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.
 


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References
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Further Reading

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Keywords

fungal pneumonia, pulmonary mycosis, mycotic pneumonia, Histoplasma capsulatum, H capsulatum, Coccidioides immitis, C immitis, Blastomyces dermatitidis, B dermatitidis, Paracoccidioides brasiliensis, P brasiliensis, Cryptococcus neoformans, C neoformans, Candida, Aspergillus, Mucor, 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

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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.

 
 
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