What Are the Symptoms of a Fungal Infection of the Lungs?

Pulmonary fungal infections are bronchial-lung diseases caused by fungal infections, including primary and secondary pulmonary fungal infections. Fungal spores and other diseases caused by inhalation into the human lung are called primary pulmonary fungal infections. Fungal infections in other parts of the body are caused by lymph or blood to the lungs, and are called secondary pulmonary fungal infections.

Basic Information

Visiting department

Internal medicine

Common locations

Lungs

Common causes

Fungal infection

Common symptoms

Occult infection, flu-like symptoms, pneumonia, bronchitis, lung abscess, empyema, tumor-like manifestations, pulmonary embolism and pulmonary infarction, etc.

Causes of pulmonary fungal infections

Pulmonary fungal infections are allergies, purulent inflammatory reactions, or chronic granulomas caused by different pathogens. Pathogenic bacteria that cause fungal infections of the lower respiratory tract are divided into pathogenic fungi and conditional pathogenic fungi: Pathogenic fungi are primary pathogenic bacteria that often cause primary fungal infections, which can invade normal immune function hosts and have immune deficiency Patients easily cause systemic dissemination. The pathogenic fungi mainly include histoplasma, coccidioides, paracoccus, dermatitis, tinea pedis, and sporotrichosis. Conditional pathogenic fungi or opportunistic fungi, such as Candida, Aspergillus, Cryptococcus, Mucor and Penicillium, Rhizopus, Pleurotus, Fusarium and Pneumocystis. Most of these fungi are saprophytic fungi, which are weakly pathogenic to the human body, but when the host has susceptible factors, it will cause deep fungal infections, but clinical cases without clear host factors can also be seen. Common clinical fungal pathogens include Candida, Aspergillus, Mucor, Cryptococcus, and Histoplasma. In recent years, with the aging of the population, organ transplantation, tumor chemoradiation, hematopoietic stem cell transplantation, application of broad-spectrum antibiotics, corticosteroids, and various catheter interventions, the incidence of pulmonary fungal infections has increased year by year.

Clinical manifestations of pulmonary fungal infections

Pulmonary fungal infections are often secondary to severe primary disease, and symptoms and signs are often non-specific. The following clinical manifestations are possible:

Occult infection

Without obvious symptoms and signs, it can heal itself.

2. Flu-like symptoms

Manifestations include fever, chills, headache, runny nose, joint pain, and myalgia.

3. Lung Performance

(1) Pneumonia or bronchitis is the most common and difficult to distinguish from general bacterial pneumonia. There may be respiratory symptoms such as fever, cough, slightly white sticky sputum or purulent sputum, hemoptysis, chest tightness, asthma, etc. The lungs can hear dry and wet snoring sounds, which can be accompanied by small to moderate pleural effusion. (2) The clinical manifestations of tuberculosis-like histiocytosis and dermatitis bacillary disease are sometimes similar to tuberculosis, with respiratory symptoms such as dry cough, hemoptysis, chest pain, and "tuberculosis symptoms" such as low fever and night sweats in the afternoon.

(3) Pulmonary abscesses and empyema are often acute, and may include chills, high fever (mostly relaxation fever), cough, and mucopurulent sputum. Sometimes the odor in the sputum is obvious, and hemoptysis is mostly blood in the sputum.

(4) Tumor-like manifestations Such as pulmonary cryptococcoma, histoplasma, and coccidioidoma, etc., resemble peripheral lung cancer. Dermatitis blastomycosis, Aspergillus infection, etc. can damage ribs and vertebrae, as well as bone destruction of metastatic cancer.

(5) Pulmonary embolism and pulmonary infarction, such as vascular mucoid, is easy to invade blood vessels, and pulmonary infection often leads to pulmonary embolism or even pulmonary infarction, like pulmonary thromboembolism.

(6) Others can cause diffuse interstitial lung disease, or similar sarcoidosis.

Diagnosis of pulmonary fungal infections

The clinical manifestations of pulmonary fungal infections are non-specific, and the diagnosis is divided into confirmed, clinical, and intended based on the diagnostic criteria for invasive pulmonary mycosis (Grade 3). The diagnosis requires only microbiological evidence (smears and cultures) as determined by histological or sterile body fluid testing, and does not involve host factors. The clinical diagnosis needs to take into account host factors, clinical characteristics, and microbiological evidence. The proposed diagnosis is in accordance with host factors, clinical characteristics, and lack of microbiological evidence. Immunological detection of serum cell wall components (1,3) --D-glucan antigen test (G test), galactomannan antigen test (GM test) positive has important diagnostic value. The diagnosis of several common pulmonary fungal infections is described below:

Pulmonary candidiasis

It is found in high-risk groups such as agranulocytosis, central venous indwelling catheters, major abdominal surgery, hormone and antibiotic treatment, diabetes, renal insufficiency, and organ transplantation. The clinical symptoms include unexplained persistent fever and respiratory symptoms, but the signs are slight. Cough, even severe cough, a small amount of white mucus or thick sputum. Disseminated blood types often develop rapidly circulating and respiratory failure. X-rays showed bronchial pneumonia changes or sheet infiltration or fusion, and voids could be formed. Lower respiratory tract secretions, lung tissue, pleural effusion, blood smears or culture of Candida can confirm the diagnosis. Candida can not be diagnosed as fungal disease by directly smearing sputum or cultivating candida. Candida albicans can be found in the sputum of 10% to 20% of normal people. Qualified sputum) Candida cultured from the same species 2 times has diagnostic reference value. Positive blood culture Candida is a reliable diagnostic evidence of Candida bacteremia. Some patients have a positive G test (with the exception of false positives), which can provide an important reference for clinical diagnosis.

2. Aspergillosis of the lungs

The clinical manifestations are complicated, and there are three common types: allergic bronchopulmonary aspergillosis (more common allergies), aspergillus (the most common symptom is hemoptysis), and invasive pulmonary aspergillosis (for agranulocytosis or receiving broad-spectrum antibiotics, hormones, Unexplained fever, dry cough, chest pain, hemoptysis, etc. during immunosuppressant treatment. The diagnostic criteria for allergic bronchopulmonary aspergillosis include:

(1) Repeated asthma-like attacks;

(2) Increase in peripheral blood eosinophils 1X10 ⁹ / L;

(3) X-ray transient or migratory lung infiltration;

(4) total serum IgE concentration 1000mg / ml;

(5) Aspergillus antigen skin test positive;

(6) Serum precipitin antibody is positive;

(7) Increased titers of specific anti-Aspergillus IgE and IgG;

(8) Central cystic bronchiectasis.

Pulmonary aspergillus bulbs can be used for clinical diagnosis based on imaging features, but they need to be distinguished from other fungal bulbs, hamartomas, lung cancer, echinococcus cysts, and lung abscesses. Confirmation requires aetiology and histopathology. Pulmonary Aspergillus CT is characterized by round, dense cavities in the lung cavity or pleural cavity with transparent halos at its edges. If the cavity is large, spherical shadows and pedicles are still connected to the cave wall, which is shaped like a pendulum. The spherical shadows can change shape with changes in body position. If the cavity is small, the spherical lesion fills most of the cavity, and its vignette is small, showing only a long and narrow semilunar translucent band. CT characteristics of invasive pulmonary aspergillosis: early inflammation is the shadow of inflammation, and the surrounding area shows a mist-like exudation ("halo sign"), followed by consolidation of the air cavity of the inflammatory lesions, bronchial inflation signs can be seen, and then the lesions can be seen as semilunar The light zone ("Half Moon Sign") can be further transformed into a complete necrotic void. The diagnosis is based on the 3-level diagnostic criteria mentioned above. Positive GM test provides important reference.

3. Pneumococcal disease

The causative agents in Cryptococcus are mainly Cryptococcus neoformans and its variants (at least 9 species at present). Clinical symptoms and signs: From asymptomatic to acute pneumonia, the difference is very large and non-specific. Patients with meningitis may have meningeal irritation signs such as headache, dizziness and vomiting.

Imaging findings: Nodular or lumpy shadows are more common, accounting for 40% to 60%, single or multiple, and are seen in one or both lung fields, often under the pleura, varying in size, 1 to 10 cm in diameter, and marginal Smoothing can also appear as blurry or with small burrs. Cavities are often formed and the walls are relatively smooth. In the early stage, there can be uniform, unconventional low density areas in the nodular density shadow. Low-density necrosis or cavities with nodules or clumps accompanied by smoothing have important reference value for Cryptococcus pneumoniae, especially in multiple cases, such signs are more common in patients with sound immune mechanisms; pulmonary parenchymal infiltration accounts for 20% 40%, unilateral or bilateral, difficult to distinguish from other pathogens pneumonia, more common in patients with low immune function; diffuse miliary shadows or pulmonary interstitial lesions are rare, can occur in AIDS patients; pleural effusion is rare, Once there is, it is of great diagnostic significance to draw fluid for pathogen examination.

Etiology and histopathological examination: The positive rate of sputum and lower respiratory tract sampling culture is not high, and the specificity is low, but it still has reference value in AIDS or other immunosuppressed patients. Antigen detection: Polysaccharide antigen detection is highly specific for Cryptococcus capsular. The positive rate of serum antigen detection in patients with pulmonary cryptococcosis is <40%, so the use of BALF and pleural effusion is recommended. Histopathological examination: Where possible, a percutaneous or transbronchial lung biopsy should be used for histopathological examination. It is of diagnostic significance to see typical yeast-type bacteria with capsule, narrow neck, budding but sterile silk in granulomatous or jelly-like lesions. In the absence of host factors, imaging suggests that the disease may be diagnosed by percutaneous or bronchial lung biopsy whenever possible to avoid unnecessary surgery.

4. Pneumocystis pneumonia

The majority of this disease is seen in patients with AIDS and patients with other causes of cellular immunosuppression. Fever, dry cough, progressive dyspnea, and hypoxemia are the main clinical symptoms of this disease. Even though there are large changes in inflammation in the lungs, there are few signs. In early imaging, it showed diffuse alveolar and interstitial infiltrative shadows, and quickly merged into extensive pulmonary consolidation, showing bronchial inflation signs. The lung apex, base, and extrapulmonary zone are generally not involved. If the patient's fever persists for> 96 hours, he is not treated with active antibiotics. He also has symptoms and signs of lung infection: cough, sputum, hemoptysis, chest pain and dyspnea, and signs of lung snoring or pleural friction; It can be seen that in addition to the main clinical features, new non-specific pulmonary infiltrates need to consider this diagnosis. Sputum, phlegm guide, bronchoalveolar lavage specimens or lung biopsy specimens are still the basic diagnostic methods for this disease.

Pulmonary fungal infections treatment

Pulmonary candidiasis

(1) Bronchial candidiasis Fluconazole, itraconazole can also be selected; if it is identified as fluconazole-resistant non-candida albicans, oral voriconazole, echinocandins or amphotericin B can be administered intravenously. The course of treatment continued until the symptoms disappeared or the fungal culture of qualified sputum specimens was negative for 2 consecutive times.

(2) Primary candidiasis pneumonia Patients with stable condition are given intravenous infusion of fluconazole, and the oral condition is changed after oral improvement; Patients with unstable condition are given fluconazole combined with 5-fluorocytosine, and itracon can also be used Intravenous administration of azole; Fluconazole-resistant lung non-albicans candidiasis: select amphotericin B (except Candida albicans and Candida portugal), voriconazole, and echinocin.

(3) Secondary candidiasis pneumonia (including primary pulmonary candidiasis combined with dissemination) who have deep venous catheters should be removed and treated according to the condition: Stable patients are given intravenous infusion of fluconazole. Polytriazole (fluconazole, itraconazole) preventive medication can choose caspofungin or micafungin intravenous drip or amphotericin or lipid-containing amphotericin B; for unstable patients One method is to give amphotericin B (or equivalent dose of lipid-containing preparation), or oral or intravenous administration in combination with 5-fluorocytosine; negative blood culture, symptoms improved or disappeared, neutrophils After returning to normal levels, change to fluconazole orally for 14 days; another method is to give fluconazole + amphotericin B (or equivalent dose of fat-containing preparation) 5 to 6 days later, change to fluconazole orally; One method is to administer voriconazole or echinocandins.

(4) Candida or localized pulmonary disease. The drug treatment is not effective, but those who can tolerate the systemic condition can consider surgery. Allergic type is given symptomatic treatment, and hormones can be tried. The value of antifungal drugs is still uncertain.

2. Aspergillosis of the lungs

(1) Parasitic pulmonary aspergillus is recommended for frequent or massive hemoptysis. Surgical resection is recommended for those who cannot tolerate surgery. Bronchial arterial embolization can be used to stop bleeding; systemic application of antiaspergillus drugs is uncertain, and oral itraconazole may be beneficial;

(2) Allergic hormone therapy is preferred for 3 months; follow-up must be followed within 1 year. If there is an increase in total serum IgE or infiltration on X-ray chest radiographs, even if there are no symptoms, retreatment should be given in the acute phase ; Chronic hormone-dependent asthma and pulmonary fibrosis patients need long-term application of hormones, advocating taking medicine every other day to reduce adverse drug reactions, in recent years, tend to combine hormones with itraconazole and reduce the amount of hormones. Inhaling hormonal preparations can improve asthma symptoms without affecting the absorption of lung infiltration.

(3) Invasive type : voriconazole, itraconazole, caspofungin or micafungin, containing lipid amphotericin B. It is now generally believed that itraconazole can be selected as mild or moderate pulmonary aspergillosis or as an empirical drug, and voriconazole should be selected for patients with severe conditions. When patients can not tolerate other drugs or other drugs are ineffective, they should use echinocin Category, the rescue of very critically ill patients can be considered in combination.

3. Pneumococcal disease

(1) Cryptococcus pneumoniae in patients with normal immune function Asymptomatic patients: medical observation or oral fluconazole for 3 to 6 months; patients with mild to moderate symptoms: oral fluconazole or itraconazole, course of treatment 6 to 12 months; amphotericin B should be applied to those who cannot take orally. Severe patients: amphoteric toxin B (or equivalent dose of lipid-containing preparations) + 5-fluorocytosine, after fever or negative culture (about 6 weeks), switch to fluconazole orally for 24 months; combined with cryptococcus Meningitis patients: Amphotericin B + 5-fluorocytosine is preferred for 2 consecutive weeks, and then fluconazole maintenance therapy is used for at least 10 weeks; amphotericin B + 5-fluorocytosine can also be used for continuous 6 to 10 weeks .

(2) Cryptococcus pneumoniae of HIV / AIDS or other immunosuppressed persons Mild to moderately ill patients: fluconazole or itraconazole, doses with the same immune function and life-long use; Severe patients: amphotericin in the induction period B combined with 5-fluorocytosine for 2 weeks, fluconazole in the consolidation phase for 10 weeks, and subsequent life-long use of fluconazole; patients with cryptococcal meningitis: amphotericin B-10 5-fluorocytosis is preferred for intensive treatment Pyrimidine is continued for 2 weeks and then switched to fluconazole for at least 10 weeks. After the intensive phase treatment is completed, life-long maintenance treatment should be continued. The medicines for maintenance treatment are fluconazole and itraconazole.

(3) Indications for surgical treatment of pulmonary cryptococcosis Pulmonary cryptococcosis rarely requires surgical treatment, but for localized or recurrent localized disease that persists after antifungal therapy, surgical treatment can be considered.

4. Pneumocystis

TMP-SMZ is the first choice. It is taken orally. Therapeutic effect: AIDS patients respond slowly (5 to 9 days), have more adverse reactions, non-AIDS patients respond quickly (3 to 5 days), and have fewer adverse reactions. The course of treatment for AIDS complicated with PCP is 3 weeks, and patients with non-AIDs can be shortened to 14 days, and clinical treatment needs to be individualized according to the treatment response. Evaluation of TMP-SMZ ineffectiveness or treatment failure requires 4-8 days of observation before judging that it is ineffective and then switching to another protocol. Patients with AID should continue to take preventive medication after the course of treatment. Ammonium and ammonium-primavalin are the most effective alternatives for prevention. Patients who cannot tolerate sulfa may also be intolerant to ammonium.

Other lung fungal diseases include: Pulmonary Mucormycosis: Diabetic acidosis and neutropenia are important risk factors for the development of pulmonary Mucormycosis. The rapid control of such basic diseases is very important to improve the prognosis. Amphotericin B is currently clinically effective. Pulmonary tissue cytoplasmosis: Rarely seen in China. The clinical manifestations of this disease are diverse and quite similar to tuberculosis. People with normal immune function can be left untreated in mild cases. Itraconazole is used in patients with moderate or immune impairment. In the past, the course of treatment was 1 year. Recently, the short course is also considered to be applicable. In severe cases, amphotericin B was first applied to a total amount of 1.0 g, and then it was treated with itraconazole orally for 9 months. Itraconazole is not recommended for meningitis. Penicillium marneffei: Inhaled through the respiratory tract, the primary infection in the lungs, similar to tuberculosis or bacterial pneumonia, lung abscess, is easily spread by blood or lymph, mainly damages the reticuloendothelial system, showing the so-called Sexually disseminated Penicillium maneffei ". The diagnosis focuses on vigilance, and the diagnosis requires fungal culture identification and histopathological examination. Amphotericin B was selected for treatment. After 2 weeks, itraconazole was taken orally for 10 weeks. Itraconazole should be used for a long time.