Fungal infections

Question 1

what are fungal infections?

Answer 1

Common mild superficial infections to severe invasive life threatening infections

Question 2

what is the burden of fungal infections?

Answer 2

Difficult to determine as many mild infections go undiagnosed such as athletes foot, ringworm.

> 1 billion people affected
11.5 million life threatening infections
1.5 million deaths annually

Question 3

who is susceptible to opportunistic fungal infections?

Answer 3

Patients with impaired immune system
Primary immunodeficiencies
HIV/AIDS
Malignancy and transplants
Premature neonates- immature immune system

Chronic Lung diseases (Aspergillosis and moulds )
Asthma
COPD
Cystic Fibrosis
Sarcoidosis
Patients in ICU –particularly on artificial ventilation

Question 4

what are the two main types of funal skin infections in the UK?

Answer 4

2 main Types fungal skin infections UK

Candidasis
Yeast like infection
Uniform commensal of mouth/GI tract
Opportunistic Infection

Tinea
Superficial Skin infections caused by Dermatophytes

Question 5

what is candida fungal infections?

Answer 5

Not part of normal skin flora

Asymptomatic until disruption (Lowering of immune system or mucosal barriers disrupted)

Non life threatening mucotaneous infections to severe invasive disseminated disease

Risk factors-
Moist areas, skin folds, obesity, diabetes, neonates, pregnancy, poor hygiene, occupation in wet environments, recent broad spectrum antibiotic

Question 6

what are symptoms and risk factors for genital cendidiasis?

Answer 6

Symptoms
Itch
Soreness and burning discomfort
Dysuria
Vulval oedema, fissures and excoriations
Cottage cheese/ white curd discharge
Bright red rash

Risk Factors
Just before and during menstruation
Obesity
Diabetes
Iron deficiency anaemia
Immunodeficiency
Recent course of broad spectrum antibiotic
High dose combined OCP /Oestrogen based HRT
Pregnancy

Non-specific Balanitis – Inflammation of Glans Penis
Bacterial or candida infection
If candida: treatment with topical clotrimazole
Good hygiene

Question 7

how is genital candidiasis diagnosed?

Answer 7

Diagnosis
Clinical
Vaginal Swab

Question 8

how is genital candidiasis managed?

Answer 8

Management
Clotrimazole- Topical antifungal pessary or cream
Oral treatment –Fluconazole
Supportive measures- Loose clothing, avoiding soap or bubble baths to wash

No evidence for probiotics or treating sexual partner

Question 9

what are risk factors for oral candidiasis?

Answer 9

Risk factors
Extreme of ages
Immunocompromised
Inhaled or oral corticosteroids
Broad spectrum antibiotics
Diabetes
Dental prosthesis
Smoking
Poor oral hygiene
Local trauma
Nutritional deficiency
Impaired salivary function

Question 10

what are symptoms of oral candidiasis?

Answer 10

Symptoms
White or yellow plaques in mouth
Mild burning
Erythema
Altered taste
‘’Furry Tongue’’
If chronic can cause dysphagia

Question 11

what is the management of oral candidiasis?

Answer 11

Management
Topical Anti-fungal
Nystatin
Miconazole gel
If extensive-oral Fluconazole

Smoking cessation
Good Oral Hygiene

Question 12

what are systemic candida infections?

Answer 12

Occurs in Immunosuppressed
HIV
Malignancy
Chemotherapy
Other risks:
recent abdominal surgery
Renal failure
Low birth weight infants
Neutropoenia
Diabetes

Candidemia (Bloodstream)

Can affect any body part – therefore presentation can vary
Typically fever and chills doesn’t respond to antibiotics

Question 13

what is invasive candidiasis?

Answer 13

Gut commensal
Infections mostly endogenous of origin
4th most common bloodstream infection (BSI) in adults: 30/100.000 admissions
Premature neonates (< 1000 g): 150/100.000 admissions
Mortality up to 40%
If concern in primary care admit to hospital
Diagnosis- Blood cultures
Requires IV/Oral antifungals

Question 14

what is tinea?

Answer 14

Caused by
Diorect spread from nfected individual or animal
Indirect contact with objects/materials which carry infection e.g bedding, clothing
Rare- contact with soil

Risk Factors:
Hot humid environments
Obesity
Tight fitting clothing
Immunocompromised
Hyperhidrosis (excess sweating )

Question 15

how is tinea diagnosed?

Answer 15

Clinical
Scaly itchy skin
Examination :
Single or multiple flat/slight raised annular patches
Typical central clearing
Asymmetrical distribution

Investigations not normally required primary care

If uncertainty – Skin scrapings or skin swab if pustular/macerated

Question 16

how is tinea managed?

Answer 16

Supportive – Loose fitting clothing , good hygiene, don’t share towels, washing clothes and bed linen frequently

Patient information leaflets

Topical Anti-fungal cream

If extensive and positive culture or strong clinical suspicion –oral terbinafine first line or itraconazole if not tolerated- Require 4 weeks of treatment

Dermatology review if extensive or persistent infection

Question 17

what is the diagnosis and management for a fungal nail infections?

Answer 17

Diagnosis – Nail clippings

managment
Conservative can do nothing – if left untreated not harmful infection
Keep nails trimmed short and well fitting shoes
Cotton absorbent socks
Topical Nail Lacquer- amorolifine 5% nail lacquer – treatment for 6 months fingernails and 9-12 months toenails
Oral terbinafine -6-12 weeks fingernails and 3-6 months for toenails- need to monitor LFTS

Question 18

what is aspergillus?

Answer 18

Type of mould
Found in:
soil, compost and other organic matter
dust and bedding
damp buildings
air conditioning systems and uncovered attic water tanks
Transmission: Inhalation by spores
Rare in healthy individuals
At risk underlying health conditions: CF, COPD, TB, Sarcoidosis or weakened immune system

Question 19

what does aspergillus cause>

Answer 19

aspergillosis

Question 20

what are symptoms of aspergillosis?

Answer 20

Symptoms
Cough
Sob
Wheeze
Pyrexia
General malaise
Headache

Question 21

what are types of aspergillosis?

Answer 21

Allergic bronchopulmonary aspergillosis

Chronic pulmonary aspergillosis

Aspergilloma

Invasive pulmonary aspergilliosis

Question 22

what is allergic bronchopulmonary aspergillosis?

Answer 22

Commonest in Asthma and CF
Due to allergic response to aspergillus mould
Longstanding cough>3weeks

Complications: can lead to pulmonary fibrosis

Patients clinical condition deteriorating e.g in asthma or C.F
Failure to respond to normal treatment
Longstanding cough>3weeks

Question 23

how is Allergic Bronchopulmonary Aspergilliosis diagnosed?

Answer 23

Bloods- eosinophilia
Sputum culture
Positive skin test for aspergillosis
Positive serology for Aspergillus spp.
CXR/CT Scan

Question 24

how is Allergic Bronchopulmonary Aspergilliosis managed?

Answer 24

Oral long term high dose oral prednisolone

Anti fungal treatment of Itraconazole also of benefit

Question 25

what is chronic pulmonary aspergillosis?

Answer 25

> 3months

Affects patients with underlying lung conditions

High Morbidity

Presentation :

Exacerbations not responding to antibiotics
Decline in lung function
Increased respiratory symptoms- cough, decreased exercise tolerance and S.O.B

Diagnosis

Primary care- sputum culture and refer for CXR
Referral to secondary care for diagnosis and management

Management – Guided by secondary care with oral anti-fungals

Question 26

what is aspergilloma?

Answer 26

A fungal mass – grows in lung cavities

At risk:
TB
Sarcoidosis
Bronchiectasis
After pulmonary infection
Bronchial cyst or bullae

Question 27

how does aspergilloma present?

Answer 27

Haemoptysis-commonest presentation
Cough and fever less frequent
Asymptomatic- identified on CXR

Ix: CXR- Mass with pulmonary cavity

Referral to secondary care
CT scan
Management may be surgical resection and long term antifungal

Question 28

who is at risk of Acute Invasive Pulmonary Aspergilliosis ?

Answer 28

Neutropenic patients
Post transplant (stem cell highest risk)
Patients with defects in phagocytes

Question 29

what is the presentation of Acute Invasive Pulmonary Aspergilliosis ?

Answer 29

Any organ can be involved
Cough, SOB
Fever
Haemoptysis
Pleuritic chest pain
Nasal congestion and pain – sinusitis develops

Can spread haematogenous
Kidneys, brain , thyroid, GI tract, eyes, skin
Therefore clinical presentation can vary

Can present as persistent febrile neutropoenia despite broad spectrum antibiotics.

High Mortality rate 50%

Management is IV anti –fungals.