Invasive Fungal Infections:

Identification Matters!
 Patient History
• A 62 year-old male patient presents to the ER with a 3-day
fever as his chief complaint.
• He develops skin lesions over the first few days of
admission, which progressively got worse.

• The patient has a history of acute myeloid leukemia (AML),

for which he received a stem cell transplant and
chemotherapy.
 Opportunistic Pathogens of the
Immunocompromised Host

• Because of his treatment for AML, the patient had a

suppressed immune system.

• Immunosuppressed patients are at risk for many

infections, which can be caused by primary or
opportunistic pathogens.
– Primary Pathogens: those that can infect otherwise
healthy individuals.
– Opportunistic Pathogens: organisms that only infect
humans in certain host conditions, such as
immunosuppression.
 Skin Biopsy Results
• The pathology report from the skin
biopsy stated there were fungal
hyphae invading the blood vessels.

• These hyphae were described as

being septated (walls between
cells) with acute angle-branching,
with some features being
compatible with the fungus
Aspergillus.
 Microbiology Work-Up
• Specimens were submitted for culture to
determine if there was a bacterial or fungal
etiologic agent causing his symptoms.

– Blood was submitted to detect disseminating

(spreading throughout the body) organisms.
– Tissue from the skin biopsy was submitted to help
identify the fungal organism that was seen on the
stain from the lesion.

• Nucleic acid, antigen, and antibody testing was

also performed to help detect infections with
viruses and fungi.
 Microbiology Laboratory Results
Stain of Blood Culture Bottle (10x)

• All bacterial and viral test

results were negative…

• BUT a fungus grew in the blood

culture bottle and was visible Stain of Blood Culture Bottle (40x)

upon Gram stain.

• The same fungus also grew

from the tissue culture.
 Medical Mycology
Colony Appearance
• Fungi are often identified using
colony appearance and
sexual/asexual reproductive
structures that are observed
microscopically
– The microbiologist must have a high-
level of expertise and experience. Microscopic Structures

• Based on phenotypic analysis, this

organism was identified as a
Fusarium species.
 Diagnosis: Fusariosis
• Many Fusarium species are primarily soil saprophytes or plant pathogens,
but certain species can be opportunistic pathogens of humans.
– Because of this patient’s immunosuppression, he is at risk for opportunistic infections.
– Fusarium infections, or fusariosis, can be superficial, locally invasive, or disseminated.

• Because of their ubiquitous nature, however, isolation of Fusarium species

in culture may be due environmental contamination. From Blood

• Therefore, the microbiologist and clinician must work

together to interpret the results.
In Tissue
• Clues for clinically significant results are:
� Fungi seen on direct stain of tissue Multiple Specimens
� Site of isolation and the host
� Same fungus from multiple specimens
� Multiple colonies from same specimen
 Importance of Mould Identification

• Some fungi may look similar in tissue stains, but

have very different susceptibility profiles to
different antifungal drugs.

• Therefore, the microbiologist plays an important

role in helping make the correct identification to
guide appropriate antifungal therapy.
 Patient Outcome
• The patient’s suppressed immune system put him
at risk for invasive fungal disease.
• Two different antifungal drugs were given and the
patient was monitored closely.
• The symptoms, including lesions, improved with
no evidence of treatment failure.
• The clinical microbiology results were essential in
making sure the patient received the appropriate
therapy! Created by:
Margaret Powers-Fletcher, Ph.D.,
Medical Microbiology Fellow
University of Utah/ARUP Laboratories

A. Michal Stevens, M.D.

Infectious Disease Fellow
Margaret Powers-Fletcher, Ph.D.

Dr. Powers-Fletcher is a Fellow in the Medical and

Public Health Laboratory Microbiology program at
the University of Utah/ARUP Laboratories. Her
research has focused primarily on medical
mycology, with emphasis on pathogenesis
mechanisms, antifungal susceptibility testing, and
fungal diagnostic and detection techniques.