[Mycotic infection in immunosuppressed patients. An anatomopathologic study].
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Trichosporon
Esophageal candidiasis
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Trichosporon
Esophageal candidiasis
Opportunistic infection
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Fungal infections affect virtually all patients with the Acquired Immunodeficiency Syndrome (AIDS). Superficial infection (seborrheic dermatitis, tinea capitis, tinea corporis and tinea cruris) is more common than in the general population and can be difficult to eradicate. Mucosal disease (oropharyngeal, oesophageal and vaginal candidosis) is very common and often recurs. In advanced AIDS, patients usually fail to respond to topical therapy and often to systemic therapy and isolates of Candida spp. from these patients are frequently resistant in vitro to fluconazole and other azoles. Systemic fungal infection is less common but life threatening. The commonest such infection is Pneumocystis carinii pneumonia (PCP) although prophylaxis is usually successful in preventing either the first episode or recurrent episodes. Histoplasmosis, coccidioidomycosis and Penicillium marneffei infections are common in endemic areas. Cryptococcal meningitis and invasive aspergillosis occur worldwide. The prophylaxis and treatment of all these except PCP are discussed and reviewed.
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AIDS-Related Opportunistic Infections
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Respiratory and systemic mycoses are globally emerging as a problem of increasing importance in infectious diseases. This is attributed to the growing population of immunocompromised patients due to epidemic outbreak of AIDS or to other factors such as use of immunosuppressive drugs in recipients of organ transplantation. The available evidence has unequivocally established the endemic occurrence of blastomycosis, histoplasmosis and penicilliosis mameffei in India. In fact, pencilliosis marneffei has emerged as a major endemic mycosis of AIDS patients in Southeast Asia. It has manifestations simulating those of histoplasmosis capsulati, and it may spread to other regions with enlarging population of AIDS patients. Comprehensive studies are indicated in order to delineate the endemic areas of the afore-mentioned systemic mycoses. Among the other important systemic mycoses reported from India are aspergillosis, cryptococcosis, candidiasis and zygomycosis. Our current knowledge of the global distribution of systemic mycoses does not depict their true prevalence. It largely reflects the geographic distribution of medical mycologists or other investigators engaged in the study of fungal diseases and their research interests. Invasive aspergillosis has emerged as an important disease in patients with neutropenia and bone narrow transplant recipients, cryptoccosis, penicilliosis marneffei and pneumocystosis in patients with AIDS, fusariosis in patients with leukaemia receiving cytotoxic therapy, zygomycosis in diabetic patients and in patients on defroxamine therapy, and Malasseziafurfur infection in patients on total parenteral nutrition: Opportunistic systemic mycoses due to yeasts and yeast-like fungi have become commoner than those due to filamentous fungi, occupying fourth position in the list of bloodstream pathogens in some centers in USA. Also, their incidence, pattern of clinical presentations and species spectrum have significantly changed, largely due to more frequent and prolonged therapeutic or prophylactic use of antifungal drugs and subsequent development of resistance. Consequently, infections with resistant yeast-like fungi such as C. lusitaniae, C. krusei, C. tropicalis, C. glabrata and Trichosporon ovoides (T. beigelii) have recently been reported with greater frequency. Since respiratory and systemic mycoses have no pathognomonic clinical or radiologic syndrome and mycological diagnostic facilities are restricted to only some of the major metropolitan centres, these diseases may be frequently confused with tuberculosis or other diseases of obscure etiology in India and other developing countries. Greater awareness and a high index of clinical suspicion are important pre-requisites for their diagnosis. Also, active collaboration of internists, pathologists, mycologists and microbiologists is advocated for their expeditous diagnosis and successful management. Further studies should focus on the development of rapid techniques for selective isolation and identification of systemic pathogenic fungi. The problem of antifungal resistance is likely to become more serious in the future as more and more patients with AIDS, bone marrow transplantation and neutropenia will require chemoprophylaxis cover against systemic fungal infections. Thus, it would be of vital importance to intensify search for more potent and less toxic antifungal drugs. It is recognized that an increasing number of people whose life is saved or prolonged due to successful treatment of their underlying diseases fall victim to opportunistic, life threatening systemic mycoses. A great majority of the deaths due to these infections occurs because they remain undiagnosed for want of mycological diagnostic services. In order to cope with the challenge of systemic mycoses, the health authorities of the developing countries are called upon to urgently take necessary measures for establishing a network of diagnostic mycology laboratories.
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The frequency of fungal infections is increasing due to immunodeficiency viruses and immunosuppressive drugs. The most common fungal infection of the oral cavity is candidiasis. The existence of Candida can be a part of normal commensal; hence, the isolation of Candida in the absence of clinical symptoms should exclude candidiasis. The pathogenicity of Candida is witnessed as opportunistic when immune status is compromised. Oral fungal infections are uncommon, but when identified, these infections are associated with greater discomfort and are sometimes destruction of tissues. Cytology and tissue biopsy are helpful in confirming the clinical diagnosis. The management of oral fungal infections must strategically focus on signs, symptoms, and culture reports. This article reviews information on diagnosis and therapeutic management of aspergillosis, cryptococcosis, histoplasmosis, blastomycosis, mucormycosis, and geotrichosis.
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The advent of the human immunodeficiency virus (HIV) and the increasing prevalence of immunocompromised individuals due to surgical and medical advances have resulted in a resurgence of opportunistic infections including oral candidiasis and other rare mycoses which were once considered exotic. It is now recognized that oral candidiasis may present in many clinical guises that may confound the unwary clinician. Other mycotic diseases such aspergillosis, cryptococcosis, histoplasmosis, and mucormycosis may manifest intraorally both as primary lesions and as secondary manifestation of systemic disease. The primary oral pathology of most of the latter mycoses is ulcerations that respond well to systemic therapy with the polyene, amphotericin B. In general, the management of oral fungal infections has been revolutionized by the triazole group of drugs, fluconazole and itraconazole, although recent reports indicate an alarming increase of resistant organisms in particular to fluconazole. The first part of this review attempts to provide an overview of clinical variants of oral candidiasis and current therapeutic techniques, while the latter part outlines the rare oral mycoses and their management.
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Persons with AIDS are predisposed to a variety of previously rare bacterial and fungal infections. Improvement in the quality and duration of survival of AIDS patients depends on the efficacy of treatment for these infections. Between 58-81% of AIDS patients contract fungal infections at some time, and 10-20% of AIDS patients die as a direct consequence of such infections. Oral candidiasis, commonly known as thrush, is the most common fungal infection among AIDS and AIDS Related Complex patients, occurring in 80-90% of cases. In a recent U.S. study, 59% of persons with oral candidiasis who were at high risk of contracting AIDS went on to develop Kaposi's sarcoma and other life- threatening infections. The most common life-threatening fungal infection experienced by AIDS patients is cryptococcosis, a disease occurring among 6% of American AIDS patients and having a mortality rate of 17% during initial infections and 75-100% on relapse. Other opportunistic infections associated with AIDS and AIDS Related Complex are bronchial candidiasis, invasive aspergillosis, disseminated histoplasmosis, and disseminated coccidioidomycosis. All are treatable but eradication i s difficult and relapse common.
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AIDS-Related Opportunistic Infections
AIDS-related complex
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Since December 2019 SARS-CoV-2 infections have affected millions of people worldwide. Along with the increasing number of COVID-19 patients, the number of cases of opportunistic fungal infections among the COVID-19 patients is also increasing. There have been reports of the cases of aspergillosis and candidiasis in the COVID-19 patients. The COVID-19 patients have also been affected by rare fungal infections such as histoplasmosis, pneumocystosis, mucormycosis and cryptococcosis. These fungal infections are prolonging the stay of COVID-19 patients in hospital. In this study several published case reports, case series, prospective and retrospective studies were investigated to explore and report the updated information regarding candidiasis, crytptococcosis, aspergillosis, mucormycosis, histoplasmosis, and pneumocystosis infections in COVID-19 patients. In this review, the risk factors of these co-infections in COVID-19 patients have been reported. There have been reports that the comorbidities and the treatment with corticoids, monoclonal antibodies, use of mechanical ventilation, and use of antibiotics during COVID-19 management are associated with the emergence of fungal infections in the COVID-19 patients. Hence, this review analyses the role of these therapies and comorbidities in the emergence of these fungal infections among COVID-19 patients. This review will help to comprehend if these fungal infections are the result of the co-morbidities, and treatment protocol followed to manage COVID-19 patients or directly due to the SARS-CoV-2 infection. The analysis of all these factors will help to understand their role in fungal infections among COVID-19 patients which can be valuable to the scientific community.
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Trends in the Postmortem Diagnosis of Opportunistic Invasive Fungal Infections in Patients With AIDS
We retrospectively evaluated autopsy-proven invasive fungal infections (IFIs) in patients with AIDS who died between 1984 and 2002. IFIs were identified in 297 (18.2%) of 1,630 autopsies. Their prevalence significantly decreased over time (from 25.0% in 1984-1988 to 15% in 1998-2002; P = .004), mainly owing to a significant decrease in pneumocystosis (P = .017) and cryptococcosis (P = .003), whereas the prevalence of aspergillosis and histoplasmosis remained relatively stable and of candidiasis and zygomycosis tended to increase in the last years (P = .028 and P = .042, respectively). IFIs were suspected or confirmed during life in only 46.8% of the cases; this proportion did not vary significantly over time (P = .320). The infections contributed to the deaths of 103 patients (34.7%), and their global impact on mortality was 6.3%. Of fatal cases, 38 (36.9%) were characterized by missed antemortem diagnoses, 17 (45%) of which met Goldman criteria for class I errors. The epidemiology of IFIs in patients with AIDS is evolving and not completely mirrored by clinical diagnoses or current diagnostic methods. Our results confirm the valuable role of autopsy data, even with highly effective therapies and advanced technologies.
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Pneumocystosis
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