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Trop Med > Fungi > Flashcards

Fungi Flashcards

1
Q

Specific cocci treatments?

A

Diffuse primary pneumonia and chronic pneumonia
- begin with AMB for diffuse dz. Otherwise, azole therapy.

Disseminated non-meningeal disease, depending on severity
- AMB initially, then azole drug
- AMB plus azole
- Itraconazole or posaconazole alone

Coccidioidal meningitis
- Fluconazole alone
- AMB intrathecal plus fluconazole
- Voriconazole for those who cannot tolerate fluconazole

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2
Q

Organisms most responsible for chromoblastomycosis?

A

Fonsecaea pedrosoi

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3
Q

Targets for fungal treatment?

A

Polyenes - amphoterecin

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4
Q

What animals transmit histoplasmosis?

A

Bats and birds, grows in soil enriched with faeces of bats and birds. Birds are not infected, bats are.

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5
Q

What azoles can be used to treat zygomycetes?

A

Posiconazole
Isavuconazole

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6
Q

What is an endemic fungi?

A

Organisms restricted to geographic or climatic environments

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7
Q

Disease forms of paracocci?

A

Acute/sub acute or juvenile - rapidly progressive (less common)
Chronic or adult - develop over years - long latency period and reactivation

3 spectrum of disease
- Acute
- chronic in immunocompetent (reactivation)
- chronic in immunocompromised (reactivation)

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8
Q

First choice azole for candidiasis both invasive and non invasive?

A

Fluconazole
(Voriconazole second line)

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9
Q

What is the epidemiology for sporotrichosis?

A

Peruvian highlands, urban Brazil

Enriched soil and decaying veg matter

Classic men in manual labour

Must have a skin trauma

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10
Q

Rx of cryptococcosis?

A

Fluconazole
2nd line vori

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11
Q

Classic feature of sporotrichosis?

A

Follows lymphatics, painful

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12
Q

Which deep fungi do you need to go to an endemic area to contract?

A

Histoplasmosis, paracocci

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13
Q

Diagnosis of PCM?

A

Direct microscopy from scrape of lesion, KOH preparation
Round yeast cell with peripheral budding (MM)

Can also do histopathology preparation, antibody detection using ELISA

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14
Q

What is the presentation of extracutaneous sporotrichosis?

A

VERY RARE
Pulmonary
CNS

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15
Q

What can use anidulafungin to treat?

A

Fungical activity against Candida; static vs Aspergillus
species; intermediate activity against dimorphic fungi
(Histoplasma, Blastomyces; Coccidioides)

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16
Q

Side effect of posiconazole?

A

Analogue of itraconazole so very similar (heart failure)

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17
Q

Skin lesions in paracocci?

A

Predominantly on face
Pleomorphic - papules, vesicles

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18
Q

What is this?

A

Sporotrichosis

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19
Q

Where do -Azoles work? How?

A

Cell membrane
Azoles inhibit the synthesis of ergosterol by blocking
demethylation of lanosterol

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20
Q

What are the deep fungal infections?

A

Histoplasma capsulatum
Cryptococcus neoforman
Paracoccidiodomycosis
Aspergillus fumigateurs

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21
Q

What is the test for cryptococcal?

A

Culture - india ink
CRAG antigen
DOESN’T stain

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22
Q

Problem of voriconazole comparative to fluconazole?

A

Visual disturbances
Hepatotoxicity
Skin rash, photosensitivity
Drug interaction

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23
Q

What are the CXR findings of Paracocci?

A

Unilateral patchy infiltrate. Less common, dense lobar or segmental infiltrate with atelectasis.
Can cause CAVITIES
Hilar and/or
mediastinal adenopathy often present.

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24
Q

Name the diagnosis

A

Mickey Mouse and ships wheel - paracocci

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25
Q

What is the difference in skin test results for acute and chronic forms of paracocci?

A

Acute: skin test -ve (this form found in HIV)
Chronic: skin test +ve

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26
Q

What is the fungus causing mycetoma?

A

Madurella mycetomatous

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27
Q

Which stains use to look for fungi?

A

PAS stain and silver stain (stain dark)

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28
Q

What are the disadvantages of Amphotericin B Deoxycholate?

A

Only available as a parenteral form (recently developed oral agent not approved yet)

Significant infusion-associated toxicity including: fever, rigors, chills,
hypotension, dyspnea

Significant renal toxicity: decreased GFR, hypokalemia,
hypomagnesemia

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29
Q

What other tests can you do in histoplasmosis apart from culture?

A

Antigen detection in urine (90% sens) and blood (50% sens)

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30
Q

What does lobomycosis look like?

A

Keloid, big blobs, can be found anywhere

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31
Q

What fungus always use echinocandins for?

A

Candida

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32
Q

Which fungal infection should you always think of when you think of eosinophilic pneumonia?

A

Cocci

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33
Q

Main side effect of ketoconzole?

A

Hepatic toxicity

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34
Q

Pattern of mucosal lesions in paracocci?

A

Soft and hard palate, anterior lesions, very painful and bleed
Ulcerative, yellow white granulations with haemorrhagic dots
Not in nose
(Differs to leishmania)

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35
Q

What is thermal diamorphism?

A

Fungi that grow as yeast at body temp and mould at lower temps (25-30).

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36
Q

What type of skin lesions are classical seen in histoplasmosis?

A

Papular lesions, different to palpate to varicella

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37
Q

What do you think of re: side effects for Ampho B?

A

Toxicity
Nephrotoxicity + low K and Ca - dose related, always occurs

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38
Q

Presentation clinically of cocci?

A

Most asymptomatic
40% flu like illness
Erythema nodosum - classic - can also have erythema multiform and disuse rash

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39
Q

Indications for histoplasmosis therapy

A

-Acute severe pulmonary disease – steroids may be
helpful

– Chronic pulmonary disease: AMBd rarely necessary

– Mediastinal granuloma – ITRA may be effective

– Fibrosing mediastinitis – No Rx effective

– Duration of therapy for uncomplicated disease is at
least 6 months, but may extend for >12 months for
PDH

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40
Q

Flucytosine uses

A

Always used with another agent (resistance)
Oral only
90% excreted in urine - can be used for candiduria

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41
Q

First line Rx for invasive candida?

A

Echinocandin

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42
Q

What is the classic presentation of Disseminated Coccidioidomycosis?

A

Asymptomatic primary infection
Skin
Lung
Joint
CNS

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43
Q

Risk factors for Disseminated Coccidioidomycosis?

A

Immunosuppressed
Male
African and phillipino
Age >60
Pregnancy

(Black people tend to present with bone disease, filipino tend to present with meningitis)

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44
Q

Difference on histopathology between acute and chronic PCM?

A

Chronic - less necrosis, see yeast structures, epithelioid granulomas
Acute - extensive necrosis, multiple yeast cells, less granulomas

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45
Q

Where do you find paracocci? And in who?

A

Latin and South America, significant rainfall and humid, 1000m upwards from sea level

Common in FARMERS (tobacco etc)
Male predominance (oestrogen protecitive)

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46
Q

What organisms causes coccidiodomycosis?

A

Coccidioides immitis (only found in California) and C. posadasii

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47
Q

How does terbinafine work?

A

Same as azoles

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48
Q

Whats this?

A

Lobomycosis - lacazia loboi

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49
Q

What is the disadvantage of cryptococcus treated with itraconazole?

A

Does not penetrate CNS well

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50
Q

What is the diagnosis?

A

Acute (juvenile) paracocci

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51
Q

Benefits of fluconazole?

A

Given once a day
Orally or parenterally
Good bioavailability - never have to give IV
Fewest drug-drug interactions

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52
Q

Treatment of PCM?

A

Itraconazole BEST for initial Rx

Duration of Rx 6-12 months

Acute form or adult form with significant resp involvement - amphoterecin B

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53
Q

Route of acquisition of cocci? Site of disease?

A

inhale fungi
Lung -> skin, bone, joint, meninges

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54
Q

Fluconazole Rx of choice for what?

A

Urinary fungal infection (only one that is excreted in urine)
CNS infection (70% crosses into CNS)

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55
Q

Life cycle of Cocci

A

an arthroconidium enlarges into a large spherule
(up to 120 mm) which in turn internally segments into
many small endospores (2-4 mm). Ruptured spherules
release endospores into tissue; endospores develop into spherules; and cycle repeats itself.

56
Q

Rx of aspergillosis?

A

Voriconazole
2nd line posi

57
Q

What are the species for paracocci?

A

P.brasiliensis, P.lutzii
Dimorphic fungus
Mould <28 deg
Yeast >36 deg

58
Q

What are the echinocandins?

A

Anidula, mica, caspo fungin

Molecular structure very similar

Large molecules so do not penetrate CNS/urine/eye

59
Q

How can you test for aspergillus?

A

Aspergillus antigen/antibody

60
Q

Endemic areas for cocci?

A

Areas in which the organism inhabits the soil, between
latitudes of 40oN and 40oS in Western Hemisphere.
In North America, places with hot summers, mild winters

61
Q

What is this?

A

Melanised fungi - copper pennies
Chromoblastomycosis

62
Q

Transmission of paracocci?

A

Respiratory route, inhalation
Dimorphic fungus - becomes yeast in body (body temp)
Pulmonary and systemic manifestations

63
Q

What is the most common histoplasmosis species and which species is found in Africa?

A

H.Capsultum
H. Dubosii

64
Q

Benefits of terbinafine?

A

VERY BROAD spectrum
First line for dermatophytes (microspora)

65
Q

What is histoplasmosis? Where is it?

A

Thermally dimorphic - Histoplasma capsulatum

North and Latin America in moist environments - not in coast of peru.

66
Q

Juvenile paracocci symptoms?

A

Hepatomegaly, splenomegaly, lymphadenopathy, pancytopenia
Rapidly progressive

67
Q

Spectrum of 5FC?

A

Active against yeasts - candida, crypto

Excellent for chromoblastomycosis - mono or combined therapy

68
Q

Who gets progressive disseminated histoplasmosis?

A

Immunocompromised
Non-immunosuppressed middle-aged to older adults - mainly males

69
Q

What is meant by the term Disseminated Coccidioidomycosis?

A

Any infection that is not pulmonary

70
Q

Difference between PCM and leish? What are the other ∆∆?

A

Leprosy, tertiary syphylis, cancer, histoplasmosis, sarcoid

71
Q

What is the treatment of choice in cocci?

A

Itraconazole 200 mg bid - RX of choice - often lifelong

Alternatives:
Fluconazole 400 – 800 mg q d
Posaconazole 300 mg qd

AMBd 0.5 – 1.0 mg/kg/d or LFAmB 3-5 mg/kg/d IF SEVERE DISEASE

72
Q

What is this?

A

Paracocci

73
Q

Typical mouth lesions in paracocci?

A

Small lesions, anterior, tooth involvement, red dots***

74
Q

What is the benefit of liposomal ambisome/Amphoterecin B lipid complex?

A

Equal in efficacy, better side effect profile (SAFER NOT MORE EFFICACIOUS)

Renal protection!!!

75
Q

What are the differential diagnoses of sporotrichosis? Sporotrichoid pattern…

A
  • Non-tuberculous mycobacteria (esp MAC,
    M chelonae, M marinum, M ulcerans)
  • Cutaneous nocardiosis (esp N. brasiliensis)
  • Leishmaniasis in the Americas
  • Other endemic fungi (histo, crypto, blasto)
  • Bacteria causing fixed ulcers (eg, S. aureus, F.
    tularensis, B anthracis)
76
Q

Can you use echinocandins to Rx CNS disease?

A

No - vert weak penetration

77
Q

What is this?

A

Chromoblastomycosis

78
Q

How do you treat histoplasmosis?

A

Itraconazole in mild to moderate disease

If disseminated, need LFAmB for 2 weeks first

79
Q

What are the superficial fungal infections of importance?

A

Sporotrichosis - sporothrix schenckii
Lobomycosis
Mycetoma
Chromoblastomycosis

80
Q

32 year old male with advanced HIV with this rash, fungi on microscopy. Which?

A

Histoplasmosis

81
Q

What is this?

A

Histoplasmosis
Hyphae, small - need Giemsa stain
Species lives in cytoplasm of macrophages (histiocytes)

82
Q

How does ampho B work?

A

Amphotericin B binds to fungal membrane sterols (ergosterol), alters permeability to K+ and Mg2+

Causes a pore, causes the fungus to leak, fungicidal

83
Q

Name 2 diamorphic fungi

A

Cocci
Histoplasmosis

84
Q

What causes sporotrichoidosis?

A

sporothrix schenckii

85
Q

What is the causative organism in blastomycosis? Where do you find it?

A

Blastomyces
dermatitidis
Mainly North America

86
Q

Rx of blastomycosis, histo, paraccoci and sphoro?

A

Itraconazole
2nd line posi or vori

87
Q

What is SSKI and what is it used for?

A

Super saturated Potassium iodide
Sporotrichosis first line (only one)

88
Q

Treatment of Sporo?

A

Potassium iodide local Rx- Associated with nausea and vomiting, lacrimation,
distorted taste, rash. Least expensive, but very effective
Often used in endemic areas

Itraconazole 200 mg BD for 3 months

89
Q

What tests are available for cocci?

A

Culture
Histopathology stain
IgG and IgM very useful

90
Q

What makes one azole better than another azole?

A

Affinity to the enzyme which blocks demethylation of lanosterol

91
Q

What is the organism for chromoblastomycosis?

A

Fonsecaea pedrosoi

92
Q

What can you not treat with anidulafungin etc?

A

NOT active against Cryptococcus, Fusarium,
Paecilomyces, Trichosporon or Zygomycetes

93
Q

What is this?

A

Cocci - Identification of spherules by special
stains

94
Q

35 year old with HIV with CD4 of 24 presenting with cough and SOB?

A

Histoplasmosis

95
Q

What are the benefits of voriconazole/posiconazole?

A

Aspergillus treatment (why they were developed, itraconazole not good)

96
Q

Disadvantage of echinocandin?

A

Can only be given IV

97
Q

What is this?

A

Aspergillosis (mould not yeast, see branching hyphae)

98
Q

Tongue biopsy for a patient with tongue lesion

A

Histoplamsosis
Very small organisms
No capsule

99
Q

What is the main organism causing paracocci?

A

Paracocci Brasiliensis

100
Q

What is the treatment of choice for blasto, histo, sporo, and non-CNS cocci?

A

Itraconazole

101
Q

What is cryptococcal neoformans? Where from?

A

Encapsulated yeast
Chickens and birds

102
Q

Tests for histoplasmosis?

A

Culture, microscopy, histo antigen urine test
Can do bone marrow Bx/blood culture too

103
Q

Bone marrow biopsy of patient with rash and 5 months hx of weight loss and cough

A

Histoplasmosis

104
Q

Side effects of flucytosine?

A

GI
Hepatic mild enzyme derangement
Bone marrow suppression
Skin rash

105
Q

What must you do if you suspect cocci and want to test for it?

A

Notify lab that Coccidioides spp. is suspected
clinically.

106
Q

How do echinocandins work?

A

inhibit (1,3)-beta-D-glucan
synthase, which forms
glucan polymers in the
cell wall

The cell wall is not present in mammals therefore VERY LOW TOXICITY

107
Q

Fluconazole side effects?

A

Rash
Deranged LFTs
GI upset

VERY WELL TOLERATED

108
Q

What are the clinical features of blastomycosis?

A

Almost always pulmonary plus else where - pretty much always disseminates!

Disease manifestions are pulmonary (60-80%),
skin (40-60%), osseous (20-30%), genitourinary
(10%), and CNS (<5%)

A great mimicker!

109
Q

Pulmonary involvement in paracocci?

A

Non specific symptoms - cough,haemoptysis, SOB
Bilateral infiltrates on CXR

Cavitating lesions and pleural effusions - NOT COMMON

110
Q

How does it appear on microscopy?

A

Yeast colonies appear, variable size, mother cell surrounded by multiple buds
Mickey mous apparence, ships wheel

111
Q

Paracocci: Difference in presentation between acute and chronic forms?

A

Acute: fever, lymphadenopathy, HSM, skin lesions
Chronic: lung disease, oral mucosal symptoms

112
Q

What is this?

A

Histoplasmosis

113
Q

How is histoplasmosis transmitted?

Principal sites of disease?

A

Respiratory - inhalation of spores

Lungs, LNs, liver, spleen, bone marrow

114
Q

What is this?

A

Blasto
Blastomyces Dermatididis
broad-based budding yeasts
Diagnosis can only be made with culture really

115
Q

Which superficial fungi does not stain - have to culture it?

A

Sporotrichosis

116
Q

What is ideal test available for histoplasmosis?

A

Culture from blood or body fluids - may take 6 weeks to be positive

117
Q

What is used to treat aspergillus first line?

A

Voriconazole (main difference to intra)

Both vori and itra Rx most fungi

118
Q

First choice azole for cocci?

A

Itra or fluconazole for non-meningeal
Fluconazole for meningeal

119
Q

Benefits of posiconazole?

A
  • Fungicidal against Aspergillus, Scedosporium
  • Highly active against Zygomycetes; less active
    against Fusarium species

HAS THE BROADEST SPECTRUM

120
Q

What is this?

A

Sporotrichosis
Sporotrichoid pattern
Lymph drainage pattern but does not involve lymph nodes
Can involve the face in KIDS

121
Q

Side effects of itraconzole?

A

Heart failure (fluid retention massive side effect) and liver toxicity
Loads of drug drug interactions

122
Q

What is this

A

Cryptococcal - india ink stain

123
Q

What is this?

A

PAS stain
Mycetoma

124
Q

Cauliflower like lesion on foot. Diagnosis and organism?

A

Fonsececa petrosi

125
Q

What is this? taken from skin lesion on foot

A

Lacazia loboi

126
Q

Organomegaly, cutaneous lesions, ora ulcersl, lung involvement from the jungle. Pancytopenia, LDH raised. Miliary pattern on CXR. Diagnosis?

A

Histoplasmosis

127
Q

Fungi that cause eosinophilia

A

Cocci
Aspergillosis

128
Q

55 yr old Indian man with facial swelling and a black lesion in mouth, microscopy shows this, diagnosis?

A

Zygomyces
Mucourmycosis

Broad aseptate 90 degree branching

129
Q

Which environment does mucour like? Who does it affect?

A

low pH, high glucose
Affects diabetics (chronic)
Immunosuppressed/on steroids/haematology pt progresses rapidly

130
Q

Fungi causing mucor?

A

Mucourale species
Zygomyces

131
Q

Most common location for mucor?

A

Rhinocerebral/oral (diabetics)
In other imm suppressed can cause GI/pulmonary/cutaneous

132
Q

Presentation of rhino-orbital-cerebral mucormycosis?

A

Facial pain, swelling, periorbital oedema
Osteomyelitis, cavernous sinus thrombosis, cranial nerve problems.
Palatine ulcers - black
Cerebral ulcers

133
Q

Management of mucor?

A

Debridement
Ampho B
Control predisposing factor e.g. T2DM

134
Q

What is this?

A

Talaromyces marneffei

135
Q

What is the reservoir for talaromyces? Transmission?

A

Spread by the Bamboo rats
Rainy season, soil, inhalation

136
Q

Who gets talaromyces? And where?

A

SE Asia - China. Immunocompromised.

137
Q

Symptoms of talaromyces?

A

Skin lesions - umbilicated
Hepatosplenomgaly, lymphadenopathy, fever

Trop Med (49 decks)

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