5-62
(sepsis)
Auscultation: coarse breath sounds, pleural friction rub
Palpation: hepatomegaly and/or splenomegaly may be seen in disseminated infection
Using Advanced Tools: CXR: Hilar or mediastinal lymphadenopathy with or without patchy infiltrates. Lab:
KOH identification on smear of sputum is usually quite difficult. Organism is a small, budding yeast (2-4 μm)
often found inside macrophages.
Assessment:
Differential Diagnosis (see respective topics)
Acute pulmonary infection - influenza
Chronic pulmonary infection - tuberculosis, other fungal infections
Plan:
Treatment
Primary: Therapy is not needed in asymptomatic or acute pulmonary infection unless associated with
hypoxemia or symptoms longer than one month. Itraconazole 200 mg daily for 6-12 weeks, can be given
in those cases that do not spontaneously improve/resolve. For severe infection, including acute or chronic
pulmonary disease, disseminated disease or meningitis, give amphotericin B 0.7-1 mg/kg IV daily. This
therapy can be changed to intraconazole 200 mg once or twice daily, for 6-24 months when clinically stable or
continued for 3-4 months (35 mg/kg total amphotericin B).
Alternative: Ketoconazole 200-800 mg/day can be used as an alternative to itraconazole.
Patient Education
General: Most acute pulmonary infections resolve spontaneously in 3-4 weeks.
Medications: See precautions listed for oral azoles (itraconazole, ketoconazole) and IV amphotericin B
in the Candidiasis section.
Prevention and Hygiene: Encourage others to avoid areas where patient was exposed.
Follow-up Actions
Return evaluation: Follow-up is required in chronic infection and during long term anitfungal therapy.
Evacuation/Consultation Criteria: Evacuate all chronic and disseminated cases for referral to specialty
care.
NOTES: Lung granulomas, and hilar and splenic calcifications are commonly seen on CXR of persons who
have had acute pulmonary histoplasmosis in the past. Outside the endemic area however, lung granulomas
and hilar calcifications more commonly represent inactive tuberculosis.
Zoonotic Disease Considerations
Principal Animal Hosts: Dogs
Clinical Disease in Animals: Nonspecific, dependent on organ involvement; emaciation, chronic cough,
persistent diarrhea, fever, anemia, hepatomegaly, splenomegaly, lymphadenopathy; ulcerative lesions on skin;
ocular disease
Probable Mode of Transmission: Environmental (aerosol) exposure primarily in river valleys
Known Distribution: Worldwide
ID: Paracoccidioidomycosis
(South American Blastomycosis)
LTC Duane Hospenthal, MC, USAIntroduction: Paracoccidioides brasiliensis is a dimorphic fungus that typically causes chronic, progressive,
pulmonary disease in rural male workers. It may occur in individuals who live in or have visited the forests
of Central or South America and southern Mexico, and present with mucocutaneous lesions of the face.
Incubation may be prolonged up to 15 years.