1. Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 18 Fungal Diseases of the Lung Figure 18-1. Fungal disease of the lung. Cross-sectional view of alveoli infected with Histoplasma capsulatum. S, Fungal spore; YLS, yeastlike substance; AC, alveolar consolidation; M, alveolar macrophage. AC S YLS M

2. Copyright © 2006 by Mosby, Inc. Slide 2 Anatomic Alterations of the Lungs  Alveolar consolidation  Alveolar-capillary destruction  Granuloma formation  Cavity formation  Fibrosis of the lung parenchyma  Airway secretions

3. Copyright © 2006 by Mosby, Inc. Slide 3 Etiology Histoplasmosis (most common fungal disease in the United States)  Screening and diagnosis  Fungal culture  Fungal stain  Serology

4. Copyright © 2006 by Mosby, Inc. Slide 4 Etiology Coccidioidomycosis  Screening and diagnosis  Direct visualization of distinctive spherules  Blood test that detects antibodies of the fungus  Culture of the organism

5. Copyright © 2006 by Mosby, Inc. Slide 5 Etiology Blastomycosis  and diagnosis  Screening and diagnosis  Direct visualization of yeast in sputum smears  Culture of the fungus

6. Copyright © 2006 by Mosby, Inc. Slide 6 Etiology Opportunistic pathogens  Candida albicans  Cryptococcus neoformans  Aspergillus

7. Copyright © 2006 by Mosby, Inc. Slide 7 Overview of the Cardiopulmonary Clinical Manifestations Associated with FUNGAL DISEASES OF THE LUNG The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Alveolar Consolidation (see Figure 9-8), and Increased Alveolar-Capillary Membrane Thickness (see Figure 9-9)—the major anatomic alterations of the lungs associated with fungal diseases of the lung (see Figure 18-1).

8. Copyright © 2006 by Mosby, Inc. Slide 8 Figure 9-8. Alveolar consolidation clinical scenario.

9. Copyright © 2006 by Mosby, Inc. Slide 9 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.

10. Copyright © 2006 by Mosby, Inc. Slide 10 Clinical Data Obtained at the Patient’s Bedside Clinical Data Obtained at the Patient’s Bedside Vital signs  Increased respiratory rate  Increased heart rate, cardiac output, blood pressure

11. Copyright © 2006 by Mosby, Inc. Slide 11 Clinical Data Obtained at the Patient’s Bedside  Chest pain/decreased chest expansion  Cyanosis  Digital clubbing  Peripheral edema and distention  Distended neck veins  Pitting edema  Enlarged and tender liver

12. Copyright © 2006 by Mosby, Inc. Slide 12 Digital Clubbing Figure 2-46. Digital clubbing.

13. Copyright © 2006 by Mosby, Inc. Slide 13 Distended Neck Veins Figure 2-48. Distended neck veins (arrows).

14. Copyright © 2006 by Mosby, Inc. Slide 14 Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2, London, 1992, Mosby-Wolfe.

15. Copyright © 2006 by Mosby, Inc. Slide 15 Clinical Data Obtained at the Patient’s Bedside  Cough, sputum production, and hemoptysis  Chest assessment findings  Increased tactile and vocal fremitus  Dull percussion note  Bronchial breath sounds  Crackles, rhonchi, and wheezing  Pleural friction rub  Whispered pectoriloquy

16. Copyright © 2006 by Mosby, Inc. Slide 16 Figure 2-11. A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.

17. Copyright © 2006 by Mosby, Inc. Slide 17 Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung unit.

18. Copyright © 2006 by Mosby, Inc. Slide 18 Figure 2-19. Whispered voice sounds auscultated over a normal lung are usually faint and unintelligible.

19. Copyright © 2006 by Mosby, Inc. Slide 19 Clinical Data Obtained from Laboratory Tests and Special Procedures

20. Copyright © 2006 by Mosby, Inc. Slide 20 Pulmonary Function Study: Expiratory Maneuver Findings FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or  FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or 

21. Copyright © 2006 by Mosby, Inc. Slide 21 Pulmonary Function Study: Lung Volume and Capacity Findings V T RV FRC TLC N or     VC IC ERV RV/TLC%    N V T RV FRC TLC N or     VC IC ERV RV/TLC%    N

22. Copyright © 2006 by Mosby, Inc. Slide 22 Arterial Blood Gases Mild to Moderate Fungal Disease  Acute alveolar hyperventilation with hypoxemia pH PaCO 2 HCO 3 - PaO 2    (Slightly)  pH PaCO 2 HCO 3 - PaO 2    (Slightly) 

23. Copyright © 2006 by Mosby, Inc. Slide 23 Time and Progression of Disease 100 50 30 80 0 0 Pa CO 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa O 2 Disease Onset Pa O 2 or Pa CO 2 Figure 4-2. Pa O 2 and Pa CO 2 trends during acute alveolar hyperventilation.

24. Copyright © 2006 by Mosby, Inc. Slide 24 Arterial Blood Gases Severe Fungal Disease with Pulmonary Fibrosis  Chronic ventilatory failure with hypoxemia pH PaCO 2 HCO 3 - PaO 2 Normal   (Significantly)  pH PaCO 2 HCO 3 - PaO 2 Normal   (Significantly) 

25. Copyright © 2006 by Mosby, Inc. Slide 25 Time and Progression of Disease 100 50 30 80 0 Pa O 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa CO 2 Chronic Ventilatory Failure Disease Onset Point at which disease becomes severe and patient begins to become fatigued Pa 0 2 or Pa C0 2 Figure 4-7. PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure.

26. Copyright © 2006 by Mosby, Inc. Slide 26 Acute Ventilatory Changes on Chronic Ventilatory Failure  Acute alveolar hyperventilation on chronic ventilatory failure  Acute ventilatory failure on chronic ventilatory failure

27. Copyright © 2006 by Mosby, Inc. Slide 27 Oxygenation Indices Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal Normal O 2 ER Sv O 2   Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal Normal O 2 ER Sv O 2  

28. Copyright © 2006 by Mosby, Inc. Slide 28 Hemodynamic Indices (Severe Fungal Disease) CVP RAPPAPCWP  Normal COSVSVICI NormalNormalNormalNormal RVSWILVSWIPVRSVR  Normal  Normal

29. Copyright © 2006 by Mosby, Inc. Slide 29 Abnormal Laboratory Tests and Procedures See Etiology and Primary Pathogen sections in this chapter

30. Copyright © 2006 by Mosby, Inc. Slide 30 Radiologic Findings Chest radiograph  Increased opacity  Cavity formation  Pleural effusion  Calcification and fibrosis  Right ventricular enlargement

31. Copyright © 2006 by Mosby, Inc. Slide 31 Figure 18-2. Acute inhalational histoplasmosis in an otherwise healthy patient. This young man developed fever and cough after tearing down an old barn. The study shows bilateral hilar adenopathy. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

32. Copyright © 2006 by Mosby, Inc. Slide 32 Figure 18-3. Histoplasmoma, showing a well-defined spherical nodule. The central portion of the nodule shows calcification. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

33. Copyright © 2006 by Mosby, Inc. Slide 33 General Management of Fungal Disease Pharmacologic agents  Amphotericin B (Fungizone)  Itraconazole (Sporanox)  Fluconazole (Diflucan)

34. Copyright © 2006 by Mosby, Inc. Slide 34 General Management of Fungal Disease Respiratory care treatment protocols  Oxygen therapy protocol  Bronchopulmonary hygiene therapy protocol  Hyperinflation therapy protocol  Mechanical ventilation protocol

35. See Next Slide for interpretation of each: Chen K. et.al. Chest 2001;120:177-184 ©2001 by American College of Chest Physicians

36. Copyright © 2006 by Mosby, Inc. Slide 36 Descriptions of chest x-rays in previous slide: Top, left: Aspergilloma. A 22-year-old man with diabetes mellitus presented with hemoptysis. Chest radiography shows a cavitary nodular lesion with air- crescent in the right lower lung. He underwent wedge resection and Aspergillus species was found. Top, right: Invasive aspergillosis. A 26-year-old woman with acute lymphoblastic leukemia status post bone marrow transplantation presented with fever. Chest radiography shows a consolidation in the left upper lung field. Aspergillus niger was isolated from specimen by percutaneous fine-needle aspiration. Middle, left: Cryptococcoma. A 53-year-old woman without any underlying diseases presented with cough. A posteroanterior chest radiograph shows a well-defined nodule in lateral aspect of the right middle lung area. She underwent thoracoscopic resection, and pathology findings revealed a cryptococcoma. Middle, right: Cryptococcal pneumonia. A 34-year-old man without any underlying diseases presented with dry cough, fever, and dyspnea. Chest radiography shows consolidations in the bilateral lower lung fields. The cryptococcal antigen titer of the aspiration specimen was 1:2,560. Bottom, center: Candida pneumonia. A 45-year-old woman with acute myeloblastic leukemia presented with fever. Chest radiography shows a lobar consolidation in the right upper lung field. C albicans was isolated from specimen of percutaneous fine-needle biopsy.

37. Copyright © 2006 by Mosby, Inc. Slide 37 Review  What is the most common fungal infection in the U.S.?  histoplasmosis  What is the common name for histoplasmosis?  Ohio Valley Fever  How does an individual acquire histoplasmosis?  Inhaling fungal spores released from the soil

38. Copyright © 2006 by Mosby, Inc. Slide 38  Which form of histoplasmosis is characterized by healed lesions in the hilar lymph nodes as well as a positive histoplasmin skin test response?  Latent asymptomatic disease  What form of histoplasmosis is most commonly seen in middle-aged Caucasian men who smoke?  Chronic pulmonary histoplasmosis  Which fungal disorder is associated with desert bumps, arthritis, or rheumatism?  Coccidioidomycosis

39. Copyright © 2006 by Mosby, Inc. Slide 39  What fungi causes the disease called San Joaquin Valley fever?  Coccidioides immitis  What fungi causes Chicago disease?  Blastomyces dermatitidis  Which fungi may be the most pervasive of all fungi?  Aspergillus fumigatus  Cryptococcus is most often seen in patients with what underlying conditions?  AIDS / patients undergoing steroid therapy

40. Copyright © 2006 by Mosby, Inc. Slide 40  What is the definition of refractory hypoxemia?  Hypoxemia that is not easily corrected by supplemental oxygen  What are the radiologic findings that can be seen with the stages of fungal infection?  Increased opacity  Cavity formation  Pleural effusion  Calcification and fibrosis  Right ventricular enlargement

41. Copyright © 2006 by Mosby, Inc. Slide 41 Classroom Discussion Case Study: Fungal Diseases of the Lung