Fungal Pneumonia.pptx

Fungal Pneumonia

1. FUNGAL PNEUMONIA DR. MD. SHAFIQUL ISLAM DEWAN RESIDENT (PULMONOLOGY) RESPIRATORY MEDICINE DEPARTMENT DHAKA MEDICAL COLLEGE HOSPITAL

2. Fungal Pneumonia Pneumonia is as an acute respiratory illness associated with recently developed radiological pulmonary shadowing that may be segmental, lobar or multi-lobar . If it is caused by fungus called fungal pneumonia. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 2

3. Fungi Fungi are eukaryotic organisms that exist in two basic forms: yeasts and molds . Yeasts are single cells, whereas molds consist of long filaments of cells called hyphae. Yeasts reproduce by budding, a process in which the daughter cells are unequal in size. Molds reproduce by cell division (daughter cells are equal in size). Some fungi are dimorphic (e.g. Exist either as yeasts or molds , depending on the temperature). At room temperature (e.g. 25°C), they are molds , whereas at body temperature they are yeasts (or some other form such as a spherule). DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 3

4. Fungal pathogens Two types of fungi causes infection in human. Endemic fungi : Endemic fungal pathogens causes infection in healthy and immunocompromised hosts , in defined geographic locations around the world. Opportunistic fungi : Opportunistic fungal pathogens causes infection in patients with congenital or acquired defects in host immune defense . DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 4

5. Endemic Fungi Histoplasmosis Coccidioidomycosis Blastomycosis Para-coccidioidomycosis Sporotrichosis Talaromycosis (formerly penicilliosis ) Emergomycosis DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 5

6. Opportunistic Fungi Cryptococcosis Candidiasis Aspergillosis Mucormycosis Non-aspergillus hyaline hyphomycetes Dematiaceous (melanized) hyphomycetes DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 6

7. Transmission Fungal infection occurs following _ Inhalation of spores. Inhalation of conidia. Reactivation of a latent infection. Hematogenous dissemination frequently occurs, especially in an immunocompromised host. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 7

8. Risk Factors Acute leukemia or lymphoma during myeloablative chemotherapy. Bone marrow or peripheral blood stem cell transplantation. Solid organ transplantation on immunosuppressive treatment. Prolonged corticosteroid therapy. Acquired immunodeficiency syndrome. Congenital immune deficiency syndromes. Prolonged neutropenia from any cause. Post splenectomy state. Genetic predisposition. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 8

9. Patient History History findings in persons with fungal pneumonia_ Fever Cough , usually nonproductive Pleuritic chest pain or dull discomfort Progressive dyspnea leading to respiratory failure Airway obstructive symptoms from enlarged mediastinal adenopathy in the endemic mycoses DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 9

10. Patient History Hemoptysis (in invasive aspergillosis or mucormycosis ). History of travel to or exposure in areas containing endemic mycoses. Symptoms from involvement of extrapulmonary systems (may suggest disease). Rheumatologic syndromes (common among endemic mycoses) - Arthritis and arthralgia, erythema nodosum, erythema multiforme, and pericarditis. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 10

11. Patient History Hypersensitivity or allergic reactions. Extrapulmonary sites in individuals who are immunocompromised. Meningoencephalitis in patients with AIDS and cryptococcosis . In individuals who are neutropenic or immunocompromised , persistent fever (even before pulmonary findings) may be an early sign of infection, especially if the fever is unresponsive to broad-spectrum antibiotics. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 11

12. Patient History Hypersensitivity or allergic reactions include_ Allergic bronchial asthma (aspergillus species, candida species). Allergic bronchopulmonary mycoses (aspergillus species, candida species). Broncho-centric granulomatosis (necrotizing granulomatous replacement and eosinophilic infiltration of bronchial mucosa in infection with aspergillus species). Extrinsic allergic alveolitis (malt worker's lung, farmer's lung). DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 12

13. Physical Examination Signs and symptoms of fungal pneumonia are not specific and are indistinguishable from those associated with respiratory infections of other origins. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 13

14. Physical Examination Physical examination findings may include_ Elevation of temperature Tachycardia Tachypnea Respiratory distress Rales Signs of pulmonary consolidation Pleural rub DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 14

15. Physical Examination Important possible extrapulmonary findings include_ Meningitis (neck stiffness, headaches, mental status change) Brain abscesses (Focal sign, raised ICP) Skin lesions (pustules, papules, plaques, nodules, ulcers, abscesses, hemorrhagic lesions, mycetomas ) Rheumatologic and allergic findings Pericardial rub DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 15

16. Complications Disease dissemination to other sites ( brain, meninges, skin, liver, spleen, kidneys, adrenals, heart, eyes) and sepsis syndrome . Blood vessel invasion , which can lead to_ Hemoptysis Pulmonary infarction Myocardial infarction Cerebral septic emboli Cerebral infarction Blindness. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 16

17. Complications Other complications may include the following_ Bronchopleural or Tracheoesophageal fistulas Chronic pulmonary symptoms Mediastinal fibromatosis (histoplasmosis) Broncholithiasis (histoplasmosis) Pericarditis and other rheumatologic symptoms DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 17

18. Investigation Complete Blood Count Imaging ( X-ray, CT scan, MRI of chest) Microscopic Examination and Culture ( Sputum, BAL, Tissue) Blood & Urine culture Serology Fiberoptic bronchoscopy Biopsy & Histopathology DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 18

19. Complete Blood Count Total white blood cell (WBC) count may be elevated in normal hosts with endemic mycoses. Eosinophilia can be observed in the differentials, particularly in persons with coccidioidomycosis. If the patient presents with neutropenia or leukopenia , the possibility of an opportunistic infection with  Candida, Aspergillus, Mucor or  Scedosporium   organisms is increased. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 19

20. Imaging (CXR) Patchy Infiltrate , Nodules , Consolidation , Cavitation , or Pleural Effusion may be observed. Mediastinal adenopathy is common in patients with endemic fungal pneumonias . The adenopathy may be either unilateral or bilateral . In neutropenic patients infected with aspergillosis, pulmonary nodules surrounded by ground-glass opacity called “ halo sign ” is a common finding. Miliary infiltration occurs in patients with disseminated disease. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 20

21. Imaging (CT scan) CT chest plays a role in the early diagnosis of nonspecific infiltrates in patients who are immunocompromised . High-resolution chest computed tomography (HRCT) scanning allows observation of the ‘ halo sign’ in patients with aspergillosis. Obtaining a CT scan of the abdomen and brain may reveal sites of dissemination. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 21

22. Imaging (MRI) Magnetic resonance imaging (MRI) may reveal the haemorrhagic content of  Aspergillus lesions . DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 22

23. Microscopic Examination and Culture Microscopic Examination show fungal hyphae or yeasts. Culture media: Selective and non-selective. But, the results must correlate with the clinical situation , because saprophytic colonization occurs in the oropharyngeal or respiratory tract of some patients and may not necessarily indicate invasive infection. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 23

24. Microscopic Examination and Culture Pulmonary Cryptococcal infection is confirmed if the organism is grown in culture from sputum or BAL fluid in a patient who has clinical symptoms and radiographic finding compatible with cryptococcosis.  Histoplasmosis is definitively diagnosed by growth of the organism in sputum ; BAL fluid, lung tissue, or mediastinal nodes can be cultured.  Pulmonary Sporotrichosis , the recovery of the fungi by culture of sputum and/or positive bronchoscopy are required for diagnosis.  DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 24

25. Microscopic Examination and Culture Cultures from sputum samples or collected by fiber optic bronchoscopy are not valuable for the diagnosis of pneumonia by  Candida.  To make the diagnosis , a biopsy is required to demonstrate tissue invasion . Colonization of the respiratory tract by Candida  is very frequent in critically ill patients with mechanical ventilation, but pneumonia by Candida is extremely rare because the innate defense mechanisms of the lungs make them relatively resistant to candida invasion. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 25

26. Fungal Culture Media DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 26

27. Blood & Urine culture Obtain a blood fungal culture to identify  Candida species (lysis centrifugation) or  Blastomyces dermatitidis if the patient has disseminated disease. Obtain a urine fungal culture in men after a prostatic massage, to identify Cryptococcus or Blastomycosis species. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 27

28. Serology Enzyme immunoassay ELISA Latex agglutination PCR-based assays DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 28

29. Fiberoptic bronchoscopy Fiberoptic bronchoscopy ( procedure of choice ) is used to obtain bronchial lavage specimens for staining and culture techniques and transbronchial biopsy specimens for identification of fungal tissue invasion.  DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 29

30. Biopsy & Histopathology Caseating or necrotizing granulomas with intracellular organisms inside macrophages ( eg , H capsulatum, C immitis ). Fungal hyphae in infection with  Aspergillus, Mucor or Scedosporium species. Intracellular yeast organisms in  Candida species infections. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 30

31. Treatment Specific treatment ( Anti-fungal drugs ) Symptomatic treatment DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 31

32. Types of Anti-fungal drugs Polyenes Azoles Echinocandins Others Flucytosine Griseofulvin Terbinafine DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 32

33. Anti-fungal drugs Polyenes Amphotericin B deoxycholate Amphotericin B lipid complex Liposomal amphotericin B Nystatin Echinocandins Caspofungin Anidulafungin Micafungin DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 33

34. Azole anti- fungals Triazoles (Systemic) Fluconazole Itraconazole Voriconazole Posaconazole Isavuconazole Imidazoles (Topical) Miconazole Econazole Clotrimazole Ketoconazole DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 34

35. Imaging of different Fungal pneumonia DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 35

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56. DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 56

57. Thank You DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY) - DMCH 57