Fungal pneumonia is caused by fungi infecting the lungs. It can be caused by either endemic or opportunistic fungi. Symptoms include fever, cough, and difficulty breathing. Diagnosis involves imaging tests showing lung lesions, microscopic examination of respiratory samples detecting fungi, and culture of samples. Treatment involves antifungal medications. Complications can include dissemination of the infection to other organs.

1. 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

2. 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

3. 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).
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 3

4. 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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 4

5. Endemic Fungi
Histoplasmosis
Coccidioidomycosis
Blastomycosis
Para-coccidioidomycosis
Sporotrichosis
Talaromycosis (formerly penicilliosis)
Emergomycosis
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 5

6. Opportunistic Fungi
Cryptococcosis
Candidiasis
Aspergillosis
Mucormycosis
Non-aspergillus hyaline hyphomycetes
Dematiaceous (melanized) hyphomycetes
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 6

7. 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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 7

8. 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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 8

9. 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
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 9

10. 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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 10

11. 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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 11

12. 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).
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 12

13. Physical Examination
Signs and symptoms of fungal pneumonia are not specific and
are indistinguishable from those associated with respiratory
infections of other origins.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 13

14. Physical Examination
Physical examination findings may include_
Elevation of temperature
Tachycardia
Tachypnea
Respiratory distress
Rales
Signs of pulmonary consolidation
Pleural rub
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 14

15. Physical Examination
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
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 15

16. 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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 16

17. Complications
Other complications may include the following_
Bronchopleural or Tracheoesophageal fistulas
Chronic pulmonary symptoms
Mediastinal fibromatosis (histoplasmosis)
Broncholithiasis (histoplasmosis)
Pericarditis and other rheumatologic symptoms
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 17

18. 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
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 18

19. 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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 19

20. 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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 20

21. 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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 21

22. Imaging (MRI)
Magnetic resonance imaging (MRI) may reveal the haemorrhagic
content of Aspergillus lesions.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 22

23. 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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 23

24. Microscopic Examination and Culture
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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 24

25. Microscopic Examination and Culture
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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 25

26. Fungal Culture Media
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 26

27. 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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 27

28. Serology
Enzyme immunoassay
ELISA
Latex agglutination
PCR-based assays
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 28

29. 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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 29

30. 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.
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 30

31. Treatment
Specific treatment (Anti-fungal drugs)
Symptomatic treatment
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 31

32. Types of Anti-fungal drugs
Polyenes
Azoles
Echinocandins
Others
Flucytosine
Griseofulvin
Terbinafine
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 32

33. Anti-fungal drugs
Polyenes
Amphotericin B deoxycholate
Amphotericin B lipid complex
Liposomal amphotericin B
Nystatin
Echinocandins
Caspofungin
Anidulafungin
Micafungin
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 33

34. Azole anti-fungals
Triazoles (Systemic)
Fluconazole
Itraconazole
Voriconazole
Posaconazole
Isavuconazole
Imidazoles (Topical)
Miconazole
Econazole
Clotrimazole
Ketoconazole
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 34

35. Imaging of different Fungal pneumonia
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 35

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57. Thank You
DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 57