From the Guidelines
Fungal pneumonia is a respiratory infection caused by various fungi, with different types distinguished by the causative organism, clinical presentation, and treatment approach. The most common types of fungal pneumonia include:
- Pneumocystis pneumonia (PCP), caused by Pneumocystis jirovecii, which primarily affects immunocompromised patients and presents with fever, dry cough, and progressive shortness of breath.
- Aspergillus pneumonia, caused by Aspergillus species, often affects severely immunocompromised patients and presents with fever, cough, chest pain, and hemoptysis.
- Cryptococcal pneumonia, caused by Cryptococcus neoformans, presents with cough, chest pain, and fever, and is treated with fluconazole 400 mg daily for mild to moderate cases or amphotericin B plus flucytosine for severe cases.
- Histoplasmosis pneumonia, endemic to certain regions, is treated with itraconazole 200 mg three times daily for three days, then twice daily for at least 12 weeks.
- Coccidioidomycosis, caused by Coccidioides species, is treated with fluconazole 400 mg daily for mild to moderate cases or amphotericin B for severe cases, as recommended by the 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis 1.
Diagnosis typically requires identification of the fungal organism through cultures, serological tests, or molecular methods, with treatment duration varying based on infection severity and immune status. The treatment approach should prioritize the use of antifungal medications, such as fluconazole, voriconazole, and amphotericin B, and may involve surgical intervention in certain cases, such as cavitary lesions or empyema. It is essential to note that the treatment of fungal pneumonia should be guided by the specific type of fungus causing the infection, as well as the patient's underlying health status and immune function, as recommended by the 2016 IDSA clinical practice guideline for the treatment of coccidioidomycosis 1 and other studies 1.
In terms of diagnosis, imaging studies such as computed tomography (CT) scans and magnetic resonance imaging (MRI) can be helpful in identifying the extent of lung involvement and guiding treatment decisions, as discussed in the Annals of Oncology study 1 and the Blood Cancer Journal study 1. The use of CT scans with angiography may increase the diagnostic specificity in some patients with pulmonary mold infections, but this method has not yet become widely applied. Follow-up thoracic CT scans should not be ordered less than 7 days after the start of treatment, as patients with invasive pulmonary aspergillosis (IPA) may show increasing volume of pulmonary infiltrates during the first week despite effective antifungal therapy, as discussed in the Annals of Oncology study 1 and the Annals of Oncology study 1.
Overall, the treatment of fungal pneumonia requires a comprehensive approach that takes into account the specific type of fungus causing the infection, the patient's underlying health status, and the extent of lung involvement, as recommended by the 2016 IDSA clinical practice guideline for the treatment of coccidioidomycosis 1 and other studies 1.
From the Research
Types of Fungal Pneumonia
- Aspergillosis
- Cryptococcosis
- Candidiasis
- Coccidioidomycosis
- Histoplasmosis
- Blastomycosis 2
Diagnostic Challenges
- Fungal pneumonias can be a diagnostic problem, especially in immunocompromised hosts 3
- Recognition of fungal pneumonia is important due to the significant health risk it poses, particularly in immunocompromised individuals 4
- Diagnosis requires consideration of host factors, epidemiologic exposures, suggestive radiographic patterns, and the presence of a non-resolving pneumonia 4
Diagnostic Approaches
- Imaging studies, such as chest computed tomographic (CT) imaging, can help guide treatment and improve survival in immunocompromised patients with suspected invasive fungal pneumonia 5
- Laboratory tools, including microscopy, culture, serological testing, and molecular testing, are used to diagnose fungal respiratory disease 6
- Knowledge of clinically important fungal pathogens, their epidemiology, and associated clinical syndromes is key in guiding appropriate diagnostic testing and result interpretation 4
Treatment Considerations
- Clinicians should consider the most appropriate and aggressive treatment of fungal pneumonias in immunocompromised patients 2
- Practice guidelines for the treatment with commonly used antifungal agents, including amphotericin B, fluconazole, itraconazole, ketoconazole, and flucytosine, are useful for managing the disease 2
- Newer antifungal agents, such as echinocandins and second-generation triazoles, may help overcome the limitations of current therapy 2