Superficial fungal infections

Superficial fungal infections are problems frequently encountered by the pediatrician. Presentation can be quite varied as causative organisms, environment, patient characteristics and secondary infections can significantly alter the clinical picture. A brief review of these common infections with an approach to examination and diagnosis is presented, as well as updated treatment recommendations.     

Neonatal cutaneous fungal infections

PURPOSE OF REVIEW: Cutaneous fungal infections are not uncommon in newborns and are seen in premature or otherwise immunocompromised neonates as well as in healthy full-term neonates. Healthy newborns can develop clinical manifestations as a result of infection with Candida species or as a result of skin colonization with Malassezia species; cutaneous infection with other fungal pathogens is rare. Immunocompromised and premature neonates, however, are susceptible to infection with opportunistic pathogens and are also at higher risk for invasive infection with common pathogens such as Candida. This review discusses the fungal species associated with cutaneous fungal infection in neonates, emphasizes the relevant clinical features, and also reviews the use of newer antifungal agents, including lipid-associated amphotericin B, voriconazole, and caspofungin. RECENT FINDINGS: Neonatal cutaneous infections with opportunistic fungal pathogens, including Aspergillus and the Zygomycetes, have been reported with increasing frequency as advances in neonatal care have improved the survival rate in very low birthweight neonates. Although these infections are frequently fatal, survival in some neonates has been reported with the use of aggressive surgical debridement and systemic antifungal therapy. Newer antifungal agents, including voriconazole and caspofungin, show promise in the treatment of potentially fatal fungal infections in neonates. SUMMARY: Cutaneous fungal infections in neonates range from generally benign conditions such as congenital candidiasis and neonatal cephalic pustulosis to potentially fatal infections with opportunistic pathogens in very low birthweight or immunocompromised neonates. The prompt recognition and appropriate treatment of cutaneous fungal disease in neonates is critical to the prevention of adverse outcomes.     

Systemic fungal infections in neonates

Systemic fungal infections, previously considered to be a rare complication, are now frequently diagnosed in VLBW infants receiving intensive care. Confirming the diagnosis by laboratory tests is difficult and a high index of suspicion is required. Prompt and aggressive use of antifungal treatment is justified in a clinically septic neonate, especially those with a raised serum concentration of C reactive protein, who do not show a satisfactory response to antibiotics. The newer generation of liposomal amphotericin and azole antifungal drugs appear to be safe, effective, and well tolerated. With increasing awareness, prompt treatment, and better neonatal intensive care, the outcome of systemic fungal infection in preterm infants should improve.     

真菌和侵袭性真菌肺部感染的微生物学和病理学特点

儿童侵袭性肺真菌感染(IPFIs)诊治指南(2009版)已发表,指南对IPFIs的诊断及治疗作了详细的论述,在学习和讨论指南时,我们对真菌以及侵袭性真菌感染的一些基础问题进行复习和讨论.     

儿童侵袭性肺部真菌感染

近年来,儿童侵袭性肺部真菌感染病例有上升趋势,早期诊断和及时治疗对于降低病死率非常重要.本文介绍了儿童侵袭性肺部真菌感染的发生因素、临床和影像学表现、微生物检查、诊断和治疗,以期提高对本病的诊治水平.     

儿童侵袭性肺部真菌感染

近年来,儿童侵袭性肺部真菌感染病例有上升趋势,早期诊断和及时治疗对于降低病死率非常重要.本文介绍了儿童侵袭性肺部真菌感染的发生因素、临床和影像学表现、微生物检查、诊断和治疗,以期提高对本病的诊治水平.     

侵袭性真菌感染及治疗策略

近年来，全球侵袭性真菌感染（invasive fungal infections，IFI）的发病明显增加，儿童IFI亦呈增加趋势，而且在医院内感染中居重要位置。由于IFI常发生在有严重基础疾病的患儿，其临床表现和组织病理变化与其他许多疾病很相似，使诊断存在一定难度，临床上容易出现误诊和漏诊，延误治疗，病死率很高。所以，IFI的诊治已成为儿科当前的重要问题。     

Treatment of fungal infections in neutropenic children

Fungal infections have emerged as one of the most significant complications of antineoplastic therapy and marrow transplantation in children. Morbidity and mortality associated with fungal infections are high. Recent trends indicate that the incidence and spectrum of fungal infections are increasing, partly because of the increase in the number of children receiving intensive chemotherapy and marrow transplantation, but also because of the successful management of bacterial and viral infections. Though many factors may contribute to risk for developing a fungal infection, prolonged neutropenia is the most important. Until recently, options for antifungal therapy were limited. Advances include less toxic formulations of amphotericin B and an expanding armamentarium of azoles as well as new antifungal compounds. This review addresses the therapeutic options available for treatment of fungal infections in immunocompromised children.     

Pulmonary fungal infections after bone marrow transplantation

Of 319 pediatric patients treated with bone marrow transplantation (BMT) during a 10-year period, 27 developed pulmonary fungal infections (PFI). Only 2 patients (7%) survived. Twenty-three patients (85%) had been treated with systemic antifungal therapy immediately before or at the time of diagnosis. Nineteen patients (70%) were neutropenic, and 4 of the 8 patients who were not neutropenic were being treated with systemic steroids for graft vs. host disease (GVHD). Seven patients (26%) died within 7 days of diagnosis. The diagnosis was made ante-mortem in 9 patients (33%). Radiographic abnormalities were variable. At the onset of chest X-ray (CXR) change, the pulmonary infiltrates were unilateral in 14 patients (52%) and, at diagnosis, bilateral in 18 (66%). At diagnosis the infiltrates were interstitial in 3 patients (11%), alveolar in 20 (74%) and mixed in 4 (15%). Six patients (22%) developed cavitary lesions. The infecting agents were Aspergillus in 21 patients (78%), Candida in 7 (26%), Mucormycosis in 3 (11%), and Fusarium in 1 (4%). Five patients (19%) had mixed fungal infections and 7 (26%) had concurrent cytomegalovirus (CMV) pulmonary infections. Although the radiographic changes are often nonspecific in PFI, alveolar or nodular infiltrates in neutropenic patients or in those being treated for GVHD should strongly suggest a fungal etiology.     

Emerging fungal infections in the immunocompromised host

Over the last 2 decades, numerous factors, including advances in cancer chemotherapy and transplant medicine and the emergence of immunocompromising illnesses such as acquired immunodeficiency syndrome, have led to the emergence of a population of vulnerable hosts with special needs. Invasive fungal infections caused by long-recognized pathogens such as Candida species and Aspergillus species, as well as emerging fungi such as Pseudallescheria species, Alternaria species, and Fusarium species, have been noted to be an important cause of mortality and morbidity. This article reviews the existing experience in diagnosis and treatment of many of such fungal infections, with a focus on immunocompromised children. A high index of suspicion for fungal infection in an immunocompromised child on broad spectrum antibiotics, especially with pneumonia, sinusitis, or new skin lesions; early and aggressive use of currently available antifungal agents; and measures directed toward reversal of the underlying predisposing conditions are key factors for a favorable outcome. Copyright © 2001 by W.B. Saunders Company     

Systemic fungal infections in south Indian infants

Systemic fungal infections were identified in 13 of 1468 necropsies of infants dying in the 1st year of life in a south Indian hospital. Candidiasis was present in 11 infants, most often as pneumonia or enteritis. Spread to other organs occurred in four cases. Intestinal candidiasis was associated with zygomycosis of the intestine in one infant and with aspergillosis of the lungs and intestine in another. One case of aspergillosis of the myocardium and one of gastric zygomycosis were also diagnosed. Septicaemia, broad spectrum antibiotic therapy, surgery and congenital abnormalities, including immune deficiencies, were important predisposing factors.     

Chitotriosidase in neonates with fungal and bacterial infections

Increased plasma and/or urine chitotriosidase activity was found in neonates with fungal infection changing in parallel with their clinical condition. Increased levels were also found in neonates with bacterial infection. Chitotriosidase activity increase is not a response specific to fungi, but serial assays could monitor the course of neonatal fungal infection.     

儿童侵袭性真菌感染临床分析

目的 分析、总结儿童侵袭性真菌感染的临床特点,以利早期诊断,改善预后.方法 回顾分析2001年至2007年住院确诊侵袭性真菌感染的6例患儿临床资料.结果 全部患儿伴有基础疾病,并且都有发热.肺部感染4例,CT扫描出现新月征或气环征2例.肺外感染2例.半乳甘露聚糖试验1/5患儿阳性.4/6患儿为曲霉菌感染.主要以二性霉素B或二性霉素B脂质体治疗,4/6患儿治愈,1例死亡.结论 恶性血液系统疾病和严重免疫抑制是儿童侵袭性真菌感染发病的重要因素.患儿临床表现缺乏特异性,应结合影像学及实验室检查全面考虑进行诊断,曲霉菌感染常见.二性霉素B治疗儿童侵袭性真菌感染有效.     

Ethanol locks therapy for resolution of fungal catheter infections

Ethanol locks have been used to treat catheter infections and to decrease the rate at which they occur. Catheter-related infections caused by Candida spp. are especially difficult to manage medically and usually require catheter removal. We report 3 consecutive patients whose catheter infections caused by Candida were successfully treated with a combination of ethanol lock therapy and systemic antifungals.     

儿童侵袭性真菌感染早期诊断的研究进展

侵袭性真菌感染多见于免疫受损人群,随着侵入性诊疗手段的提高和运用及免疫抑制剂和广谱抗生素的大量使用,儿童中的发病率呈逐年上升趋势.目前尚缺乏快速的诊断方法,其实验室早期诊断对临床至关重要.近年来,血清学和分子生物学检测方法的进步推动了早期诊断研究.     

Bacterial and fungal infections after cardiac surgery in children

Of 245 children operated on for congenital heart diseases in 1983–1984, bacterial and fungal infections occurred in 3.6% compared to 17.8% of 469 in 1968–1972. Staphylococcal infections decreased from 3.4%–0.8% and those by gramnegative bacteria from 6.9%–0%;Candida albicans infections increased from 0%–1.2%. Perioperative prophylaxis was performed with cefotaxime plus piperacillin in 1983–1984 versus oxacillin plus ampicillin in 1968–1972. It is argued that reduction of the infection rate is not only due to newer and more effective antibiotics but is mainly related to more advanced surgical techniques and improved hygiene in our intensive care units.