Snapshot A 40-year-old woman presents to the emergency room with a week of fever, cough, and hemoptysis. She has a history of HIV and has been noncompliant with her medications and has a history of tuberculosis that was adequately treated. She reports feeling increasing fatigue. A chest CT shows nodules with a halo sign. A bronchoalveolar lavage with biopsy eventually reveals fungus with septate hyphae branching at acute angles invading into lung tissue. (Invasive aspergillosis) Candida albicans Classification yeast with budding and pseudohyphae germ tube formation at 37°C (diagnostic) can be part of normal flora Risk factors immunocompromised status hospital admission, especially in the ICU Clinical syndrome immunocompetent hosts present with skin and mucous membrane infections oral thrush white plaque on the tongue that can be scraped off associated with use of inhaled corticosteroids candidal intertrigo well-demarcated, erythematous, and itchy plaques in the skin folds vulvovaginitis thick "cottage cheese" white discharge itchiness immunocompromised hosts usually present with systemic disease local infection is due to T-cell deficiency while systemic infection is due to neutropenia esophagitis dysphagia and throat pain endoscopy shows white plaques along the esophagus endocarditis associated with IV drug users fevers and a new murmur disseminated/invasive candidiasis fever and septic shock Studies definitive diagnosis requires blood or other tissue culture wet mount with potassium hydroxide prep of vaginal fluid shows yeast with pseudohyphae germ tube formation at 37°C Treatment nystatin local infections azoles local and systemic infections first-line if the fungus is not resistant echinocandins systemic infections first-line due to increased resistance to azoles amphotericin B systemic infections second-line or for pregnant women Cryptococcus neoformans Classification urease-positive monomorphic encapsulated yeast with 5-10 μm narrow budding transmitted via inhalation and found in soil and pigeon droppings Risk factors immunocompromised status HIV/AIDS patients Clinical syndrome pulmonary cryptococcosis most common site of infection cryptococcal meningitis cryptococcal encephalitis presents with fevers, headaches, and generalized malaise Studies and imaging head imaging with computed tomography (CT) or magnetic resonance imaging (MRI) soap bubble lesions variable enhancing lesions hydrocephalus detection of capsular antigen in serum or cerebrospinal fluid (CSF) latex agglutination test CSF studies culture on Sabouraud agar India ink stain shows yeast with clear halos mucicarmine shows yeast with red inner capsules Treatment amphotericin B + flucytosine for 10-14 days fluconazole after treatment with amphotericin B and flucytosine maintenance and suppressive therapy Aspergillus spp. Classification most commonly Aspergillus fumigatus monomorphic fungus with septate hyphae branching at acute angles (45 degrees) found in soil and decomposed material transmission via inhalation of spores called conidia Risk factors immunocompromised status hematologic malignancy asthma pre-existing lung disease Clinical syndrome invasive aspergillosis invasive infection of the lung causes persistent fever and cough with hemoptysis aspergilloma mycetoma ("fungal ball") in pre-existing cavity (i.e., tuberculosis) causes cough with hemoptysis or asymptomatic allergic bronchopulmonary aspergillosis (ABPA) hypersensitivity reaction in patients with cystic fibrosis or asthma causes bronchiectasis and eosinophilia causes cough with hemoptysis, brownish black mucus plugs in expectorate, and wheezing Studies and imaging invasive aspergillosis nodules with halo sign and cavitary lesions on computed tomography (CT) pathologic examination showing invasive hyphae into tissue positive cultures or serology aspergilloma mobile round or ovoid mass on chest CT positive cultures or serology ABPA bronchiectasis on CT elevated eosinophils or IgE in ABPA Treatment invasive aspergilloma voriconazole + amphotericin B first-line caspofungin second-line aspergilloma surgical resection ABPA steroids first-line Mucormycosis Classification Mucor and Rhizopus spp. fungi with irregular, broad, and nonseptate hyphae branching at wide or right angles found in soil and decomposed material transmission via inhalation of spores or direct inoculation through trauma Risk factors diabetic ketoacidosis immunocompromised status trauma or burns Clinical syndrome mucormycosis (rhinocerebral infection) headache congestion sinus pressure and pain black necrotic eschar on face, particular nares or palate Studies and imaging computed tomography (CT) shows air-fluid levels in the sinuses and bony destruction biopsy of affected tissue shows nonseptate hyphae with wide-angle branching Treatment amphotericin B first-line isavuconazole second-line surgical debridement for patients who need it, in addition to antifungals Pneumocystis jiroveci Classification a yeast-like fungus transmission via airborne Risk factors immunocompromised status (e.g., hyper IgM syndrome) HIV smoking Clinical syndrome interstitial pneumonia progressive exertional dyspnea chest pain nonproductive cough fever and chills hemoptysis is rare Imaging chest radiograph will show bilateral infiltrates computed tomography will show patchy ground-glass opacities sand pneumatoceles Studies histology with methenamine silver, Diff-Quik, or Wright stain of lung tissue disc-shaped yeast Treatment trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis (CD4+ count < 200 cells/mm3) and first-line therapy corticosteroids severe cases pentamidine, atovaquone, or dapsone second-line therapy if resistant to TMP-SMX or allergic