Minimal - dermatophyte, ringworm, tinea

Acute - candidiasis

Ganulomatous - histoplasmosis

mild, flu-like symptoms

2-3 wks infection, T cell-mediated granulomatous inflammation, antibody is produced several weeks later

Acute lungs, 1%, 2 weeks duration, calcification of hilar nodes

Chronic lungs immunosuppressed, elderly

Usually associated w/ disseminated disease

Tongue, palate, buccal mucosa, gingiva, floor of mouth

Mimics malignancy clinically

Granulomatous inflammation, pseudoepitheliomatous hyperplasia (PEH), periodic acid Schiff reagent, methenamine silver

Yeasts 1-2 microns diameter

Tissue sections

Serological testing for antibodies

Detection of H. capsulatum antigen

Acute is usually self-limited so manage w/ supportive analgesics and antipyretics

Chronic amphotericin B, ketoconazole, itraconazole

Disseminated same as chronic

Chronic without treatment may be progressive & death in 20%

Disseminated disaese mortality 20% even with treatment

Acute pneumonia: fever, cough, night sweats, chest pain; rarely is fatal

Chronic: more common mimics TB; low grade fever, night sweats, productive cough

Chest xrays clear

Disseminated pulmonary --> skin, oral: oral leasions mimic malignancy

acute and granulomatous inflammation

Pseudoepitheliomatous hyperplasia (PEH)

Examination of tissue section

KOH

Culture from sputum or non-fixed biopsy specimen

DNA probe on mycelia phases 5-7da culture

Most require no treatment

If seriously ill, not improving, sick over 2 wks then itraconazole, ketoconazole or amphotericin B

Prior to amphotericin B 80-90% mortality

Itraconazole has 95% cure rate

Acquired by inhalation, 40% symptomatic

1-4 weeks incubation period

Increased incidence in blacks & Filipinos

Disseminated disease in immunocompromised

Acute and granulomatous inflammation

Special stains PAS and methenamine silver to help identify

(collect in endospores)

Tissue specimen

Cytology

Culture

Serological testing and skin testing

Immunocompromised, severe lung, disseminated or life-threatening disease

Ketoconazole or fluconazole

Amphotericin B

Mild disease- excellent

Immunocompromised/HIV/disseminated - guarded, may required life-long daily antifungal medication

found worldwide in soil, spread by pigeons

Disease results from inhalation of spores (destroyed by neutrophils and macrophages in healthy, asymptotic or flu-like symptoms)

Cause disease in immunocompromised; oral lesions rare!

Granulomatous inflammation

4-6 microns round to oval mo w/ clear capsule

stain w/ PAS, methenamine silver or mucicarmine (stains mucopolysarccharide capsule)

Biopsy

Culture

Detection of cryptococcal antigen in CSF

Amphotericin B and flucytosine

Fluconazole & itraconazole

Guarded

Depends on control of underlying condition and response to antifungal medications

Opportunistic infection, usually saprophytic mo

Absidia, mucor, Rhizopus

Nasal obstruction, facial pain, headache, visual disturbance, facial swelling

Maxillary sinus: intraoral swelling or ulceration

Opacification of sinus, destruction of bone

Mimics malignancy (Fungus ball can damage sinus)

Large, right angle branching, nonseptate hyphae

Involve small blood vessel walls and occlude (fungal angitis), tissue invasion

Necrosis secondary to infarction

Surgical debridement (quickly as possible)

Antifungal medication-amphotericin B

Control underlying disease

Allergic reaction in normal host or invasive in immunocompromised; common

Aspergillus saprophytic mo in soil or water (A. flavus and A. fumigatus most common medically important)

infection results from inhalation of spores

(Nosocomial-hospital ventilation system --> hospitals)

(dependent on host status and presence or absence of tissue damage)

Allergic symptoms "allergic fungal sinusitis"

Low-grade infection of sinus, fungus ball "aspergilloma"; localized pain, swelling, yellow or black ulcer

Disseminated lung -> CNS, eye, skin, bone, GI (leukemia, corticosteroids)

Branching acute angle, septate hyphae

Angiotrophic

Occludes vessles -> necrosis

in immunosuppressed individual, tissue reaction may be absent or minimal

Identify mo in tissue sections

Culture mo from lesions

In disseminated disease sputum and blood cultures may be negative

Amphotericin B

May require surgical debridement

20% Candida albicans

60% Mixed C. albicans/Staph aureus

20% Staph aureus

Chronic persistent fungal infection; area has decreased vascularity w/ decreased resistance

Langerhan cells decreased in number in MRG (suggest localized defect in immune surveillance)

Older than 40 y/o

"Kissing lesions" may occur w/ diffuse oral/perioral candidiasis

Increased frequency in diabetics, immunosuppressed, especially HIV

Characteristic clinical and microscopic features

PEH mimics SCCA

SCCA of dorsum is rare

Rare, 3-5% of tongue

May mimic MRG, erosive lichen planus, amyloidosis, or granular cell tumor

recent lesions - complete resolution

Chronic lesions - complete or partial improvement

Association with malignancy is rare

Clinical w/ empirical treatment

Cytologic smear

KOH prep

Biopsy

Culture

OTC miconazole nitrate 2% (angular cheilitis)

Nystatin, clotrimazole, ketoconazole, fluconazole, itraconazole, miconazole, voriconazole

Chlorhexidine mouthwas is fungicidal

Avoid fresh fruits and vegetables

Eat active culture yogurt 2x daily

Nature's bounty chewable probiotic Acidophilus w/ Bifidum