Seminars in respiratory and critical care medicine
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Pneumocystis (carinii) jiroveci pneumonia can occur in immunocompromised individuals, especially hematopoietic stem and solid organ transplant recipients and those receiving immunosuppressive agents, and is the most common opportunistic infection in persons with advanced human immunodeficiency virus (HIV) infection. The Pneumocystis genus was initially mistaken as a trypanosome and later as a protozoan. Genetic analysis identified the organism as a unicellular fungus. ⋯ Fulminant respiratory failure associated with fever and dry cough is typical in non-HIV-infected patients. Definitive diagnosis relies on histopathological testing of sputum, induced or sampled by fiberoptic bronchoscopy with bronchoalveolar lavage. The first-line drug for treatment and prevention is trimethoprim-sulfamethoxazole.
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Coccidioidomycosis refers to the spectrum of disease caused by the dimorphic fungi Coccidioides immitis and Coccidioides posadasii. Clinical manifestations vary depending upon both the extent of infection and the immune status of the host. ⋯ The majority of patients with coccidioidomycosis resolve their initial infection without sequelae; however, several patients develop complications of disease ranging in severity from complicated pulmonary coccidioidomycosis to widely disseminated disease with immediately life-threatening manifestations. This review focuses on complications of pulmonary coccidioidomycosis with an emphasis on the management of primary coccidioidal infection, solitary pulmonary nodules, pleural effusions, cavitary disease, acute respiratory distress syndrome (ARDS), miliary disease, and sepsis.
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Aspergillosis remains a significant cause of morbidity and mortality. The spectrum of disease is diverse and ranges from noninvasive disease with an excessive immune response, such as in allergic bronchopulmonary aspergillosis (ABPA), to a lack of an immune response as seen in patients with quantitative or qualitative granulocyte deficits and subsequent invasive pulmonary aspergillosis. ⋯ Voriconazole remains the preferred agent in the treatment of invasive pulmonary aspergillosis, and recent data have increased interest in the potential of combination therapy against this often lethal infection. The role of host genetics in selecting patients that may benefit from more aggressive antifungal prophylaxis or treatment practices remains unclear but is likely to guide therapeutic choices as newer data become available.