Continuing medical educationAngioinvasive fungal infections impacting the skin: Diagnosis, management, and complications
Section snippets
Diagnosis and workup
Key points Obtaining a sterile punch biopsy specimen and a fungal culture are standard components of the diagnostic workup It is important to notify the microbiology laboratory if mucormycosis is suspected, because tissue samples should be handled gently (ie, no grinding or stomaching); this decreases the likelihood of a false negative Frozen sectioning or touch preparations of a punch biopsy specimen can be an effective method to quickly ascertain the presence of fungal organisms in tissue
Angioinvasive
Histopathology
Key points Histopathology can help identify fungi and their morphologic features regarding septated hyphae and pigmentation, but it is not possible to completely accurately speciate a fungal organism subtype via histology alone The presence of septated hyphae largely rules out Mucorales spp, which present as nonseptated and wide, ribbon-like organisms Septated and nonpigmented hyphae can represent several hyalohyphomycotic species, including Fusarium spp, Aspergillus spp, and Pseudallescheria spp Candida spp
Tissue culture
Key points Tissue culture provides pathogen speciation and treatment susceptibilities Aspergillus spp should be considered a true pathogen if isolated in an immunocompromised patient Growth rates vary widely by species, and adequate time for growth is important
Tissue culture is often an essential component of the diagnostic workup, both to determine the etiologic organism and to perform susceptibility testing. Historically, fungal culture has been practically challenging because of highly specific growth
Blood culture
Key points For disseminated candidiasis, positive blood culture is the gold standard Infection by Fusarium spp has a high frequency of positive blood cultures, as Fusarium spp sporulate in vivo
Fungal blood cultures may be necessary to confirm or establish a diagnosis. With some angioinvasive fungal infections, blood cultures are often the main mode for diagnosis (Candida spp), where for others, they are rarely positive (Aspergillus spp). For disseminated candidiasis, a positive blood culture is the
Imaging
Key points Imaging can be helpful to identify other organ involvement in angioinvasive fungal infections Computed tomography imaging of the sinuses and chest is necessary for suspected rhinocerebral and disseminated mucormycosis, respectively In disseminated candidiasis, with elevated liver enzymes or hepatosplenomegaly, computed tomography and magnetic resonance imaging are 90% sensitive in determining hepatosplenic involvement The brain and respiratory tract are preferred sites for disseminated
Additional tests
Key points When negative, galactomannan antigen and 1,3-beta-D-glucan assays are useful for ruling out disseminated mucormycosis The galactomannan antigen assay is positive in Aspergillus spp, but also cross reacts with Fusarium spp, Talaromyces marneffei, and Histoplasma capsulatum The 1,3-beta-D-glucan assay can detect Aspergillus spp, Candida spp, Pneumocystis jiroveci, Pseudomonas aeruginosa, and occasionally Cryptococcus neoformans The T2Candida assay is a panel that can detect very low levels of
Treatment
Key points Empiric therapy, such as liposomal or lipid-based amphotericin B and posaconazole, should be started promptly in severely ill patients with suspected angioinvasive fungal infection Intravenous echinocandin therapy is first-line for disseminated candidiasis and fluconazole is no longer recommended because of resistance For severe invasive aspergillosis, voriconazole and an echinocandin agent should be used in immunocompromised patients Empiric treatment with intravenous liposomal amphotericin B and
Complications
Key point Prompt initiation of treatment is essential to prevent severe morbidity and mortality
Angioinvasive fungal infections are aggressive infections that result in significant morbidity and, if left untreated, carry mortality rates ranging from 50% to 100% depending upon the etiologic organism.101 Complications include dissemination to visceral organs with subsequent organ dysfunction, which is often fatal.102 More severe immunosuppression is associated with a higher risks of mortality.102, 103 Early
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Date of release: April 2019
Expiration date: April 2022
Dr Wanat is currently affiliated with the Medical College of Wisconsin, Department of Dermatology, Milwaukee, WI.
Dr Wanat received a Dermatology Foundation Career Development Award.
Conflicts of interest: None disclosed.