Endemic Mycoses In Immune Compromised Patients

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Endemic Mycoses In Immune Compromised Patients
EORTC-MSG Definitions II
Carol A. Kauffman, M.D. Professor of Internal
Medicine University of Michigan Chief,
Infectious Diseases Section VA Ann Arbor
Healthcare System Ann Arbor USA
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ENDEMIC MYCOSES IN IMMUNE COMPROMISED PATIENTS

• Organisms
• ? Histoplasma capsulatum
• ? Blastomyces dermatitidis
• ? Coccioides immitis
• ? Sporothrix schenckii
• ? Paracoccidioides brasiliensis
• ? Penicillium marneffei

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ENDEMIC MYCOSES IN IMMUNE COMPROMISED PATIENTS

• True pathogens cause disease in healthy host,
  more severe disease in immune compromised host
• Restricted niches so geography (both past and
  present) of crucial importance
• Both new infection and reactivation can occur
  with most endemic mycoses

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ENDEMIC MYCOSES IN IMMUNE COMPROMISED PATIENTS

• Diagnosis of proven infection with endemic
• mycoses is relatively easy
• ? Do not colonize humans
• ? Never a lab contaminant
• Diagnosis of proven infection with endemic
• mycoses can be difficult
• ? Growth in culture can be slow and tedious
  
• ? Non-culture methods decrease reliance on
  cultures

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ENDEMIC MYCOSES IN IMMUNE COMPROMISED PATIENTS

• Proven Infection Requires the Following
• Affected site, temporally related, typical Sx
• ? () culture or
• ? () histopathologic or direct microscopic
• evidence for characteristic organisms
• () blood culture

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ENDEMIC MYCOSES IN IMMUNE COMPROMISED PATIENTS

• Proven Infection Requires the Following
• Disseminated histoplasmosis
• ? EIA () for histo Ag in urine, serum, CSF
• ? () blood or bone marrow smear
• Disseminated coccidioidomycosis
• ? 4-fold rise in serum Ab for cocci
• ? CSF Ab () for cocci

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Urine
100
95
90
(75/79)
82
81
80
80
(14/17)
(26/32)
(8/10)
70
60
Sensitivity ()
50
40
34
30
(22/65)
20
14
10
(2/14)
0
AIDS
Acute
Sub-acute
Chronic
IS
NIS
Disseminated Pulmonary
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New 2nd Gen Assay
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ENDEMIC MYCOSES IN IMMUNE COMPROMISED PATIENTS

• There are Caveats re Criteria for Proven D.
• Dx of histoplasmosis by histopathology
• requires expertise in mycopathology C.
• glabrata Leishmania look similar, but
• tissue reaction different
• Serology and antigen EIA must be done by lab
• with expertise in fungal diagnostics

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ENDEMIC MYCOSES IN IMMUNE COMPROMISED PATIENTS

• Probable and Possible Infection Categories
• Do not apply to endemic mycoses
• Any () growth or microscopy is proven
• infection
• ? Do not colonize humans
• ? Never a lab contaminant
• Empiric Rx not common clinical practice

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CRYPTOCOCCOSIS IN IMMUNE COMPROMISED PATIENTS

• Proven Infection Requires the Following
• Normally sterile site, signs/symptoms infection
• ? () culture or
• ? () histopathologic or direct microscopic
• evidence for encapsulated budding
  yeasts or
• () blood culture or
• () CSF cryptococcal antigen

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CRYPTOCOCCOSIS IN IMMUNE COMPROMISED PATIENTS

• Probable Infection Requires the Following
• Meet at least 1 criterion from 3 categories
• 1 host 1 clinical 1 microbiologic
• ? sputum, BAL, bronchial brush
• () culture or direct microscopy
• ? () cryptococcal antigen in serum
• (false include T. asahii, R.
  mucilaginosa, RF)

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CRYPTOCOCCOSIS IN IMMUNE COMPROMISED PATIENTS

• Probable Infection Uncommon with Crypto
• Pt. with pneumonia, () BAL, no lung Bx
• Pt. with pneumonia, no BAL, () serum Ag
• Pt. with CNS D., no LP, () serum Ag
• Possible Infection Does Not Apply to Crypto
• Will always have to meet at least one micro
• criterion to consider cryptococcosis