Updated: 1/5/2017

Systemic Mycoses

Topic
Review Topic
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Questions
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Evidence
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Introduction
  • Systemic mycoses consist of 4 dieases
    • Histoplasmosis (Histoplasma capsulatum)
    • Coccidiomycosis (Coccidioides immitis)
    • Blastomycosis (Blastomyces dermatitidis)
    • Paracoccidioidomycosis (Paracoccidioides brasiliensis)
  • Characteristics of systemic mycoses
    • dimorphic
      • mold in soil ("mold in the cold" - 25 deg C)
        • grown on Sabouraud's agar
      • yeast in tissue (37 deg C)
        • grown on blood agar
      • Coccidioides immitis is an exception
        • spherule (not yeast) in tissue
    • endemic to a specific area
  • Pathogenesis
    • fungi inhaled in spore
    • lungs are locally infected
    • infection disseminates hematogenously
Histoplasma capsulatum
  • Diseases
    • histoplasmosis (pneumonia)
      • hilar lymphadenopathy
      • ulcerated tongue lesions
  • Pathogenesis
    • invades macrophages 
      • oval yeast cells seen within macrophages
      • the only systemic fungus with yeast phagocytosed by macrophages
  • Transmission
    • cave exploring/spelunking  
    • endemic to Mississippi and Ohio River Valleys
      • Ohio and Tennessee
    • found in bird and bat droppings (chicken farms)
  • Laboratory
    • NOT encapsulated despite name
Coccidioides immitis
  • Diseases
    • coccidioidomycosis 
      • mild pneumonia
        • opportunistic infection in AIDS patients in Arizona
      • meningitis
      • disseminated disease to skin and bone in immunocompromised
  • Transmission
    • endemic to southwest U.S.
      • AZ, NM, southern CA, and San Joaquin Valley
    • incidence ↑ after earthquakes
      • spherules released from soil
  • Laboratory
    • spherule (not yeast) in tissue
      • spherules contain endospores seen on biopsy 
Blastomyces dermatitidis
  • Diseases
    • blastomycosis (most severe disease of the group)
      • chronic inflammatory lung disease
      • granulomatous nodules
      • dissemination to skin and bone
    • rarest of the group
  • Transmission
    • endemic to Mississippi River Valley and Central America
    • found in soil and rotting wood
  • Laboratory
    • round, broad-based budding yeast
      • thick, double refractive walls
Paracoccidioides brasiliensis 
  • Diseases
    • paracoccidioidomycosis (pneumonia) 
  • Transmission
    • endemic to Latin America
  • Laboratory
    • "captain's wheel" appearance
    • budding yeast
Presentation (Systemic mycoses)
  • 3 presentations
    • asymptomatic
      • majority of cases
      • most people never visit the doctor
    • pneumonia
      • fever
      • cough
      • may be acute or chronic
      • clinical presentation is similar to TB
    • disseminated disease
      • fever, malaise
      • meningitis, bone lytic and skin granulomas
      • seen in immunocompromised
Evaluation (Systemic mycoses)
  • Radiographs
    • CXR will show lesion
  • Biopsy
    • stained with silver stain directly or KOH prep
    • cultured on Sabouraud's or blood agar
  • Delayed hypersensitivity reaction
    • can be used to show previous exposure (similar to PPD)
      • coccidioidin
      • histoplasmin
Differential (Systemic mycoses)
  • Tuberculosis
    • similarities with TB
      • inhaled lung infection
      • wide range of severity (asymptomatic to chronic)
      • granulomas, cavitations, and calcifications
      • hematogenous dissemination
      • show previous exposure with PPD-like hypersensitivity reaction
      • however, these infections do NOT transmit from person-to-person, unlike TB
Treatment (Systemic mycoses)
  • Fluconazole or ketoconazole
    • indications
      • local infection
  • Amphotericin B
    • indications
      • systemic infection
 

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Questions (6)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8 - 20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: <= 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, toal, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70 - 110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time (template) 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm^3
Female: 3.5-5.5 million mm^3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c <=6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm^3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm^3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm^3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm^3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m^2
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(M1.MC.12) A 43-year-old man presents to the emergency department with cough and fever. On a sputum sample he is found to have spherules containing endospores, as shown in Figure A. How is he most likely to have contracted his disease? Review Topic

QID: 101471
FIGURES:
1

Hunting in the woods of Connecticut

3%

(12/374)

2

Swimming in a freshwater pond in Louisiana

5%

(18/374)

3

Hiking in the deserts of Arizona

53%

(198/374)

4

Walking in caves in the Mississippi River Valley

18%

(68/374)

5

Cleaning out pigeon coops in Ohio

18%

(67/374)

M1

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(M1.MC.14) A 59-year-old man with no significant past medical history presents to the emergency room with the ulcerative skin lesion shown in Figure A. He had a bad pneumonia several weeks ago. His vital signs are stable, and the remainder of his physical examination is benign. The lesion is swabbed and cultured revealing the organism shown in Figure B. Which of the following is most likely true regarding this disease? Review Topic

QID: 104899
FIGURES:
1

The patient received the illness from bat droppings and may be treated with PO itraconazole

4%

(1/25)

2

The patient received the illness in the Southwest and may be treated with PO fluconazole or itraconazole

48%

(12/25)

3

The patient received the illness in the Mississippi River Valley and may be treated with PO itraconazole

32%

(8/25)

4

The patient received the illness in Latin America and the organism may form a captain's wheel formation

0%

(0/25)

5

The patient received the illness from plant material and may be treated with potassium iodide

12%

(3/25)

M1

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