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Chapter 18Chapter 18 Fungal Diseases of the Lung 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
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Anatomic Alterations of the LungsAnatomic Alterations of the Lungs
Alveolar consolidationAlveolar consolidation
Alveolar-capillary destructionAlveolar-capillary destruction
Granuloma formationGranuloma formation
Cavity formationCavity formation
Fibrosis of the lung parenchymaFibrosis of the lung parenchyma
Airway secretionsAirway secretions
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EtiologyEtiology
Histoplasmosis Histoplasmosis (most common fungal disease(most common fungal diseasein the United States)in the United States)
Screening and diagnosisScreening and diagnosis Fungal cultureFungal culture
Fungal stainFungal stain
SerologySerology
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EtiologyEtiology
CoccidioidomycosisCoccidioidomycosis
Screening and diagnosisScreening and diagnosis Direct visualization of distinctive spherulesDirect visualization of distinctive spherules
Blood test that detects antibodies of the fungusBlood test that detects antibodies of the fungus
Culture of the organismCulture of the organism
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EtiologyEtiology
BlastomycosisBlastomycosis
Screening and diagnosis and diagnosis Direct visualization of yeast in sputum smearsDirect visualization of yeast in sputum smears
Culture of the fungusCulture of the fungus
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EtiologyEtiology
Opportunistic pathogensOpportunistic pathogens
Candida albicansCandida albicans
Cryptococcus neoformansCryptococcus neoformans
AspergillusAspergillus
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Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Clinical Manifestations
Associated with Associated with FUNGAL DISEASES OF THE LUNGFUNGAL DISEASES OF THE LUNG
The following clinical manifestations result from The following clinical manifestations result from the pathophysiologic mechanisms caused (or the pathophysiologic mechanisms caused (or activated) by activated) by Alveolar ConsolidationAlveolar Consolidation (see (see Figure 9-8)Figure 9-8), , and and Increased Alveolar-Capillary Increased Alveolar-Capillary Membrane ThicknessMembrane Thickness (see Figure 9-9)—the (see Figure 9-9)—the major anatomic alterations of the lungs major anatomic alterations of the lungs associated with fungal diseases of the lung (see associated with fungal diseases of the lung (see Figure 18-1). Figure 18-1).
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Figure 9-8. Alveolar consolidation clinical scenario.
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Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.
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Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside
Vital signsVital signs
Increased respiratory rateIncreased respiratory rate
Increased heart rate, cardiac output, Increased heart rate, cardiac output, blood pressureblood pressure
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Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside
Chest pain/decreased chest expansionChest pain/decreased chest expansion
CyanosisCyanosis
Digital clubbingDigital clubbing
Peripheral edema and distentionPeripheral edema and distention Distended neck veinsDistended neck veins
Pitting edemaPitting edema
Enlarged and tender liverEnlarged and tender liver
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Digital Clubbing
Figure 2-46. Digital clubbing.Figure 2-46. Digital clubbing.
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DistendedDistendedNeck VeinsNeck Veins
Figure 2-48. Distended neck veins (Figure 2-48. Distended neck veins (arrowsarrows).).
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Figure 2-47. Pitting edema. From Bloom A, Ireland J: Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetesColor atlas of diabetes, ed 2,, ed 2,London, 1992, Mosby-Wolfe.London, 1992, Mosby-Wolfe.
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Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside
Cough, sputum production, and hemoptysisCough, sputum production, and hemoptysis
Chest assessment findingsChest assessment findings Increased tactile and vocal fremitusIncreased tactile and vocal fremitus
Dull percussion noteDull percussion note
Bronchial breath soundsBronchial breath sounds
Crackles, rhonchi, and wheezingCrackles, rhonchi, and wheezing
Pleural friction rubPleural friction rub
Whispered pectoriloquyWhispered pectoriloquy
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Figure 2-11. Figure 2-11. A short, dull, or flat percussion note is typically produced over areas A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.of alveolar consolidation.
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Figure 2-16. Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung Auscultation of bronchial breath sounds over a consolidated lung unit.unit.
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Figure 2-19. Figure 2-19. Whispered voice sounds auscultated over a normal lungWhispered voice sounds auscultated over a normal lungare usually faint and unintelligible.are usually faint and unintelligible.
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Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special
ProceduresProcedures
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Pulmonary Function Study: Pulmonary Function Study: Expiratory Maneuver FindingsExpiratory Maneuver Findings
FVC FEVT FEF25%-75% FEF200-1200
N or N or N
PEFR MVV FEF50% FEV1%
N N or N N or
FVC FEVT FEF25%-75% FEF200-1200
N or N or N
PEFR MVV FEF50% FEV1%
N N or N N or
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Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings
VT RV FRC TLC
N or
VC IC ERV RV/TLC%
N
VT RV FRC TLC
N or
VC IC ERV RV/TLC%
N
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Arterial Blood GasesArterial Blood Gases
Mild to Moderate Fungal DiseaseMild to Moderate Fungal Disease
Acute alveolar hyperventilation with Acute alveolar hyperventilation with hypoxemiahypoxemia
pH PaCO2 HCO3- PaO2
(Slightly)
pH PaCO2 HCO3- PaO2
(Slightly)
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Time and Progression of Disease Time and Progression of Disease
100100
5050
3030
8080
00
PaCO2
1010
2020
4040
Alveolar HyperventilationAlveolar Hyperventilation
6060
7070
9090 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
PaO2
Disease OnsetDisease OnsetP
aO2
or
PaC
O2
PaO
2 o
r P
aCO
2
Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.
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Arterial Blood GasesArterial Blood Gases
Severe Fungal Disease with PulmonarySevere Fungal Disease with PulmonaryFibrosisFibrosis
Chronic ventilatory failure with hypoxemiaChronic ventilatory failure with hypoxemia
pH PaCO2 HCO3- PaO2
Normal (Significantly)
pH PaCO2 HCO3- PaO2
Normal (Significantly)
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Time and Progression of DiseaseTime and Progression of Disease
100100
5050
3030
80
0
PaO2
1010
2020
4040
Alveolar HyperventilationAlveolar Hyperventilation
6060
7070
9090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
PaCO 2
Chronic Ventilatory Failure Chronic Ventilatory FailureDisease OnsetDisease Onset
Point at which disease becomes severe and patient begins to become fatigued
Point at which disease becomes severe and patient begins to become fatigued
Pa0
2 o
r P
aC0 2
Pa0
2 o
r P
aC0 2
Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.
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Acute Ventilatory Changes on Acute Ventilatory Changes on Chronic Ventilatory FailureChronic Ventilatory Failure
Acute alveolar hyperventilation on chronic Acute alveolar hyperventilation on chronic ventilatory failureventilatory failure
Acute ventilatory failure on chronic ventilatory Acute ventilatory failure on chronic ventilatory failurefailure
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Oxygenation IndicesOxygenation Indices
QS/QT DO2 VO2 C(a-v)O2
Normal Normal
O2ER SvO2
QS/QT DO2 VO2 C(a-v)O2
Normal Normal
O2ER SvO2
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Hemodynamic Indices Hemodynamic Indices (Severe Fungal Disease)(Severe Fungal Disease)
CVP CVP RAPRAP PAPA PCWPPCWP
NormalNormal
COCO SVSV SVISVI CICI
NormalNormal NormalNormal NormalNormal Normal Normal
RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR
NormalNormal NormalNormal
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Abnormal Laboratory Tests Abnormal Laboratory Tests and Proceduresand Procedures
See Etiology and Primary Pathogen See Etiology and Primary Pathogen sections in this chaptersections in this chapter
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Radiologic FindingsRadiologic Findings
Chest radiographChest radiograph
Increased opacityIncreased opacity
Cavity formationCavity formation
Pleural effusionPleural effusion
Calcification and fibrosisCalcification and fibrosis
Right ventricular enlargementRight ventricular enlargement
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Figure 18-2. Acute inhalational histoplasmosis in an otherwise healthy patient. This young man 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 developed fever and cough after tearing down an old barn. The study shows bilateral hilar
adenopathy. (From Armstrong P et al: adenopathy. (From Armstrong P et al: Imaging of diseases of the chest,Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.) ed 2, St. Louis, 1995, Mosby.)
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Figure 18-3. Histoplasmoma, showing a well-defined spherical nodule. The central portion of Figure 18-3. Histoplasmoma, showing a well-defined spherical nodule. The central portion of the nodule shows calcification. (From Armstrong P et al: the nodule shows calcification. (From Armstrong P et al: Imaging of diseases of the chest,Imaging of diseases of the chest,
ed 2, St. Louis, 1995, Mosby.)ed 2, St. Louis, 1995, Mosby.)
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General Management of General Management of Fungal DiseaseFungal Disease
Pharmacologic agents Pharmacologic agents
Amphotericin B (Fungizone)Amphotericin B (Fungizone)
Itraconazole (Sporanox)Itraconazole (Sporanox)
Fluconazole (Diflucan)Fluconazole (Diflucan)
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General Management of General Management of Fungal DiseaseFungal Disease
Respiratory care treatment protocolsRespiratory care treatment protocols
Oxygen therapy protocolOxygen therapy protocol
Bronchopulmonary hygiene therapy protocolBronchopulmonary hygiene therapy protocol
Hyperinflation therapy protocolHyperinflation therapy protocol
Mechanical ventilation protocolMechanical ventilation protocol
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Classroom DiscussionClassroom DiscussionCase Study: Case Study:
Fungal Diseases of the LungFungal Diseases of the Lung