Systemic mycoses

These are systemic fungal infections - either endemic or opportunistic, generally only infecting those who are immunocompromised.¹²See also separate Pilzinfektionen der Lunge Artikel.

Endemic fungal infections

Histoplasmosis³

Histoplasmosis is linked to exposure to bird and bat droppings especially along the Ohio and Mississippi river valleys in the USA. It usually occurs as an atypical pneumonia, in the acute form appearing in epidemics with prostration, fever and respiratory symptoms.

• Progressive disseminated histoplasmosis - fever, dyspnoea, cough, loss of weight and prostration with hepatosplenomegaly. Usually fatal within six weeks.

• Chronic progressive pulmonary histoplasmosis is usually seen in older patients with chronic obstructive pulmonary disease (COPD).

• Disseminated disease when seen in the immunocompromised is usually due to reactivation of prior infection often seen in HIV infection.

Behandlung
Itraconazole for mild-to-moderate cases; amphotericin in severe cases or for those who fail on itraconazole.⁴

Coccidioidomycosis⁵

Coccidioidomycosis is caused by a mould that grows in the soil in Southwestern USA, Mexico and Central and South America. <1% of immunocompetent affected people suffer dissemination but in these cases mortality is high. 40% of primary infections are symptomatic, usually presenting with respiratory tract symptoms plus fever, with pleuritic pain. There may be arthralgia with swelling (often knees and ankles). Management: intravenous (IV) amphotericin for severe infections; in mild cases oral fluconazole or itraconazole continued for six months or longer.⁶Surgery may be needed to drain cavities or abscesses or to resolve diagnostic dilemmas in nodular disease.⁷

Pneumocystosis

Siehe separat Pneumocystis Jirovecii Pneumonie article. It is very rarely symptomatic in immunocompetent patients but, in immunocompromised patients (especially HIV), there can be abrupt onset of fever, tachypnoea, shortness of breath and non-productive cough. If untreated, there is rapid deterioration to death.⁸

• Aspergillose.⁹Siehe separat Aspergillose article. This is usually caused by Aspergillus fumigatus; patients with very advanced HIV infection are particularly at risk, mostly with pulmonary disease leading to severe necrotising pneumonia.

• Mucormycosis.¹⁰This was previously called zygomycosis. It is found in patients with predisposing conditions such as diabetic ketoacidosis, chronic kidney disease and immunosuppressant drugs. Treatment is surgical debridement under cover of amphotericin.

• Myzetom.¹¹Siehe separat Mycetoma (Madura Foot) article. This includes maduromycosis and actinomycetoma, which is a slowly progressive locally destructive infection beginning in subcutaneous tissues often after trauma, and spreading to contiguous structures. A maduromycosis is a mycetoma caused by true fungi. It may start as a papule, nodule or abscess and it progresses over months or years to form multiple abscesses and sinus tracts reaching deep into the tissue.¹²

• Blastomycosis.¹³This usually occurs in men working outdoors in certain areas of South, Central and Midwestern USA and Canada; it usually affects the lung but can disseminate to the skin, bones and urogenital tract. Symptoms include cough, fever, dyspnoea and chest pain. It may resolve or progress with bloody, purulent sputum, pleurisy, fever, chills, loss of weight and prostration. In disseminated form, there are raised verrucous skin lesions with an abrupt, downward-sloping border often seen.

• Paracoccidioidomycosis.¹⁴Also known as South American blastomycosis, it is only found in patients who have lived in South or Central Africa or Mexico and initially affects the upper respiratory tract. It usually appears with ulceration of the upper respiratory tract. Ulcers can coalesce to destroy the epiglottis, vocal cords and uvula. Eating and drinking are very painful. There may be skin lesions on the face.

• Sporotrichosis.¹⁵This occurs when the organism is inoculated into the skin during gardening. It usually causes a skin infection - a hard, non-tender, subcutaneous nodule which later ulcerates. Similar nodules then appear along the lymphatics draining the area.

• Chromoblastomycosis.¹⁶This is a mainly tropical skin infection, usually affecting agricultural workers and causing skin infections. It begins as a papule or ulcer, usually on a lower extremity, and enlarges over months or years to become a papillomatous, verrucous nodule.

• Cryptococcus neoformans.¹⁷Siehe separat Kryptokokkose article. This is a yeast found in soil and dried pigeon droppings. Infection is usually transmitted by inhalation. Immunodeficient patients develop progressive lung disease and dissemination. It can involve any organ but mainly the central nervous system. It often presents with meningitis.

• Kandidose. See separate Kandidose article. This is normally associated with predisposing factors - eg, neutropenia, antibiotic use, indwelling lines and abdominal surgery. It can cause candidaemia and disseminated candidiasis; also, deep focal candidiasis, in which it infects the peritoneum or meninges, is often implanted following dialysis or surgery.¹⁸