Fungal Infections of the Lower Respiratory Tract

DISEASE ADDITIONAL INFORMATION

Coccidioidomycosis (Valley Fever). Coccidioidomycosis Pathogen. Coccidioidomycosis is caused by Coccidioides immitis, a
starts as a respiratory infection, with fever, chills, cough, dimorphic fungus. It exists as a mould in soil and on culture media
and, rarely, pain. The primary infection may heal (25°C), where it produces arthrospores (arthroconidia). In tissues, it
completely or may progress to the disseminated form of the appears as spherical yeast cells called spherules that reproduce by
disease, which is often fatal. Disseminated endospore formation. C. immitis arthrospores have potential use as a
coccidioidomycosis may include lung lesions and bioterrorist agent.
abscesses throughout the body, especially in Reservoirs and Mode of Transmission. Arthrospores are present in
subcutaneous tissues, skin, bone, and the central nervous soil in arid and semiarid areas of the Western Hemisphere; in United
system. Other tissues and organs, such as inguinal lymph States, from California to southern Texas; and in Mexico, Central
nodes, kidneys, thyroid gland, heart, pituitary gland, America, and South America. Transmission occurs by inhalation of
esophagus, and pancreas, may also be involved. arthrospores, especially during wind and dust storms. It is not directly
Patient Care. Use Standard Precautions for hospitalized transmissible person to person or animal to person.
patients with draining lesions or pneumonia. Laboratory Diagnosis. Coccidioidomycosis is diagnosed by direct
examination and culturing of sputum, pus, urine, cerebrospinal fluid, or
biopsy materials. The mould form is highly infectious. All work must be
performed in a biosafety level (BSL)-2 or BSL-3 facility (refer to
CDROM Appendix 4). Skin tests, molecular diagnostic procedures,
and immunodiagnostic procedures are also available.
Cryptococcosis. Cryptococcosis starts as a lung infection,
but usually spreads via the bloodstream to the brain. The
disease is described later in the chapter, in the section
entitled “Fungal Infections of the Central Nervous System.”
Histoplasmosis. Histoplasmosis is a systemic mycosis of Pathogen. Histoplasmosis is caused by Histoplasma capsulatum var.
varying severity, ranging from asymptomatic to acute to capsulatum, a dimorphic fungus that grows as a mould in soil and as a
chronic. The primary lesion is usually in the lungs. The yeast in animal and human hosts (refer back to Fig. 5-13 in Chapter
acute disease involves malaise, fever, chills, headache, 5).
myalgia, chest pains, and a nonproductive cough (i.e., Reservoirs and Mode of Transmission. Reservoirs include warm,
sputum is not produced). Histoplasmosis is the most moist soil containing a high organic content and bird droppings,
common systemic fungal infection in AIDS patients. especially chicken droppings, but also bat droppings in caves and
Patient Care. Use Standard Precautions for hospitalized around starling, blackbird, and pigeon roosts. Transmission occurs via
patients. inhalation of conidia (asexual spores) from soil. Bulldozing and
excavation may produce aerosols of spores. Histoplasmosis is the
most common systemic fungal disease in the United States, occurring
primarily in the Ohio, Mississippi, and Missouri River valleys.
Histoplasmosis is not transmitted from person to person.
Laboratory Diagnosis. H. capsulatum yeasts may be observed in
Giemsa- or Wright-stained smears of ulcer exudates, bone marrow,
sputum, and blood. H. capsulatum produces mould colonies when
incubated at room temperature and yeast colonies when incubated at
body temperature. Conversion from the mould form to the yeast form
can sometimes be accomplished in the laboratory. Skin tests and
immunodiagnostic procedures are available.
Pneumocystis Carinii Pneumonia (PCP, Interstitial Pathogen. The etiologic agent of PCP is Pneumocystis jiroveci
Plasma-Cell Pneumonia). PCP is an acute-to-subacute (formerly P. carinii). This organism has both protozoal and fungal
pulmonary disease found in malnourished, chronically ill properties. It was classified as a protozoan for many years, but is
children; premature infants; and immunosuppressed currently classified as a nonfilamentous fungus.
patients, such as those with AIDS. Patients have fever, Reservoirs and Mode of Transmission. Infected humans serve as
difficulty in breathing, rapid breathing, dry cough, cyanosis, reservoirs. The mode of transmission is unknown—perhaps direct
and pulmonary infiltration of alveoli with frothy exudate. contact, perhaps transfer of pulmonary secretions from infected to
PCP is usually fatal in untreated immunosuppressed susceptible persons, perhaps airborne.
patients. It is a common contributory cause of death in Laboratory Diagnosis. Diagnosis of PCP is made by demonstration
AIDS patients. Pneumocystis causes an asymptomatic of Pneumocystis in material from bronchial brushings, open lung
infection in immunocompetent people. Patient Care. Use biopsy, lung aspirates, or smears of tracheobronchial mucus by
Standard Precautions for hospitalized patients. Do not various staining methods. P. jiroveci cannot be cultured.q
place PCP patients in the same room with an
immunocompromised patient.
Pulmonary Zygomycosis. The term zygomycosis Pathogens. Many different fungi can cause zygomycosis, including
(formerly mucormycosis or phycomycosis) refers to a some that are often referred to as bread moulds. These fungi, which
disease caused by one of the many fungi in the class include species of Mucor, Rhizopus, and Absidia, are responsible for
Zygomycetes. These fungi are widely distributed in soil and the white or gray fuzzy growth seen on foods such as bread and
vegetative matter. Although being discussed in the section cheese. The fuzziness is the result of aerial hyphae.
on lower respiratory diseases, these fungi cause diseases Reservoirs and Modes of Transmission. Most commonly, humans
with a wide range of clinical manifestations. Other clinical become infected with zygomycetes by inhaling airborne spores,
syndromes caused by members of the Zygomycetes class although ingestion and direct inoculation through traumatic breaks in
include sinusitis, cerebral infection, cutaneous disease, the skin and mucous membranes can also lead to infection.
gastrointestinal disease, and disseminated disease, which Zygomycosis is not transmitted from person to person.
involve virtually every organ. Laboratory Diagnosis. Diagnosis of zygomycosis can be made by
Patient Care. Use Standard Precautions. microscopic observation of distinctive, ribbonlike, broad, aseptate
hyphae in tissue sections and by culture of biopsy tissue.
 FUNGAL INFECTIONS OF THE SKIN
Disease Additional Information
Dermatophytoses Dermatophytoses are also known as tinea Pathogens. Dermatomycoses are caused by various filamentous fungi
(ringworm) infections and dermatomycoses. (moulds), collectively referred to as dermatophytes. Examples include
Diseases. (See preceding sections on superficial and cutaneous species of Microsporum, Epidermophyton, and Trichophyton.
mycoses.) Some of the dermatomycoses cause only limited irritation,
scaling, and redness. Others cause itching, swelling, blisters, and Reservoirs and Mode of Transmission. Infected humans and animals and
severe scaling. soil serve as reservoirs. Transmission is by direct or indirect contact with
lesions of humans or animals; or contact with contaminated floors, shower
Patient Care. Use Standard Precautions. stalls, or locker room benches; barbers’ clippers, combs, and hairbrushes; or
clothing.

Laboratory Diagnosis. Microscopic examination of potassium hydroxide

(KOH) preparations of skin scrapings or hair or nail clippings can reveal the
presence of fungal hyphae (The KOH preparation is described in CD-ROM)
Dermatophytes can be cultured on various media, including Sabouraud
dextrose agar. Moulds are identified using a combination of macroscopic
and microscopic observations

FUNGAL INFECTIONS OF THE ORAL REGION

Disease Additional Information
Thrush Disease. Thrush is a yeast infection of the oral cavity. It is Pathogens. The yeast, C. albicans and related species.
common in infants, elderly patients, an immunosuppressed individuals.
White, creamy patches occur on the tongue, mucous membranes, and Reservoir and Mode of Transmission. Infected humans serve as
the corners of the mouth Thrush can be a manifestation of reservoirs. Transmission occurs by contact with secretions or excretions of
disseminated Candidainfection (candidiasis). Candida albicans is the mouth, skin, vagina, or feces of patients or carriers; also by passage from
yeast and the fungus most commonly isolated from clinical specimens mother to neonate during childbirth and by
— sometimes isolated as a pathogen and sometimes isolate endogenous spread (i.e., from one area of the body to another).

Laboratory Diagnosis. Thrush can be diagnosed by observation of yeast

cells and pseudohyphae (strings of elongated buds) in microscopic
examination of wet mounts, and by culture confirmation

FUNGAL INFECTIONS OF THE GENITOURINARY SYSTEM

Disease Additional Information
Yeast Vaginitis Disease. The three most common causes of vaginitis Pathogens. The yeast, C. albicans, causes about 85% to 90% of yeast
in the United States, each causing about one third of the cases, are C. vaginitis; other Candida spp. can also cause this disease.
albicans (a yeast), Trichomonas vaginalis (a protozoan), and a mixture
of bacteria (including bacteria in the genera Mobiluncus and Reservoir and Mode of Transmission. (See previous section on
Gardnerella). A saline wet mount preparation is usually used to “Thrush.”)
diagnose vaginitis; this test procedure is described in CD-ROM
Appendix 5. Typical symptoms of yeast vaginitis are vulvar pruritis Laboratory Diagnosis. Yeast vaginitis can be diagnosed by microscopic
(itching), a burning sensation, dysuria, and a white discharge. Vulvar examination of a saline wet mount of vaginal discharge material, in which
erythema (redness) and rash sometimes occur. yeasts and hyphae may be observed. The vaginal discharge material
should also be cultured. Candida spp. grow well on blood agar and
Sabouraud dextrose agar. Candidaspp. can usually be identified using a
commercial yeast identification minisystem. It is important to keep in mind
that the vaginal microflora of up to 25% of healthy women can contain
Candida spp.

FUNGAL INFECTIONS OF THE CENTRAL NERVOUS SYSTEM

Disease Additional Information
Cryptococcosis (Cryptococcal Meningitis) Disease. Cryptococcosis Pathogens. Cryptococcosis can be caused by three subspecies of C.
starts as a lung infection, but spreads via the bloodstream to the brain. It neoformans, an encapsulated yeast The capsule enables C. neoformans
usually presents as a subacute or chronic meningitis. Infection of the to adhere to mucosal surfaces and avoid phagocytosis by white blood
lungs, kidneys, prostate, skin, and bone may also occur. Cryptococcosis is cells.
a common infection in acquired immunodeficiency syndrome (AIDS)
patients. Reservoirs and Modes of Transmission. Reservoirs include pigeon
nests; pigeon, chicken, turkey, and bat droppings; and soil contaminated
Patient Care. Use Standard Precautions for hospitalized patients. with bird droppings. Growth of C. neoformans is stimulated by the
alkaline pH and high nitrogen content of bird droppings. Transmission
occurs by inhalation of yeasts, often projected into the air by sweeping or
excavation. Cryptococcus is not transmitted from person to person or
animal to person.

Laboratory Diagnosis. Cryptococcal meningitis is often diagnosed by

observing encapsulated, budding yeasts in cerebrospinal fluid
specimens examined by an India ink preparation. (Details of the India ink
preparation can be found in CD-ROM Appendix 5, Clinical Microbiology
Laboratory Procedures.) Yeasts may also be observed in sputum, urine,
and pus examined by an India ink preparation or Gram stain C.
neoformanscan be cultured on routine media used in the Mycology
Section. A sensitive Cryptococci antigen detection test is available.