# Opportunistic Fungi in Cancer and Hematopoietic Stem-Cell Transplant Patients: Diagnosis and Management Strategies
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Clinical Evaluation: Physical Examination

Examination of the skin is helpful in patients with IFI. Widespread erythematous maculopapular skin lesions, usually not noted until after engraftment, may be among the first signs of disseminated candidiasis.24 This rash can be difficult to distinguish from that of GVHD, but the fact that GVHD rash is likely to begin on the palms and soles and may be associated with a sclerotic dermatosis can help distinguish the one from the other.27

Cutaneous involvement with Aspergillus infection is caused by hematogenous seeding in the highly immunocompromised individual. These single or multiple lesions occur most often on the extremities. They first appear as indurated, erythematous, usually nontender papules, which subsequently become pustular, ulcerate and develop a black eschar.28-30 Aspergillus infection located at the exit site or tunnel of a Hickman catheter may represent a primary localized manifestation of airborne disease.

Infection with Fusarium species may present as cellulitis in the periorbital region of patients with sinus involvement, or around the nails in patients with onychomycosis. Widespread cutaneous involvement can occur. In contrast to aspergillosis, the skin lesions are usually painful and evolve from a subcutaneous nodule to a necrotic lesion with a central ulcer and a surrounding area of cellulitis.31

A dilated examination of the retina should be performed in patients with documented or suspected candidemia. Endophthalmitis may be one of the first manifestations of disseminated candidiasis, although it is rarely noted in neutropenic patients before engraftment.24

Inspection of the nasal septum and turbinates is important to establish early IFI of the sinuses due to aspergillosis, zygomycosis, or fusariosis. Localized pallor of the nasal mucosa, sometimes with a greyish tinge, hypesthesia to light touch, and the absence of bleeding on abrasion are all early warning signs.32 Purulent or bloody nasal discharge and nasal eschars warn of invasive fungal involvement, and face pain out of proportion to physical findings, or facial swelling and tenderness over sinus areas, should be aggressively pursued, as they are often associated with IFI.

Chest examination may reveal a pleural rub or localized wheezing, signs that may be indicative of infection with Aspergillus or other angioinvasive fungi. Hepatomegaly and/or splenomegaly is present in about 50% of patients with hepatosplenic candidiasis 26 and almost two-thirds have right upper quadrant or diffuse abdominal tenderness.33

Patients with new-onset focal neurologic signs should undergo immediate evaluation for IFI, especially for angioinvasive fungi such as Aspergillus and the Zygomycetes. An altered sensorium or mental state is also an early clue to cerebral involvement.

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Therapeutic Approaches to Fungal
   Clinical Evaluation: History
    Clinical Evaluation: Physical Examination
      Invasive Aspergillosis
      Hepatosplenic Candidiasis
   Histologic and Microscopic Examination
   Culture of Fungal Pathogens
   Testing for Fungal Antigens and DNA

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Course Number: V035D

This CME Expires on July 1, 2005; no tests will be accepted after this date.

This course is accredited by The University of Pittsburgh School of Medicine, Center for Continuing Education and The International Immunocompromised Host Society

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