OPPORTUNISTIC SYSTEMIC MYCOSIS

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Aspergillosis Systemic candidosis Cryptococcosis Pneumocystis carinii infection Penicillium marneffi and others

Aspergillosis
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> 100 spp of Aspergillus but only a few implicated in human disease Most important: - A. fumigates - A. niger - A. flavus - A. terreus - A. nidulans All are mycelial fungi with septate hyphae and distinctive sporing structures: ie: - The spore-bearing hyphae (conidiophores) terminates in a swollen vesicle surrounded by 1 to 2 rows of cells (sterigmata) From sterigmata are produced chains of asexual conidia Aspergillus spores are ubiquitious - Esp. prevalent in decating vegetation like hay - Spore couns up to 2 x 10^7/m^3 reported! even inside buildings! Aspergillosis most frequently affect the lungs. Infections to other sites like: - Nasal sinuses - Superficial tissue = may occur Disease is most frequently caused by A. fumigates, through inhalation of spores. This may lead to: - Colonization of existing lung cavities (ASPERGILLOMA form) - Hypersensitivity reaction (ALLERGIC ASPERGILLOSIS) Rarely, Aspergillus spp may cause invasive disease of the lung with dissemination to other organs (usually in SEVERELY IMMUNOCOMPROMISED PATIENTS!)

ALLERGIC ASPERGILLOSIS
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Usually seen in atopic individuals Increase IgE About 10-20 % asthamatics react to A.fumigatus Asthma with eosinophilia is the more chronic form. Fungus can grow in airway -> plug it with mycelia -> coughed out! If observation under microscope (+) = diagnostic. Allergic alveolitis follows after heavy exposure to spores (several hours post-exposure): - Breathlessness

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- Fever - Malaise Repeated attacks -> Lung damage E.g. Maltster s lung (A. clavatus in barley during malting process)

ASPERGILLOMA (fungal ball)
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Colonizes pre-existing cavities (usually tuberculous) -> compact ball of mycelium. Eventually surrounded by dense fibrous wall Usually solitary Patient usually asymptomatic But can -> cough with sputum or hemoptysis Treatment : Surgical resection

INVASIVE ASPERGILLOSIS
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Usually in severly immunocompromised individuals Lung sole site in 70% cases Dissemination to other organ ofren occurs -> widespread destructive growth of aspergillus spp in tissue Can invade blood vessels Lead to: - Thrombosis - Emboli -> organs Prognosis : Poor Often diagnosed at P.M Endocarditis in immunosuppressed patients or in open-heat surgery Paranasal granuloma - Usually A. favius or A.fumigatus - Invade paranasal sinuses -> orbit of eye -> brain

Lab Diagnosis
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Depends on clinical form of disease Direct microscopy: Sputum - Non-pigmented septate mycelium (3-5 icrom) - Dichotomous branching (characteristic) - Mycelial head of aspergillus present In allergy sputum : fungus +++ Myceliul plugs + In aspergilloma fungus may be difficult to visualize Invasive aspergillosis: - Microscopy usually (-) - Biopsy = PAS or methenamine-silver

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Culture Sabouraud s agar without Cycloheximide 1-2 days : colonies (+) Skin test: Ag A.fumigatus Treatment: Type I HS In Eosinophilia: 70% type III HS (Arthus reaction) Serology: - ID, CIE, LPA, RIA, ELISA - Treatment: Amphotericin B, beta conazole, Itraconazole