Fungal Pneumonia Diagnosis and Investigations

FUNGAL PNEUMONIA
D R. MD . S HAFIQUL I S LAM D EWAN
R E S I D E N T ( P U L M O N O L O G Y )
R E S P I R A T O R Y M E D I C I N E D E P A R T M E N T
DHAKA MEDICAL COLLEGE HOSPITAL

Fungal Pneumonia
Pneumonia is as an acute respiratory illness associated with
recently developed radiological pulmonary shadowing that may be
segmental, lobar or multi-lobar.
If it is caused by fungus called fungal pneumonia.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 2

Fungi
Fungi are eukaryotic organisms that exist in two basic forms: yeasts and molds.
Yeasts are single cells, whereas molds consist of long filaments of cells called
hyphae.
Yeasts reproduce by budding, a process in which the daughter cells are
unequal in size.
Molds reproduce by cell division (daughter cells are equal in size).
Some fungi are dimorphic (e.g. Exist either as yeasts or molds, depending on
the temperature). At room temperature (e.g. 25°C), they are molds, whereas at
body temperature they are yeasts (or some other form such as a spherule).

Fungal pathogens
Two types of fungi causes infection in human.
Endemic fungi: Endemic fungal pathogens causes infection in healthy and
immunocompromised hosts, in defined geographic locations around the
world.
Opportunistic fungi: Opportunistic fungal pathogens causes infection in
patients with congenital or acquired defects in host immune defense.

Endemic Fungi
Histoplasmosis
Coccidioidomycosis
Blastomycosis
Para-coccidioidomycosis
Sporotrichosis
Talaromycosis (formerly penicilliosis)
Emergomycosis

Opportunistic Fungi
Cryptococcosis
Candidiasis
Aspergillosis
Mucormycosis
Non-aspergillus hyaline hyphomycetes
Dematiaceous (melanized) hyphomycetes

Transmission
Fungal infection occurs following_
Inhalation of spores.
Inhalation of conidia.
Reactivation of a latent infection.
Hematogenous dissemination frequently occurs, especially in an
immunocompromised host.

Risk Factors
Acute leukemia or lymphoma during myeloablative chemotherapy.
Bone marrow or peripheral blood stem cell transplantation.
Solid organ transplantation on immunosuppressive treatment.
Prolonged corticosteroid therapy.
Acquired immunodeficiency syndrome.
Congenital immune deficiency syndromes.
Prolonged neutropenia from any cause.
Post splenectomy state.
Genetic predisposition.

Patient History
History findings in persons with fungal pneumonia_
Fever
Cough, usually nonproductive
Pleuritic chest pain or dull discomfort
Progressive dyspnea leading to respiratory failure
Airway obstructive symptoms from enlarged mediastinal adenopathy in
the endemic mycoses

Patient History
Hemoptysis (in invasive aspergillosis or mucormycosis).
History of travel to or exposure in areas containing endemic
mycoses.
Symptoms from involvement of extrapulmonary systems (may
suggest disease).
Rheumatologic syndromes (common among endemic mycoses) -
Arthritis and arthralgia, erythema nodosum, erythema multiforme,
and pericarditis.

Patient History
Hypersensitivity or allergic reactions.
Extrapulmonary sites in individuals who are immunocompromised.
Meningoencephalitis in patients with AIDS and cryptococcosis.
In individuals who are neutropenic or immunocompromised,
persistent fever (even before pulmonary findings) may be an early
sign of infection, especially if the fever is unresponsive to broad-
spectrum antibiotics.

Patient History
Hypersensitivity or allergic reactions include_
Allergic bronchial asthma (aspergillus species, candida species).
Allergic bronchopulmonary mycoses (aspergillus species, candida species).
Broncho-centric granulomatosis (necrotizing granulomatous replacement
and eosinophilic infiltration of bronchial mucosa in infection
with aspergillus species).
Extrinsic allergic alveolitis (malt worker's lung, farmer's lung).

Physical Examination
Signs and symptoms of fungal pneumonia are not specific and
are indistinguishable from those associated with respiratory
infections of other origins.

Physical examination findings may include_
Elevation of temperature
Tachycardia
Tachypnea
Respiratory distress
Rales
Signs of pulmonary consolidation
Pleural rub

Important possible extrapulmonary findings include_
Meningitis (neck stiffness, headaches, mental status change)
Brain abscesses (Focal sign, raised ICP)
Skin lesions (pustules, papules, plaques, nodules, ulcers, abscesses,
hemorrhagic lesions, mycetomas)
Rheumatologic and allergic findings
Pericardial rub

Complications
Disease dissemination to other sites ( brain, meninges, skin, liver,
spleen, kidneys, adrenals, heart, eyes) and sepsis syndrome.
Blood vessel invasion, which can lead to_
 Hemoptysis
 Pulmonary infarction
 Myocardial infarction
 Cerebral septic emboli
 Cerebral infarction
 Blindness.

Complications
Other complications may include the following_
Bronchopleural or Tracheoesophageal fistulas
Chronic pulmonary symptoms
Mediastinal fibromatosis (histoplasmosis)
Broncholithiasis (histoplasmosis)
Pericarditis and other rheumatologic symptoms

Investigation
Complete Blood Count
Imaging ( X-ray, CT scan, MRI of chest)
Microscopic Examination and Culture ( Sputum, BAL, Tissue)
Blood & Urine culture
Serology
Fiberoptic bronchoscopy
Biopsy & Histopathology

Complete Blood Count
Total white blood cell (WBC) count may be elevated in normal hosts
with endemic mycoses.
Eosinophilia can be observed in the differentials, particularly in persons
with coccidioidomycosis.
If the patient presents with neutropenia or leukopenia, the possibility of
an opportunistic infection with Candida, Aspergillus, Mucor
or Scedosporium organisms is increased.

Imaging (CXR)
Patchy Infiltrate, Nodules, Consolidation, Cavitation, or Pleural Effusion may be
observed.
Mediastinal adenopathy is common in patients with endemic fungal pneumonias.
The adenopathy may be either unilateral or bilateral.
In neutropenic patients infected with aspergillosis, pulmonary nodules surrounded by
ground-glass opacity called “halo sign” is a common finding.
Miliary infiltration occurs in patients with disseminated disease.

Imaging (CT scan)
CT chest plays a role in the early diagnosis of nonspecific infiltrates
in patients who are immunocompromised.
High-resolution chest computed tomography (HRCT) scanning
allows observation of the ‘halo sign’ in patients with aspergillosis.
Obtaining a CT scan of the abdomen and brain may reveal sites of
dissemination.

Imaging (MRI)
Magnetic resonance imaging (MRI) may reveal the haemorrhagic
content of Aspergillus lesions.

Microscopic Examination and Culture
Microscopic Examination show fungal hyphae or yeasts.
Culture media: Selective and non-selective.
But, the results must correlate with the clinical situation, because
saprophytic colonization occurs in the oropharyngeal or respiratory
tract of some patients and may not necessarily indicate invasive
infection.

Pulmonary Cryptococcal infection is confirmed if the organism is grown
in culture from sputum or BAL fluid in a patient who has clinical
symptoms and radiographic finding compatible with cryptococcosis.
Histoplasmosis is definitively diagnosed by growth of the organism in
sputum; BAL fluid, lung tissue, or mediastinal nodes can be cultured.
Pulmonary Sporotrichosis, the recovery of the fungi by culture of
sputum and/or positive bronchoscopy are required for diagnosis.

Cultures from sputum samples or collected by fiber optic bronchoscopy are
not valuable for the diagnosis of pneumonia by Candida.
To make the diagnosis, a biopsy is required to demonstrate tissue invasion.
Colonization of the respiratory tract by Candida is very frequent in critically ill
patients with mechanical ventilation, but pneumonia by Candida is extremely
rare because the innate defense mechanisms of the lungs make them relatively
resistant to candida invasion.

Fungal Culture Media

Blood & Urine culture
Obtain a blood fungal culture to identify Candida species (lysis
centrifugation) or Blastomyces dermatitidis if the patient has
disseminated disease.
Obtain a urine fungal culture in men after a prostatic massage, to
identify Cryptococcus or Blastomycosis species.

Serology
Enzyme immunoassay
ELISA
Latex agglutination
PCR-based assays

Fiberoptic bronchoscopy
Fiberoptic bronchoscopy (procedure of choice) is used to obtain
bronchial lavage specimens for staining and culture techniques and
transbronchial biopsy specimens for identification of fungal tissue
invasion.

Biopsy & Histopathology
Caseating or necrotizing granulomas with intracellular organisms
inside macrophages (eg, H capsulatum, C immitis).
Fungal hyphae in infection with Aspergillus, Mucor or
Scedosporium species.
Intracellular yeast organisms in Candida species infections.

Treatment
Specific treatment (Anti-fungal drugs)
Symptomatic treatment

Types of Anti-fungal drugs
Polyenes
Azoles
Echinocandins
Others
Flucytosine
Griseofulvin
Terbinafine

Anti-fungal drugs
Polyenes
Amphotericin B deoxycholate
Amphotericin B lipid complex
Liposomal amphotericin B
Nystatin
Echinocandins
Caspofungin
Anidulafungin
Micafungin

Azole anti-fungals
Triazoles (Systemic)
Fluconazole
Itraconazole
Voriconazole
Posaconazole
Isavuconazole
Imidazoles (Topical)
Miconazole
Econazole
Clotrimazole
Ketoconazole

Imaging of different Fungal pneumonia

Thank You

Fungal Pneumonia Diagnosis and Investigations

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