Clinical Mycology Book

[Princesex Voskamp]

TheUK Clinical Mycology Network (UKCMN) is a structured network of laboratories with a steering committee to guide and promote best practice in clinical mycology. This is achieved through regular meetings for all members, input into PHE UK Standards for Microbiology Investigations guidelines, and National Institute for Health & Care Excellence guidelines, and co-ordination of the following:

Welcome to the International Society for Human and Animal Mycology (ISHAM) Clinical Mycology Course. This is a follow-on course to the ISHAM Diagnostic Mycology Course. At the end of this course, participants should have a good understanding of the clinical management of cryptococcal infections, invasive candidiasis, invasive mold infections, and endemic mycoses.

The course consists of 12 cases and addresses differential diagnosis, selection of therapeutics, pharmacokinetic considerations, and management of treatment failure for each pathogen. At the end of the course, there is a final examination. Participants who pass the final course exam will receive a certificate from ISHAM recognizing their participation in the course.

The cases in this course have been developed by four expert mycologists: Dr Martin Hoenigl, Dr Ilan S. Schwartz, Dr Matteo Bassetti, and the course chair, Dr John R. Perfect, the President-elect of the ISHAM. We wish to thank Dr H. Ruth Ashbee, Ms Julia Tushla, Dr Lisa Tushla, and Ms Theresa Corso-Stegmiller for editorial assistance.

Presented by Dr Ilan S. Schwartz 65-Year-Old Woman with Fever and Acute Respiratory Insufficiency

Presented by Dr Matteo Bassetti A 70-Year-Old Man with Prosthetic Valve Endocarditis

Presented by Dr Matteo Bassetti 56-Year-Old Man with Head Injury and Newly Diagnosed AML

Presented by Dr Martin Hoenigl Man with Long-Term Abdominal Discomfort Presenting with Fever

Presented by Dr Ilan S. Schwartz 41-Year-Old Male with Obesity and History of Stem Cell Transplant

Presented by Dr Martin Hoenigl A 45-Year-Old Man with a Hard Mass in his Thigh

Presented by Dr John R. Perfect 74-Year-Old Man in a Long-Term Care with Fever and Abdominal Pain

Presented by Dr Matteo Bassetti Nausea, Vomiting, and Headache in a Kidney-Transplant Patient

Presented by Dr John R. Perfect Please click here to begin the posttest/evaluation and generate your certificate of completion Faculty John R. Perfect, MDJohn R. Perfect, MD is James B Duke Professor of Medicine, Professor of Molecular Genetics and Microbiology and Chief of Infectious Diseases at Duke University. His general research focus for four decades has been on cryptococcosis: pathogenesis and management. He also investigates other fungal infections through basic, translational and clinical trials with a worldwide net of collaborators. He interacts as a consultant for many pharmaceutical companies in the antifungal space and holds multiple NIH grants to support his research. He has published approximately 650 papers and 7 books. He is a Fellow in the Infectious Disease Society of American, American Society of Microbiology, American Association for the Advancement of Science, and Association of American Physicians. At Duke he has been honored as University Scholar/Teacher of the year, Research Mentoring Award, and Alumni Associations Distinguished Faculty Award. He is recipient of the Maxwell Littman Award from Medical Mycology Society of New York, the Rhoda Benham Award from the Medical Mycology Society of the Americas, Lucille Georg Award from ISHAM, and the IDSA Edward H. Kass Lecturer. He has directly mentored or trained over 70 graduate students, post-docs, ID fellows or Junior Faculty at Duke. Along with his basic science research portfolio, he also teaches students and attends to patients at the bedside. He is Past-President of the Mycoses Study Group (MSG) based in USA and now President of the international Society of Human and Animal Mycology (ISHAM).

Matteo Bassetti is Head of the Infectious Diseases Clinic of the Policlinico San Martino University Hospital in Genoa and Full Professor of Infectious Diseases of the University of Genoa, Italy. Dr Bassetti studied at the University of Genoa School of Medicine and continued his medical education at the Yale University School of Medicine, New Haven, USA with an Infectious Diseases fellowship.

Dr Ilan S. Schwartz MD PhD FRCPC FECMM FIDSA is an Infectious Diseases physician-researcher at Duke University School of Medicine in Durham, NC. His clinical focus is in preventing and managing infections in immunocompromised hosts and his research involves emerging and endemic fungal infections. He is a co-author of multiple treatment guidelines for the endemic mycoses, including those from the European Confederation of Medical Mycology and Infectious Diseases Society of America. He serves on the board of directors of the Mycoses Study Group Education & Research Consortium and is an Associate Editor for Clinical Infectious Diseases.

Martin Hoenigl, M.D., Assoc. Prof., FECMM is an Associate Professor for Translational Mycology at the Division of Infectious Diseases, Medical University of Graz, Austria. He has obtained his venia docendi in internal medicine in 2012 and is author to over 290 pub med listed publications in the field of infectious diseases, the majority in leading authorships (i.e., first or last author; ORCiD: 0000-0002-1653-2824). Dr. Hoenigl has particular expertise in conducting research on clinical mycology, including fungal diagnostics and pharmacology of antifungal drugs and correlation with clinical findings. He is the current president of the European Confederation of Medical Mycology (ECMM), and the delegate of the Austrian Society for Medical Mycology (OEGMM). Dr. Hoenigl serves as Deputy Editor for the journal Mycopathologia, and associate editor for Mycoses. Dr. Hoenigl has been awarded with the Researcher of the year 2011 award at the Medical University of Graz, and with the Research Promotion award 2014 of the German Speaking mycological society.

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Despite the existence of endemic mycoses in Latin America and the Caribbean, in addition to a large population of patients at risk for invasive mycoses, the capability of medical centres to perform a proper diagnosis in mycology has not been studied in the region. Moreover, availability of antifungal drugs in the region is unknown. Here, we report the results of a survey involving 129 centres in 24 countries. Only 9% of centres would have the potential to apply for the minimum standards in mycology, as determined by the European Confederation of Medical Mycology. There is an urgent need to improve diagnostic conditions in Latin America and the Caribbean, as well as providing access to safer and more efficacious antifungal drugs.

Through the years, studies have shown the importance of the radiologic, molecular, and non-molecular methods for the diagnosis and follow-up of patients with invasive fungal infections (IFIs) and their impact on patient outcome.

(1) Accurate fungal species identification is essential. (2) Histopathology can be insightful, and the clinical mycology laboratory needs to collaborate with the pathology department for optimization of care. (3) Rapid diagnosis is important and biomarkers need to carefully replace or reduce spiraling antifungal empiricism. (4) Culture techniques need to be carefully integrated with rapid diagnostic methods. (5) IFIs are deadly but a combination of a receptive and progressive mycology laboratory and a small cadre of antifungal agents can save lives. (6) The clinical mycology laboratory needs to be carefully linked to clinical practices, antifungal stewardship, and infection control challenges.

In medical mycology today and particularly in high-risk patients for mold infections, such as those with hematological malignancies and bone marrow transplants, it is important to note that a primary tool for IFI diagnosis that does not necessarily utilize the medical mycology laboratory is radiology. For instance, high-resolution computer tomography (CT) may detect nodular infiltrates with or without ground glass attenuation (surrounding halo sign) in a high percentage of high-risk patients early in neutropenia [3]. Furthermore, as a mold infection progresses in the lung, a high-resolution CT pulmonary angiography can detect a vessel occlusion sign or angioinvasion, a hallmark of the invasive mold infection, seen in over 80% of macrodense infiltrates produced by mold infections. This specific radiographic finding can be appreciated and linked to invasive mold infections [4]. Along with these sensitive radiographic tests, the positron emission tomography (PET) scan has now been taken to a new level with the introduction of novel probes for non-invasive detection of Aspergillus lung infections. Antibody-guided PET and magnetic resonance (immunoPET/MR) imaging can now allow for increased specificity regarding the identification of lung lesion [5]. Although the immunoPET/MR is in its early stages of development, its principles may be extended routinely for the non-invasive diagnosis of IFIs with further refinements. It is clear that radiographs are an important part of the diagnostic strategy for IFIs and are encouraged to be used by clinicians early in evaluation of high-risk patients. However, it is also obvious that radiology still has significant limitations in identifying specific pathogens as well as measuring their susceptibility to antifungal agents. Therefore, the clinical mycology laboratory remains a pivotal and essential force in helping to accurately diagnose and manage IFIs. In the following discussion, the clinical mycology laboratory will be reviewed to identify what it can and should provide for the clinicians managing immunosuppressed patients at risk for development of an IFI.

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