Cryptococcus (CID 2010;50:291)

Epidemiology: immunosupp. (esp. AIDS) most susceptible; can occur in healthy host,

esp. elderly, EtOH, DM. Consider C. gattii (typically in healthy host).

Clinical manifestations

CNS (meningitis): HA, fever, meningismus, ↑ ICP, CN abnl, ± stupor, often subacute.

Dx: CSF CrAg, India ink stain, fungal cx. Cell counts vary; serum CrAg >1:8 Se/Sp

in AIDS.

Other sites: pulm, GU, cutaneous, CNS cryptococcoma. With any crypto dx, LP all Pts.

Treatment

CNS: if ↑ ICP, repeat large-volume LPs or temp. lumbar drain; few require VP shunt

CNS Rx has induction (ampho ± flucytosine x2 wks), consolidation and maintenance

(fluconazole) phases (NEJM 2013;368:1291). If r/o CNS disease, then fluconazole. Dosing

and duration vary by host.

Non-CNS disease (pulm, skin, bone, blood) in HIV ⊖ Pts: consider fluconazole

Histoplasmosis (CID 2007;45:807)

Endemic to central & SE US, but sporadic cases throughout U.S.

Clinical manifestations

Acute: often subclinical, but may see mild to severe PNA ± cavitary & hilar LAN

Chronic pulm: ↑ productive cough, wt loss, night sweats, apical infiltrates, cavitation

Disseminated (typically in immunosupp.): fever, wt loss, HSM, LAN, oral ulcers, skin

lesion, fibrosing mediastinitis, reactive arthritis, pericarditis

Treatment: itraconazole (monitor levels); ampho ± steroids if severe or immunosupp

Coccidioidomycosis (CID 2016;63:112)

Endemic to SW U.S. (San Joaquin or “Valley” fever)

Clinical manifestations
Acute: 50–67% subclinical; PNA w/ cough, chest pain, fever, arthralgias, fatigue

Chronic pulm: nodule(s), cavity or progressive fibrocavitary PNA (can be asx or sx)

Disseminated (typically in immunosupp.): fever, malaise, diffuse pulmonary process,

bone, skin, & meningeal involvement

Treatment: monitor mild disease closely q3–6mo; for severe disease: fluconazole,

itraconazole or amphotericin

Blastomycosis (CID 2008;46:1801)

Endemic to south central, SE, and Midwest U.S.

Clinical manifestations

Acute: 50% subclinical; cough, multilobar PNA; can progress to ARDS

Chronic pulm: cough, wt loss, malaise, CT w/ masses & fibronodular infiltrates

Disseminated: (25–40% of all but ↑ in immunosupp.): verrucous & ulcerated skin

lesions, bone, & GU involvement; CNS rare unless immunosupp.

Treatment: itraconazole (monitor levels); ampho if severe, disseminated or immunosupp.