Seminars in respiratory and critical care medicine
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Paracoccidioidomycosis (formerly known as South American blastomycosis) is produced by the thermally dimorphic fungus Paracoccidioides brasiliensis. Most often this mycosis runs a chronic progressive course affecting preferentially the lungs followed by the skin, mucous membranes, adrenals, and reticuloendothelial organs. Acute-subacute presentations can be observed in children and immunosuppressed patients. ⋯ No outbreaks have been reported. P. brasiliensis is capable of entering into prolonged periods of latency as is demonstrated by its diagnosis in patients who have moved outside the recognized endemic areas. This review updates clinicians and laboratory workers on the characteristics of a mycosis seldom reported outside of the Latin American countries.
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Pulmonary manifestations of histoplasmosis were last reviewed in Seminars in 2004. This review highlights the management of the most common clinical syndromes, emphasizing recognition, diagnosis, and treatment. The reader is referred to the earlier review for subjects not fully addressed herein. ⋯ Antigen testing is most useful in patients with more diffuse pulmonary involvement and those with progressive disseminated disease due to the high fungal burden. Detection of antigen in bronchoalveolar lavage fluid may be particularly helpful in certain circumstances. Guidelines for antifungal therapy have been updated and will be discussed for pulmonary syndromes.
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The frequency and diversity of serious fungal infections are increasing. Persons who are severely immunocompromised are particularly vulnerable to infection from unusual molds and yeasts that are often found naturally in the environment. Clinical manifestations from these unusual fungal infections range from colonization of airways to chronic localized lesions to acute invasive or disseminated disease. ⋯ Furthermore, many emerging opportunistic molds demonstrate in vitro resistance to the older azoles and amphotericin B. As a result, successful treatment may require adjunct surgical debridement and, when possible, reconstitution of the host immune system. Also, the newer triazoles such as voriconazole and posaconazole may be useful to treat some of these infections caused by rare and emerging molds.
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Coccidioidal infection can manifest as pulmonary or extrapulmonary disease. Pulmonary coccidioidomycosis occurs in 95% of all cases and can be divided into three main categories: primary, complicated, and residual pulmonary coccidioidomycosis. The primary infection occurs with inhalation of airborne arthroconidia. ⋯ Progression of primary pulmonary disease to acute respiratory distress syndrome (ARDS) can also qualify as a complication. The third category of residual disease comprises only two entities: pulmonary nodule and fibrosis. This review focuses on uncomplicated and complicated pulmonary coccidioidomycosis and its management as outlined earlier in addition to special considerations of coccidioidal fungemia, pulmonary coccidioidomycosis in pregnancy, and organ transplantation.
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Cryptococcosis is a common opportunistic infection in acquired immunodeficiency syndrome (AIDS) patients, also occurring in other immunosuppressed patients and occasionally those with no apparent immunocompromise. The majority of cases are caused by the ubiquitous encapsulated yeast, Cryptococcus neoformans, whereas Cryptococcus GATTII accounts for a smaller proportion of cases, often in immunocompetent patients. Severe meningoencephalitis is the commonest presentation; however, pulmonary cryptococcosis in human immunodeficiency virus (HIV)-seropositive individuals is underdiagnosed and without appropriate treatment leads to severe disseminated disease. ⋯ Radiological presentations are varied and nonspecific, influenced by the underlying immune status of the patient. Diagnosis is based on isolation of Cryptococcus from, or detection of cryptococcal antigen in, a pulmonary specimen, coupled with appropriate clinical, radiological, and histopathological findings. Antifungal treatment with amphotericin B +/- flucytosine is recommended for severe disease, whereas fluconazole is the treatment of choice for mild and localized infections.