Rare and Emerging Fungal Pulmonary Infections

Jay B. Varkey, MD; John R. Perfect, MD

Disclosures

Semin Respir Crit Care Med. 2008;29(2):121-131. 

In This Article

Conclusions

In this review, we attempted to provide insights into the major rare and emerging fungal pathogens that produce pulmonary disease. We did not emphasize signs, symptoms, and radiographic presentations because they are not particularly specific or helpful to the clinician. What is most important is that the clinician recognizes the host risk factors and immune status, and in unexplained pulmonary disease, there must be aggressive collection of pulmonary tissue for histopathology, culture, and possibly PCR identification. Proper identification of recovered fungi can allow prediction of disease-producing potential even when recovery is from nonsterile sites such as BAL fluid. On the other hand, the lung is exposed to a nonsterile environment, and some fungal spores cannot produce disease even in the "human petri dish" that some of our patients have become. For instance, even in lung transplant recipients, the frequent isolation from BALs of the very nonpathogenic species such as Penicillium, Rhinocladiella, and most Cladosporium species are rarely significant. However, if Cladophialophora bantiana or Dactylaria galloparum were grown from BAL, then searching for clinical disease is very important.

In Table 1 ,[85,89,90,91,92,93,94,95,96,97,98,99] we have listed several examples of some of the unusual fungi that have caused pulmonary disease. This list is not comprehensive, and it is likely that many more unusual fungi have and will continue to cause disease in the future, but this table helps one to appreciate that the combination of immune suppression and environmental exposure can produce the perfect condition for an unusual fungus to produce disease. In fact, the case of Fonsecaea pneumonia[89] illustrates another important principle. Rare fungi may be causing disease as a coinfection with another pathogen or even another fungus at the same or different site. The clinician must be aggressive in making the correct diagnosis, and then management is individualized. With several classes of antifungals, surgery and control of underlying disease, success in management can be achieved for these rare and emerging fungi, but we have to document that they are producing disease.

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