially HIV), there can be abrupt onset of fever, tachypnoea, shortness of breath and non-productive cough. If untreated, there is rapid deterioration to death.
- Aspergillosis.See separate Aspergillosis article. This is usually caused by Aspergillus fumigatus; patients with very advanced HIV infection are particularly at risk, mostly with pulmonary disease leading to severe necrotising pneumonia.
- Mucormycosis.This was previously called zygomycosis. It is found in patients with predisposing conditions such as diabetic ketoacidosis, chronic kidney disease and immunosuppressant drugs. Treatment is surgical debridement under cover of amphotericin.
- Mycetoma.See separate Mycetoma (Madura Foot) article. This includes maduromycosis and actinomycetoma, which is a slowly progressive locally destructive infection beginning in subcutaneous tissues often after trauma, and spreading to contiguous structures. A maduromycosis is a mycetoma caused by true fungi. It may start as a papule, nodule or abscess and it progresses over months or years to form multiple abscesses and sinus tracts reaching deep into the tissue.
- Blastomycosis.This usually occurs in men working outdoors in certain areas of South, Central and Midwestern USA and Canada; it usually affects the lung but can disseminate to the skin, bones and urogenital tract. Symptoms include cough, fever, dyspnoea and chest pain. It may resolve or progress with bloody, purulent sputum, pleurisy, fever, chills, loss of weight and prostration. In disseminated form, there are raised verrucous skin lesions with an abrupt, downward-sloping border often seen.
- Paracoccidioidomycosis.Also known as South American blastomycosis, it is only found in patients who have lived in South or Central Africa or Mexico and initially affects the upper respiratory tract. It usually appears with ulceration of the upper respiratory tract. Ulcers can coalesce to destroy the epiglottis, vocal cords and uvula. Eating and drinking are very painful. There may be skin lesions on the face.
- Sporotrichosis.This occurs when the organism is inoculated into the skin during gardening. It usually causes a skin infection - a hard, non-tender, subcutaneous nodule which later ulcerates. Similar nodules then appear along the lymphatics draining the area.
- Chromoblastomycosis.This is a mainly tropical skin infection, usually affecting agricultural workers and causing skin infections. It begins as a papule or ulcer, usually on a lower extremity, and enlarges over months or years to become a papillomatous, verrucous nodule.
- Cryptococcus neoformans.See separate Cryptococcosis article. This is a yeast found in soil and dried pigeon droppings. Infection is usually transmitted by inhalation. Immunodeficient patients develop progressive lung disease and dissemination. It can involve any organ but mainly the central nervous system. It often presents with meningitis.
- Candidiasis. See separate Candidiasis article. This is normally associated with predisposing factors - eg, neutropenia, antibiotic use, indwelling lines and abdominal surgery. It can cause candidaemia and disseminated candidiasis; also, deep focal candidiasis, in which it infects the peritoneum or meninges, is often implanted following dialysis or surgery.
Further reading and references
Badiee P, Hashemizadeh Z; Opportunistic invasive fungal infections: diagnosis & clinical management. Indian J Med Res. 2014 Feb139:195-204.
Benedict K, Park BJ; Invasive fungal infections after natural disasters. Emerg Infect Dis. 2014 Mar20(3):349-55. doi: 10.3201/eid2003.131230.
Silva RF; Chapter 8: Fungal infections in immunocompromised patients. J Bras Pneumol. 2010 Jan-Feb36(1):142-7.
Low CY, Rotstein C; Emerging fungal infections in immunocompromised patients. F1000 Med Rep. 20113:14. doi: 10.3410/M3-14. Epub 2011 Jul 1.
Zollner MS, Rezende KM, Birman S, et al; Clinical and evolutionary characteristics of four patients with pulmonary histoplasmosis reported in the Paraiba Paulista Valley region. Rev Soc Bras Med Trop. 2010 Sep-Oct43(5):599-601.
McKinsey DS, McKinsey JP; Pulmonary histoplasmosis. Semin Respir Crit Care Med. 2011 Dec32(6):735-44. doi: 10.1055/s-0031-1295721. Epub 2011 Dec 13.
Seitz AE, Prevots DR, Holland SM; Hospitalizations associated with disseminated coccidioidomycosis, Arizona and California, USA. Emerg Infect Dis. 2012 Sep18(9):1476-9. doi: 10.3201/eid1809.120151.
Information for Healthcare Professionals about Valley Fever (Coccidioidomycosis); Centers for Disease Control and Prevention, 2014
Jaroszewski DE, Halabi WJ, Blair JE, et al; Surgery for pulmonary coccidioidomycosis: a 10-year experience. Ann Thorac Surg. 2009 Dec88(6):1765-72. doi: 10.1016/j.athoracsur.2009.07.075.
Castro JG, Morrison-Bryant M; Management of Pneumocystis Jirovecii pneumonia in HIV infected patients: current options, challenges and future directions. HIV AIDS (Auckl). 20102:123-34. Epub 2010 Feb 18.
Kaur S, Singh S; Biofilm formation by Aspergillus fumigatus. Med Mycol. 2014 Jan52(1):2-9. doi: 10.3109/13693786.2013.819592.
Tacke D, Koehler P, Markiefka B, et al; Our 2014 approach to mucormycosis. Mycoses. 2014 Sep57(9):519-24. doi: 10.1111/myc.12203. Epub 2014 May 15.
Buonfrate D, Gobbi F, Angheben A, et al; Autochthonous cases of mycetoma in Europe: report of two cases and review of literature. PLoS One. 2014 Jun 259(6):e100590. doi: 10.1371/journal.pone.0100590. eCollection 2014.
Landis E et al; Treating Rare Fungal Infections: Maduromycosis, The dermatologist, 2014.
Mondada K, Fullmer J, Hungerford E, et al; Blastomyces dermatitidis: Antibody Detection in Sera from Dogs with Blastomycosis with Yeast Lysate Antigens Produced from Human and Dog Isolates. Vet Med Int. 20142014:376725. doi: 10.1155/2014/376725. Epub 2014 Feb 27.
Gegembauer G, Araujo LM, Pereira EF, et al; Serology of paracoccidioidomycosis due to Paracoccidioides lutzii. PLoS Negl Trop Dis. 2014 Jul 178(7):e2986. doi: 10.1371/journal.pntd.0002986. eCollection 2014 Jul.
Freitas DF, Valle AC, da Silva MB, et al; Sporotrichosis: an emerging neglected opportunistic infection in HIV-infected patients in Rio de Janeiro, Brazil. PLoS Negl Trop Dis. 2014 Aug 288(8):e3110. doi: 10.1371/journal.pntd.0003110. eCollection 2014 Aug.
de Sousa Mda G, Belda W Jr, Spina R, et al; Topical application of imiquimod as a treatment for chromoblastomycosis. Clin Infect Dis. 2014 Jun58(12):1734-7. doi: 10.1093/cid/ciu168. Epub 2014 Mar 14.
Chan M, Lye D, Win MK, et al; Clinical and microbiological characteristics of cryptococcosis in Singapore: predominance of Cryptococcus neoformans compared with Cryptococcus gattii. Int J Infect Dis. 2014 Sep26:110-5. doi: 10.1016/j.ijid.2014.05.019. Epub 2014 Jul 11.
Yapar N; Epidemiology and risk factors for invasive candidiasis. Ther Clin Risk Manag. 2014 Feb 1310:95-105. doi: 10.2147/TCRM.S40160. eCollection 2014.