eMedicine Specialties > Pulmonology > Infectious Lung Diseases

Pneumonia, Fungal: Follow-up

Author: Romeo A Mandanas, MD, FACP, Director, Western Oklahoma Blood and Marrow Transplant Program, Site Research Leader, Cancer Care Associates-Oklahoma City
Contributor Information and Disclosures

Updated: Sep 17, 2009

Follow-up

Further Inpatient Care

  • Watch for rapidly progressive respiratory failure in patients who are neutropenic; patients may need ventilatory support.
  • Consider rapidly reducing or withdrawing immunosuppressive therapy (eg, corticosteroids) if feasible.
  • Correct hyperglycemia and acidosis.
  • Consider correction of neutropenia by administration of growth factors (eg, filgrastim [Neupogen], pegfilgrastim [Neulasta], sargramostim [Leukine]) or leukocyte transfusions.

Further Outpatient Care

  • Offer maintenance therapy to suppress reactivation or recurrent disease in patients infected with HIV or other individuals who are immunocompromised.
  • Ensure appropriate follow-up care to monitor for possible recurrence.

Deterrence/Prevention

  • Instruct patients to avoid travel to and exposure in endemic areas.
  • For patients undergoing bone marrow transplantation, solid organ transplantation, or antileukemic chemotherapy, use air filtration systems in the treatment units to minimize patient risk of exposure to Aspergillus spores.
  • Administer prophylactic antifungal (ie, intranasal or intravenous amphotericin B or its other formulations) therapy in patients at high risk for opportunistic fungal infection, including patients with a history of fungal infection.22
  • Posaconazole was shown to be superior to fluconazole in reducing invasive aspergillosis incidence (1% vs 5.9%) in allogeneic hematopoietic stem cell transplant recipients with clinically significant graft versus host disease.23 In another trial, posaconazole also reduced the incidence of invasive aspergillosis to 1%, compared with 7%, in the group receiving either fluconazole or itraconazole in neutropenic patients undergoing chemotherapy for acute leukemia or myelodysplasia.24

Complications

  • Disease dissemination to other sites (ie, brain, meninges, skin, liver, spleen, kidneys, adrenals, heart, eyes) and sepsis syndrome
  • Blood vessel invasion: This can lead to pulmonary hemoptysis, infarction, myocardial infarction, cerebral emboli, cerebral infarction, or blindness.
  • Other complications
    • Bronchopleural or tracheoesophageal fistulas
    • Chronic pulmonary symptoms
    • Mediastinal fibrosis (histoplasmosis)
    • Broncholithiasis (histoplasmosis)
    • Pericarditis and other rheumatologic symptoms

Prognosis

  • The mortality rate for untreated disseminated histoplasmosis is 80%, and it is reduced to 25% with treatment.
  • Coccidioidomycosis has a mortality rate of 70% in patients with AIDS.
  • Aspergillosis and mucormycosis have mortality rates of 50-85% in transplant recipients, especially bone marrow transplants.
  • The individual prognosis ultimately is linked to the severity and outcome of the underlying disease and to whether the reversal of factors affecting the patient's immune status is possible.

Patient Education

  • Patients undergoing bone marrow transplantation or any period of prolonged neutropenia are advised to avoid activities (eg, gardening, cleaning, agitating debris) or objects (eg, potted plants, flowers, fresh fruits, vegetables) that may unduly cause exposure to spores of Aspergillus species or other ubiquitous fungi.

Miscellaneous

Medicolegal Pitfalls

  • In patients who are severely neutropenic, rapid progression of fungal pneumonia and dissemination of fungal infection (eg, aspergillosis) necessitate a high degree of suspicion, early empiric antifungal therapy, and corrective measures (if possible) to reverse neutropenia or other causes of immunosuppression.
  • Patients with ongoing immune deficiencies may require prolonged or lifelong maintenance therapy with triazole agents to prevent recurrences.
 


More on Pneumonia, Fungal

Overview: Pneumonia, Fungal
Differential Diagnoses & Workup: Pneumonia, Fungal
Treatment & Medication: Pneumonia, Fungal
Follow-up: Pneumonia, Fungal
Multimedia: Pneumonia, Fungal
References
[ CLOSE WINDOW ]

References

  1. Hung CC, Chang SC. Impact of highly active antiretroviral therapy on incidence and management of human immunodeficiency virus-related opportunistic infections. J Antimicrob Chemother. Nov 2004;54(5):849-53. [Medline].

  2. Bochud PY, Chien JW, Marr KA, et al. Toll-like receptor 4 polymorphisms and aspergillosis in stem-cell transplantation. N Engl J Med. Oct 23 2008;359(17):1766-77. [Medline].

  3. Kesh S, Mensah NY, Peterlongo P, et al. TLR1 and TLR6 polymorphisms are associated with susceptibility to invasive aspergillosis after allogeneic stem cell transplantation. Ann N Y Acad Sci. Dec 2005;1062:95-103. [Medline].

  4. Buchheidt D, Hummel M, Schleiermacher D, Spiess B, Hehlmann R. Current molecular diagnostic approaches to systemic infections with aspergillus species in patients with hematological malignancies. Leuk Lymphoma. Mar 2004;45(3):463-8. [Medline].

  5. Herbrecht R, Letscher-Bru V, Oprea C, et al. Aspergillus galactomannan detection in the diagnosis of invasive aspergillosis in cancer patients. J Clin Oncol. Apr 1 2002;20(7):1898-906. [Medline].

  6. Mennink-Kersten MA, Donnelly JP, Verweij PE. Detection of circulating galactomannan for the diagnosis and management of invasive aspergillosis. Lancet Infect Dis. Jun 2004;4(6):349-57. [Medline].

  7. Musher B, Fredricks D, Leisenring W, Balajee SA, Smith C, Marr KA. Aspergillus galactomannan enzyme immunoassay and quantitative PCR for diagnosis of invasive aspergillosis with bronchoalveolar lavage fluid. J Clin Microbiol. Dec 2004;42(12):5517-22. [Medline].

  8. Maertens JA, Klont R, Masson C, et al. Optimization of the cutoff value for the Aspergillus double-sandwich enzyme immunoassay. Clin Infect Dis. May 15 2007;44(10):1329-36. [Medline].

  9. Penack O, Rempf P, Graf B, Blau IW, Thiel E. Aspergillus galactomannan testing in patients with long-term neutropenia: implications for clinical management. Ann Oncol. May 2008;19(5):984-9. [Medline].

  10. Viscoli C, Machetti M, Cappellano P, et al. False-positive galactomannan platelia Aspergillus test results for patients receiving piperacillin-tazobactam. Clin Infect Dis. Mar 15 2004;38(6):913-6. [Medline].

  11. Del Bono V, Mikulska M, Viscoli C. Invasive aspergillosis: diagnosis, prophylaxis and treatment. Curr Opin Hematol. Nov 2008;15(6):586-93. [Medline].

  12. Greene RE, Schlamm HT, Oestmann JW, et al. Imaging findings in acute invasive pulmonary aspergillosis: clinical significance of the halo sign. Clin Infect Dis. Feb 1 2007;44(3):373-9. [Medline].

  13. Mussini C, Pezzotti P, Miro JM, et al. Discontinuation of maintenance therapy for cryptococcal meningitis in patients with AIDS treated with highly active antiretroviral therapy: an international observational study. Clin Infect Dis. Feb 15 2004;38(4):565-71. [Medline].

  14. Kaffarnik M, Utzolino S, Blaich A, Hopt UT. Successful multimodal therapy of invasive pulmonary and central nervous system aspergillosis in a neutropenic surgical patient: case report and review of the literature. Mycoses. Jan 2008;51(1):74-8. [Medline].

  15. Denning DW, Ribaud P, Milpied N, et al. Efficacy and safety of voriconazole in the treatment of acute invasive aspergillosis. Clin Infect Dis. Mar 1 2002;34(5):563-71. [Medline].

  16. Herbrecht R, Denning DW, Patterson TF, et al. Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med. Aug 8 2002;347(6):408-15. [Medline].

  17. Johnson LB, Kauffman CA. Voriconazole: a new triazole antifungal agent. Clin Infect Dis. Mar 1 2003;36(5):630-7. [Medline].

  18. Benjamin DK Jr, Driscoll T, Seibel NL, et al. Safety and pharmacokinetics of intravenous anidulafungin in children with neutropenia at high risk for invasive fungal infections. Antimicrob Agents Chemother. Feb 2006;50(2):632-8. [Medline].

  19. [Best Evidence] Reboli AC, Rotstein C, Pappas PG, et al. Anidulafungin versus fluconazole for invasive candidiasis. N Engl J Med. Jun 14 2007;356(24):2472-82. [Medline].

  20. Turner MS, Drew RH, Perfect JR. Emerging echinocandins for treatment of invasive fungal infections. Expert Opin Emerg Drugs. May 2006;11(2):231-50. [Medline].

  21. [Guideline] Walsh TJ, Anaissie EJ, Denning DW, et al. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. Feb 1 2008;46(3):327-60. [Medline].

  22. Hamza NS, Ghannoum MA, Lazarus HM. Choices aplenty: antifungal prophylaxis in hematopoietic stem cell transplant recipients. Bone Marrow Transplant. Sep 2004;34(5):377-89. [Medline].

  23. Ullmann AJ, Lipton JH, Vesole DH, et al. Posaconazole or fluconazole for prophylaxis in severe graft-versus-host disease. N Engl J Med. Jan 25 2007;356(4):335-47. [Medline].

  24. Cornely OA, Maertens J, Winston DJ, et al. Posaconazole vs. fluconazole or itraconazole prophylaxis in patients with neutropenia. N Engl J Med. Jan 25 2007;356(4):348-59. [Medline].

  25. Avery RK. Aspergillosis in hematopoietic stem cell transplant recipients: risk factors, prophylaxis, and treatment. Curr Infect Dis Rep. May 2009;11(3):223-8. [Medline].

  26. Catanzaro A. Fungal pneumonias. Curr Opin Pulm Med. Mar 1997;3(2):146-50. [Medline].

  27. Conces DJ Jr. Endemic fungal pneumonia in immunocompromised patients. J Thorac Imaging. Jan 1999;14(1):1-8. [Medline].

  28. Connolly JE Jr, McAdams HP, Erasmus JJ, Rosado-de-Christenson ML. Opportunistic fungal pneumonia. J Thorac Imaging. Jan 1999;14(1):51-62. [Medline].

  29. Crawford SW. Respiratory Disease in Bone Marrow and Hematopoietic Stem Cell Transplantation. In: Fishman AP, ed. Fishman's Pulmonary Diseases and Disorders. Vol. 2. 3rd ed. New York, NY: McGraw-Hill; 1998:2147-8.

  30. Fishman JA. Pulmonary infections in Neutropenia and Cancer. In: Fishman AP, ed. Fishman's Pulmonary Diseases and Disorders. Vol. 2. 3rd ed. New York, NY: McGraw-Hill; 1998:2124-6.

  31. Fishman JA. HIV Infection and Opportunistic Pulmonary Infections in AIDS. In: Fishman AP, ed. Fishman's Pulmonary Diseases and Disorders. Vol. 2. 3rd ed. New York, NY: McGraw-Hill; 1998:2114-5.

  32. Goldman M, Wheat LJ. Cryptococcal Infections. In: Fishman AP, ed. Fishman's Pulmonary Diseases and Disorders. Vol 2. 3rd ed. New York, NY: McGraw-Hill; 1998:2305-12.

  33. Larone DH, Mitchell TG, Walsh TJ. Histoplasma, Blastomyces, Coccidioided, and other Dimorphic Fungi causing systemic Mycoses. In: Murray PR, ed. Manual of Clinical Microbiology. 7th ed. Washington DC: ASM Press; 1999:1259-74.

  34. Lass-Flörl C, Gunsilius E, Gastl G, Freund M, Dierich MP, Petzer A. Clinical evaluation of Aspergillus-PCR for detection of invasive aspergillosis in immunosuppressed patients. Mycoses. 2005;48 Suppl 1:12-7. [Medline].

  35. Maertens J, Raad I, Petrikkos G, et al. Efficacy and safety of caspofungin for treatment of invasive aspergillosis in patients refractory to or intolerant of conventional antifungal therapy. Clin Infect Dis. Dec 1 2004;39(11):1563-71. [Medline].

  36. Pound MW, Drew RH, Perfect JR. Recent advances in the epidemiology, prevention, diagnosis, and treatment of fungal pneumonia. Curr Opin Infect Dis. Apr 2002;15(2):183-94. [Medline].

  37. Rickerts V, Bialek R, Tintelnot K, Jacobi V, Just-Nubling G. Rapid PCR-based diagnosis of disseminated histoplasmosis in an AIDS patient. Eur J Clin Microbiol Infect Dis. Nov 2002;21(11):821-3. [Medline].

  38. Sarosi GA. Cryptococcal pneumonia. Semin Respir Infect. Mar 1997;12(1):50-3. [Medline].

  39. Segal BH, Walsh TJ. Current approaches to diagnosis and treatment of invasive aspergillosis. Am J Respir Crit Care Med. Apr 1 2006;173(7):707-17. [Medline].

  40. Sugar AM, Olek EA. Aspergillus syndromes, Mucormycosis, and Pulmonary Candidiasis. In: Fishman AP, ed. Fishman's Pulmonary Diseases and Disorders. Vol. 2. 3rd ed. New York, NY: McGraw-Hill; 1998:2265-87.

  41. Wheat LJ. Endemic Mycoses of North America: Histoplasmosis, Coccidioidomycosis, and Blastomycosis. In: Fishman AP, ed. Fishman's Pulmonary Diseases and Disorders. Vol. 2. 3rd ed. New York, NY: McGraw-Hill; 1999:2289-2303.

  42. White PL, Archer AE, Barnes RA. Comparison of non-culture-based methods for detection of systemic fungal infections, with an emphasis on invasive Candida infections. J Clin Microbiol. May 2005;43(5):2181-7. [Medline].

  43. Won HJ, Lee KS, Cheon JE, et al. Invasive pulmonary aspergillosis: prediction at thin-section CT in patients with neutropenia--a prospective study. Radiology. Sep 1998;208(3):777-82. [Medline].

  44. Worthy SA, Flint JD, Muller NL. Pulmonary complications after bone marrow transplantation: high-resolution CT and pathologic findings. Radiographics. Nov-Dec 1997;17(6):1359-71. [Medline].

  45. Yamada H, Kotaki H, Takahashi T. Recommendations for the treatment of fungal pneumonias. Expert Opin Pharmacother. Aug 2003;4(8):1241-58. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

fungal pneumonia, pulmonary mycosis, mycotic pneumonia, , endemic fungal pneumonia, aspergillosis, meningoencephalitis, cryptococcosis, acute leukemia, lymphoma, myeloablative chemotherapy, bone marrow transplantation, peripheral blood stem cell transplantation, allogeneic stem cell transplantation, unrelated donor transplantation, graft-versus-host disease, graft versus host disease, solid organ transplantation on immunosuppressive treatment, prolonged corticosteroid therapy, AIDS, congenital immune deficiency syndromes

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Romeo A Mandanas, MD, FACP, Director, Western Oklahoma Blood and Marrow Transplant Program, Site Research Leader, Cancer Care Associates-Oklahoma City
Romeo A Mandanas, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Blood and Marrow Transplantation, American Society of Clinical Oncology, American Society of Hematology, and Oklahoma State Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Ryland P Byrd Jr, MD, Professor, Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University; Chief of Pulmonary Medicine, Medical Director of Respiratory Therapy, Intensive Care Unit, Program Director of Pulmonary Diseases and Critical Care Medicine Fellowship, James H Quillen Veterans Affairs Medical Center
Ryland P Byrd Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H, Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California Keck School of Medicine
Om Prakash Sharma, MD, FRCP, FCCP, DTM&H is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Osler Society, American Thoracic Society, New York Academy of Medicine, and Royal Society of Medicine
Disclosure: Keck School of Medicine, USC None None

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.