Dr. Walraven

Question 1

Which fungi are yeasts

Answer 1

• Candida

- Cryptococcus

Question 2

Which fungi are molds

Answer 2

• Coccidioidomycosis
• Histoplasmosis
• Aspergillus
• Mucormycosis

Question 3

Candida Epidemiology

Answer 3

• Most common cause of fungal infection
• Usually healthcare associated
• Mortality rate 40-50%

Question 4

Physical exam findings with Candida

Answer 4

• Skin lesions

- Muscle soreness

Question 5

Candida risk factors

Answer 5

• Catheters
• Broad spectrum abx
• Dialysis
• Parenteral nutrition
• Corticosteroids

Question 6

Candida Treatment Guidelines

Answer 6

-Echinocandins are first line therapy (2 week duration)
(Micafungin, Caspofungin, etc)
-Alternatives
1) Fluconazole-if not critically ill
2) AmB- if suspected azole or echinocandin resistance

Question 7

Management of Candidemia

Answer 7

• Remove catheters if possible
• Dilated opthalmological exam
• Repeat blood cultures

Question 8

Aspergillosis Epidemiology

Answer 8

• Ubiquitous mold
• Found all over the world
• Exposure via inhalation

Question 9

Aspergillosis Disease Spectrum

Answer 9

• Immunocompetent host = Allergic reaction (ABPA)
• Immune impairment = chronic necrotizing pulmonary aspergillosis (Fungal ball)
• Immune compromised = Acute invasive infection (lower RTI, dissemination to other tissues)

Question 10

Aspergillosis risk factors

Answer 10

• Prolonged neutropenia
• Stem cell or organ transplant recipient
• HIV/AIDS
• Chronic granulomatous disease

Question 11

Aspergillosis radiographic findings

Answer 11

• Halo sign (early stages)

- Air crescent sign (late phase)

Question 12

Aspergillosis Treatment Guidelines

Answer 12

• Voriconazole is first line treatment
• Alternatives
  1) Liposomal AmB
  2) Isavuconazole
• Echinocandins are NOTTTT recommended

Question 13

Histoplasmosis Epidemiology

Answer 13

• Dimorphic fungi
• Endemic to Ohio, Mississippi river valleys
• Grows in bird/bat droppings
• Found in abandoned buildings and caves

Question 14

Chest radiograph findings in Histoplasmosis

Answer 14

-Extensive upper lobe cavitary

Question 15

Treatment guidelines for Histoplasmosis

Answer 15

• Chronic mild to moderate infection
  1) Itraconazole (for non-sever infection)
  2) AmB or Fluconazole can be used as alternatives
• Moderate to severe/ CNS disease
  1) Lipid AmB followed by Itraconazole

Question 16

Coccidioidomycosis Epidemiology

Answer 16

-Endemic to the south west (CA, AZ, NM, TX, NV, UT)

Question 17

5 main clinical manifestations in Coccidioidomycosis

Answer 17

• Acute pneumonia
• Chronic progressive pneumonia
• Pulmonary nodules/ cavities
• Extra-pulmonary disease
• Meningitis

Question 18

Coccidioidomycosis clinical presentation

Answer 18

-Signs/symptoms are indistinguishable for CAP
(headache, fatigue, chest pain)
-More common in A.A, filipino, pregnant women

Question 19

Treatment guidelines for Coccidioidomycosis

Answer 19

• Fluconazole 400mg po qd
• Alternatives
  1) Itraconazole
  2) AmB (lipid or dex form)
• Do NOT treat asymptomatic patients

Question 20

Cryptococcus epidemiology

Answer 20

• Fungi

- Endemic to the west coast (CA, WA, OR, up into Canada too)

Question 21

Cryptococcus clinical manifestations

Answer 21

• Blunted immune response
• Pulmonary infection
• Cryptococcal meningitis
• Can infect ANY organ in the body

Question 22

Treatment Guidelines for Cryptococcus

Answer 22

• Mild to moderate disease
  1) Fluconazole
• Severe/ Cryptococcal meningitis
  1) AmB PLUS 5-FC x 2 wks
• maintenance fluconazole x 6 months

Question 23

Mucormycosis risk factors

Answer 23

• Major trauma
• Burn
• Diabetes
• Stem cell/ organ transplant
• Immunosuppression

Question 24

Clinical presentation of Mucormycoses

Answer 24

• Infarction and necrosis of host tissue
• Usually begins at nasal turbinates
• 90% mortality rate

Question 25

Treatment guidelines for Mucormycosis

Answer 25

-First line therapy
1) Surgical debridement PLUS
Lipid AmB 5 to 10mg/kg/day
-Alternatives
1) Posaconazole
2) Isavuconazole

Question 26

When to monitor drug levels for

Itraconazole, Voriconazole, Posaconazole and 5-FC

Answer 26

• All of the Azoles you check the trough after 4 days

- 5 FC check the PEAK after 3 days

Question 27

Why is there such a high morbidity and mortality rate with IFIs

Answer 27

• Because they are hard to diagnosis

- So your initial treatment may be incorrect

Question 28

How do you treat a sever Aspergillius infection?

Answer 28

-Lipid AmB 5mg/kg/day

Question 29

How do you treat a C. glabrata infection?

Answer 29

• C. glabrata can have acquired resistant to azoles

- Do susceptibility testing to see if you can use an azole, if not use AmB