Fingal & Viral Infections

Question 1

How is CMV pneumonia best diagnosed? How about in lung transplants?

Answer 1

Usually, diagnosed by identifying CMV inclusion cells from BAL or lung biopsy. In lung transplants, PCR from BAL is acceptable.

Question 2

How does aspergillus lung disease present in:

• Normal lungs?
• Cavitary lung lesions?
• Chronic lung dz or mild immunosuppression?
• Immunocompromised?
• Asthma

Answer 2

• Normal = no sequelae
• Cavitary = aspergilloma
• Chronic lung dz / mild immunosupp = Chronic necrotizing aspergillosis
• Immunocompromised = invasive pulmonary aspergillosis
• Asthma = ABPA

Question 3

What are symptoms of invasive pulmonary aspergillosis?

Answer 3

• fever, cough, sputum, dyspnea
• vascular invasion: hemoptysis, pleurisy, infarcts
• hematogenous spread to brain

Question 4

What is a typical CT finding for invasive pulmonary aspergillosis?

Answer 4

Halo sign, air-crescent sign (aspergilloma), multiple nodules

Question 5

What is the treatment for invasive pulmonary aspergillosis?

Answer 5

Voriconazole

Question 6

What is the prophylaxis against invasive pulmonary aspergillosis? Who needs it?

Answer 6

• Posaconazole.

- AML, MDS, GVHD

Question 7

Patient has chronic lung disease or mild immunosuppression, and CAP that “just won’t go away”. What do they have?

Answer 7

Chronic necrotizing pulmonary aspergillosis.

Question 8

What are the treatment options for chronic necrotizing pulmonary aspergillosis?

Answer 8

Voriconazole, amphotericin B, itraconazole, caspofungin.

Question 9

What is the typical imaging finding of an aspergilloma?

Answer 9

Fungus ball that moves w/in a cavity

Question 10

What are the treatment options for aspergilloma?

Answer 10

• Asymptomatic: observation
• Itraconazole (60% effective)
• Surgical resection
• Bronchial artery embolization if hemoptysis

Question 11

What underlying diseases are required to have ABPA?

Answer 11

Asthma or CF

Question 12

What is the treatment of ABPA?

Answer 12

Steroids, +/- itraconazole

Question 13

What is the diagnosis for ABPA?

Hint: Major/minor diagnostic criteria

Answer 13

1. Must have asthma or CF
2. Major criteria (must have both)
   - IgE > 1,000
   - Aspergillus skin test or Anti-Fumagitus IgE
3. Minor criteria (2 of 3)
   - Fumigatus IgE
   - Radiographic pulmonary opacities
   - Eosinophils >500

Question 14

Where is blastomycosis found?

Answer 14

Mississippi valley, eastern US

Question 15

What is the first and second most common symptom of blastomycosis?

Answer 15

1st: recurrent pneumonia
2nd: skin lesion (verrucous, ulcerative)

Question 16

How is blastomycosis diagnosed?

Answer 16

Antigen detection from urine, serum, or BAL.

False positive with histo or other fungi

Question 17

Dogs can get what pulmonary pathogen and share with humans?

Answer 17

Blastomycosis

Question 18

What does blastomycosis look like on microscopy?

Answer 18

broad-based budding

Question 19

What is the treatment of blastomycosis?

Answer 19

• Severe: amphotericin B for 1-2 weeks, then itraconazole
• Mild-moderate: itraconazole for 6-12 months
• CNS Dz: Amphotericin B
• Pregnant: Amphotericin B (avoid azoles)

Question 20

What Candida species is usually resistant to antifungals?

Answer 20

Candida Glabrata

Question 21

What Candida species is usually catheter related?

Answer 21

Candida Parapsilosis

Question 22

What Candida species is seen in neutropenics & what is the resistance pattern?

Answer 22

Candida Krusei.

Intrinsic azole resistance, but also resistant to Amphotericin B.

Question 23

What is the treatment for systemic candida infections in general?

Answer 23

Echinocandins first, the ntransition to azoles if susceptible. Treat for 2 weeks.
-Remove catheters.

Question 24

What are the skin manifestations of coccidiomycosis?

Answer 24

Erythema Nodosum

Question 25

How is coccidiomycosis diagnosed?

Answer 25

Antibody ELISA testing, or culture

Question 26

What is treatment for coccidiomycosis?

Answer 26

If immunocompetent, observe for first 6 weeks. | If immunocompromised, use fluconazole or amphotericin B.

Question 27

What body systems to cryptococcus infect?

Answer 27

Lungs & CNS

Question 28

What is the treatment of cryptococcus neoformans infections?

Answer 28

If pneumonia, fluconazole. | If CNS infection, flucytosine + amphotericin B

Question 29

Where is histoplasmosis found? What is the reservoir?

Answer 29

Soil, bird/bat droppings in eastern US (Indiana)

Question 30

What fungal infections can be PET (+) on imaging?

Answer 30

Histoplasmosis

Question 31

HIV (+) patients get what advanced disease from histoplasmosis?

Answer 31

Broncholithiasis, fibrosis mediastinitis, dissiminated histo.

Question 32

What is the treatment for histoplasmosis?

Answer 32

Mild or chronic: observation Moderate: Itraconazole Severe: Amphotericin B

Question 33

What are the imaging findings of mucormycosis pneumonia?

Answer 33

multiple pulmonary nodules, pleural effusion | vs invasive pulmonary aspergillosis, which does nto have effusion

Question 34

What is the histology of mucormycosis?

Answer 34

filamentous, ribbon, pauci-septated hypae, branching at 90 degrees

Question 35

what is gold standard for diagnosis of mucormycosis?

Answer 35

culture

Question 36

What is treatment for mucormycosis?

Answer 36

- Amphotericin B is first line. Posaconazole and isovuconazole also approved. - Combo of antifungals, surgical resection/debridement, immune reconstitution - Stop deferoxamine, it is siderophore for mucor.

Question 37

Does HIV (+) or (-) patients have more acute PJP?

Answer 37

HIV negative have more severe disease.

Question 38

What is treatment for PJP pneumonia?

Answer 38

3 weeks of bactrim | -Add steroids if A-a > 35.

Question 39

What is morphology of aspergillus?

Answer 39

Acute, branching hyphae