FungusFungus

Danielle Hansen, DODanielle Hansen, DO

Internal Medicine Lecture SeriesInternal Medicine Lecture Series

April 4, 2007April 4, 2007

Predisposing FactorsPredisposing Factors ImmunosuppressedImmunosuppressed Broad-Spectrum AntibioticsBroad-Spectrum Antibiotics Central Venous CathetersCentral Venous Catheters TraumaTrauma BurnsBurns Total Parenteral NutritionTotal Parenteral Nutrition Hemodialysis or Peritoneal DialysisHemodialysis or Peritoneal Dialysis Abdominal SurgeryAbdominal Surgery GI Tract Perforations and Anastomotic LeaksGI Tract Perforations and Anastomotic Leaks Gradual OnsetGradual Onset

DermatophytesDermatophytes

RingwormRingworm 5 Million DO Visits Annually5 Million DO Visits Annually >$200 Million>$200 Million TypesTypes

EpidermophytonEpidermophyton TrichophytonTrichophyton MicrosporumMicrosporum

DiagnosisDiagnosis KOH TestKOH Test CultureCulture

Gray Patch Tinea CapitisGray Patch Tinea Capitis

Microsporum CanisMicrosporum Canis Animal to Person SpreadAnimal to Person Spread Erythematous, Scaling, Erythematous, Scaling,

Well-DemarcatedWell-Demarcated Spreads Weeks – MonthsSpreads Weeks – Months Persists for YearsPersists for Years Hair Breaks off at 1-2mmHair Breaks off at 1-2mm KerionKerion Fluoresce under Woods Fluoresce under Woods

LampLamp

Black Dot Tinea CapititsBlack Dot Tinea Capitits

African AmericansAfrican Americans Person to Person Person to Person

SpreadSpread Erythematous, Erythematous,

ScalingScaling Slowly EnlargesSlowly Enlarges Hair Breaks off FlushHair Breaks off Flush KerionKerion Do Not FluoresceDo Not Fluoresce

Tinea Capitis TreatmentTinea Capitis Treatment

GriseofulvinGriseofulvin 250mg PO BID x 6-12 250mg PO BID x 6-12 weeksweeks

Terbinafine 250mg PO QD x 4 weeksTerbinafine 250mg PO QD x 4 weeks ItraconazoleItraconazole FluconazoleFluconazole

Tinea PedisTinea PedisACUTEACUTE CHRONICCHRONIC

Trichophyton Trichophyton MentagrophytesMentagrophytes Trichophyton RubrumTrichophyton Rubrum

Vesicular LesionsVesicular Lesions Interdigital FissuresInterdigital Fissures

Sole, Between ToesSole, Between Toes Sole, Between Toes, Sole, Between Toes, TopTop

Self-LimitedSelf-Limited Persists IndefinitelyPersists Indefinitely

Tinea Pedis TreatmentTinea Pedis Treatment

Topical Antifungal x 4 weeksTopical Antifungal x 4 weeks Oral AntifungalOral Antifungal

Griseofluvin 250 – 500mg BIDGriseofluvin 250 – 500mg BID Terbinafine 250mg QDTerbinafine 250mg QD Itraconazole 200mg QDItraconazole 200mg QD

Foot PowderFoot Powder Non-occlusive FootwearNon-occlusive Footwear

Topical AntifungalsTopical Antifungals

Tinea CorporisTinea Corporis

Pruritic, Circular, Erythematous Pruritic, Circular, Erythematous Scaling LesionScaling Lesion

Spreads CentifugallySpreads Centifugally Central ClearingCentral Clearing Raised, Advancing BorderRaised, Advancing Border

Tinea Corporis TreatmentTinea Corporis Treatment

Topical AntifungalsTopical Antifungals

Tinea CrurisTinea Cruris

Men > WomenMen > Women ObesityObesity Foot to GroinFoot to Groin Macular, ErythematousMacular, Erythematous Speads CentrifugallySpeads Centrifugally Partial Central ClearingPartial Central Clearing Raised, Sharply Demarcated BorderRaised, Sharply Demarcated Border Tiny VesiclesTiny Vesicles

Tinea Cruris TreatmentTinea Cruris Treatment

Topical AntifungalsTopical Antifungals Systemic Antifungals if Resistant to Systemic Antifungals if Resistant to

TopicalsTopicals Recurs if Fail to Treat Tinea PedisRecurs if Fail to Treat Tinea Pedis Talcum or Desiccant PowderTalcum or Desiccant Powder No Hot BathsNo Hot Baths Loose Fitting ClothingLoose Fitting Clothing

Topical AntifungalsTopical Antifungals

Candidal IntertrigoCandidal Intertrigo

Skin FrictionSkin Friction ObesityObesity Chafing ClothingChafing Clothing Rubbing ActivitiesRubbing Activities

MoistureMoisture ObesityObesity Occlusive ClothingOcclusive Clothing HyperhidrosisHyperhidrosis

DMDM CorticosteroidsCorticosteroids ABXABX HIVHIV ChemotherapyChemotherapy ImmunosuppresantsImmunosuppresants Occupational Occupational

Exposure to SugarExposure to Sugar

Candidal IntertrigoCandidal Intertrigo

Erythematous, Erythematous, Macerated Plaques Macerated Plaques and Erosionsand Erosions

Peripheral ScalingPeripheral Scaling Satelite Satelite

PapulopustulesPapulopustules PruriticPruritic KOH TestKOH Test CultureCulture

Candidal Intertrigo Candidal Intertrigo TreatmentTreatment

Topical AntifungalTopical Antifungal Drying AgentsDrying Agents

Antifungal PowdersAntifungal Powders Aluminum Acetate SolutionAluminum Acetate Solution Gentian VioletGentian Violet Talcum PowderTalcum Powder

Systemic AntifungalsSystemic Antifungals

Topical AntifungalsTopical Antifungals

OnychomycosisOnychomycosis

Distal Distal SubungualSubungual

Proximal Proximal SubungualSubungual

White White SuperficialSuperficial

YeastYeast

Great ToeGreat Toe HIVHIV Fingernails, Fingernails, ImmunodeficieImmunodeficie

ntnt

White/Brown/White/Brown/

YellowYellowDull White Dull White

SpotsSpotsThick, Thick,

Yellow/BrownYellow/Brown

Distal to Distal to CuticleCuticle

Proximal to Proximal to DistalDistal

CentrifugallyCentrifugally

Onychomycosis TreatmentOnychomycosis Treatment

Indications for TreatmentIndications for Treatment Cellulitis in LECellulitis in LE Diabetics with Additional Risk Factor for CellulitisDiabetics with Additional Risk Factor for Cellulitis PainPain CosmeticsCosmetics

Terbinafine 250mg/day x 6-12wks Terbinafine 250mg/day x 6-12wks Itraconazole 200mg/day x 6-12wks or Itraconazole 200mg/day x 6-12wks or

200mg/day x 7days/month x 2 mo200mg/day x 7days/month x 2 mo SurgerySurgery

OtomycosisOtomycosis

External Auditory CanalExternal Auditory Canal 6.5 – 12.5% of Otitis Externa6.5 – 12.5% of Otitis Externa 61+ Species of 28 Genera61+ Species of 28 Genera

Aspergillus NigerAspergillus Niger CandidaCandida

Tropical and Subtropical RegionsTropical and Subtropical Regions Swimming, Canal CleaningSwimming, Canal Cleaning Antibiotic Ear DropsAntibiotic Ear Drops

Otomycosis Clinical Otomycosis Clinical ManifestationsManifestations

ItchingItching Sensation of Something in EarSensation of Something in Ear DiscomfortDiscomfort DischargeDischarge

Otomycosis TreatmentOtomycosis Treatment

Clean CanalClean Canal SteroidsSteroids AntisepticsAntiseptics

Gentian VioletGentian Violet CresylateCresylate MerthiolateMerthiolate

Acidifying SolutionsAcidifying Solutions VoSolVoSol Otic DomeboroOtic Domeboro

AntifungalsAntifungals Drying AgentsDrying Agents

A. NigerA. Niger C. C. AlbicansAlbicans

C. C. ParapsilosisParapsilosis

Amphotericin BAmphotericin B ++ ++++ ++++

ClotrimoazoleClotrimoazole ++++ ++++ ++++

FlucytosineFlucytosine 00 00 00

MiconazoleMiconazole ++ ++++ ++++

NatamycinNatamycin ++++ ++ ++

NystatinNystatin ++ ++++ ++++

TolnaftateTolnaftate 00 00 00

Fungal EndophthalmitisFungal Endophthalmitis

EpidemiologyEpidemiology Trauma Trauma SurgerySurgery Hematogenous Seeding Hematogenous Seeding

of Retina and Choroidof Retina and Choroid

Clinical ManifestationsClinical Manifestations Eye PainEye Pain Gradual Decrease in Gradual Decrease in

Visual AcuityVisual Acuity Focal, Glistening, White, Focal, Glistening, White,

Infiltrative, Mound-like Infiltrative, Mound-like Lesion on RetinaLesion on Retina

Vitreal HazeVitreal Haze Fluffy, White Balls in Fluffy, White Balls in

VitreousVitreous

Fungal EndophthalmitisFungal Endophthalmitis

IV AntifungalIV Antifungal Intravitreal AntifungalIntravitreal Antifungal Surgical Removal of Vitreous and Surgical Removal of Vitreous and

Foreign MaterialForeign Material

Oropharyngeal CandidiasisOropharyngeal Candidiasis

EpidemiologyEpidemiology Elderly with DenturesElderly with Dentures AntibioticsAntibiotics Inhaled CorticosteroidsInhaled Corticosteroids ChemotherapyChemotherapy Radiation of Head and NeckRadiation of Head and Neck Cellular Immune DeficiencyCellular Immune Deficiency XerostomiaXerostomia

Clinical ManifestationsClinical Manifestations Cotton MouthCotton Mouth Loss of TasteLoss of Taste OdynophagiaOdynophagia Pain with DenturesPain with Dentures

Oropharyngeal CandidiasisOropharyngeal Candidiasis Diagnosis Diagnosis

White Plaques on White Plaques on Buccal Mucosa, Buccal Mucosa, Palate, Tongue, Palate, Tongue, Oropharynx, under Oropharynx, under DenturesDentures

Budding Yeast with Budding Yeast with or without or without Pseudohyphae from Pseudohyphae from ScrapingScraping

TreatmentTreatment Nystatin Swish and Nystatin Swish and

Swallow 5x/day Swallow 5x/day Fluconazole 200mg Fluconazole 200mg

x1, then 100mg QD x1, then 100mg QD Chlorhexidine Chlorhexidine

Gluconate Soak for Gluconate Soak for DenturesDentures

Duration of Duration of Treatment 7-14 daysTreatment 7-14 days

Candida EsophagitisCandida Esophagitis EpidemiologyEpidemiology

HIVHIV Hematologic Hematologic

MalignaniesMalignanies ThrushThrush

Clinical ManifestationsClinical Manifestations OdynophagiaOdynophagia

DiagnosisDiagnosis White Mucosal Plaque-White Mucosal Plaque-

like Lesions on EGDlike Lesions on EGD Biopsy Shows Yeast and Biopsy Shows Yeast and

Pseudohyphae Invading Pseudohyphae Invading Mucosal CellsMucosal Cells

Culture + CandidaCulture + Candida TreatmentTreatment

Fluconazole 100-200mg Fluconazole 100-200mg QD x 14-21 daysQD x 14-21 days

Candida PneumoniaCandida Pneumonia

EpidemiologyEpidemiology Infection vs Colonization vs Infection vs Colonization vs

ContaminationContamination Primary Candida Pneumonia < 1%Primary Candida Pneumonia < 1% Aspiration of Oropharyngeal ContentsAspiration of Oropharyngeal Contents

Clinical ManifestationsClinical Manifestations FeverFever TachypneaTachypnea Nonspecific Patchy Infiltrates on CXRNonspecific Patchy Infiltrates on CXR

Candida PneumoniaCandida Pneumonia

DiagnosisDiagnosis Sputum CultureSputum Culture

Sensitivity 85%Sensitivity 85% Specificity 60%Specificity 60%

Bronchoalveolar Bronchoalveolar LavageLavage

Sensitivity 71%Sensitivity 71% Specificity 57%Specificity 57%

TreatmentTreatment No TreatmentNo Treatment

Immunocompetent Immunocompetent with + Sputumwith + Sputum

Amphotericin B 0.7-Amphotericin B 0.7-1.0 mg/kg daily1.0 mg/kg daily

Isolated Pneumonia Isolated Pneumonia Treatment for Treatment for

Disseminated Disseminated DiseaseDisease

Secondary PneumoniaSecondary Pneumonia

Pulmonary HistoplasmosisPulmonary Histoplasmosis

Ohio and Mississippi River ValleysOhio and Mississippi River Valleys Mediastinal or Hilar Mass or Lymphadenopathy on Mediastinal or Hilar Mass or Lymphadenopathy on

CXRCXR Diagnosis Diagnosis

BiopsyBiopsy CulturesCultures Antigen DetectionAntigen Detection

TreatmentTreatment Self-Limiting – No TherapySelf-Limiting – No Therapy Systemic Antifungals for Systemic Antifungals for

Immunosuppressed or Severely IllImmunosuppressed or Severely Ill Itraconazole 200mg PO TID x 3 Days, Itraconazole 200mg PO TID x 3 Days,

then 200mg QD-BIDthen 200mg QD-BID

Fungal EndocarditisFungal Endocarditis

EpidemiologyEpidemiology Prosthetic Heart Prosthetic Heart

ValvesValves IV Drug UsersIV Drug Users Central Venous Central Venous

CathetersCatheters Prolonged Prolonged

FungemiaFungemia

Clinical Clinical ManifestationsManifestations FeverFever MurmurMurmur Signs and Signs and

Symptoms of Heart Symptoms of Heart FailureFailure

Peripheral Peripheral EmbolismEmbolism50-100% Mortality

Candida EndocarditisCandida Endocarditis

DiagnosisDiagnosis Persistent Persistent

CandidemiaCandidemia Vegetations on Vegetations on

EchocardiographyEchocardiography

TreatmentTreatment Amphotericin B +/- Amphotericin B +/-

Flucytosine x 6 Flucytosine x 6 weeksweeks

Surgical ResectionSurgical Resection

Fungal PeritonitisFungal Peritonitis

EpidemiologyEpidemiology Gut PerforationGut Perforation Anastomotic LeaksAnastomotic Leaks Acute Necrotizing Acute Necrotizing

PancreatitisPancreatitis Peritoneal DialysisPeritoneal Dialysis Gangrenous Gangrenous

CholecystitisCholecystitis C. Albicans > C. C. Albicans > C.

Galbrata > OthersGalbrata > Others

Clinical ManifestationsClinical Manifestations Fevers/ChillsFevers/Chills Abdominal PainAbdominal Pain

DiagnosisDiagnosis Culture of AspirateCulture of Aspirate

CT guidedCT guided U/S GuidedU/S Guided

Culture at time of Culture at time of SurgerySurgery

Culture from Drain Culture from Drain InadequateInadequate

Fungal Peritonitis TreatmentFungal Peritonitis Treatment

Fluconazole 400mg dailyFluconazole 400mg daily Preferred unless C. GalbrataPreferred unless C. Galbrata

Amphotericin B 0.7mg/kg dailyAmphotericin B 0.7mg/kg daily C. GalbrataC. Galbrata

CaspofunginCaspofungin C. GalbrataC. Galbrata

Duration of Therapy at Least 2 WeeksDuration of Therapy at Least 2 Weeks Surgical InterventionSurgical Intervention

Fungal Infection of Fungal Infection of Bladder and KidneysBladder and Kidneys

CandidaCandida AspergillusAspergillus TrichosporonTrichosporon ZygomycetesZygomycetes Dematiaceous MoldsDematiaceous Molds Cryptococcus NeoformansCryptococcus Neoformans Dimorphic FungiDimorphic Fungi

Fungal UTI Risk FactorsFungal UTI Risk Factors

0102030405060708090

100

Foley ABX DM Pathology Malignancy

CharacteristicsCharacteristics

Bladder Infection Vs. ColonizationBladder Infection Vs. Colonization Acute Renal InfectionAcute Renal Infection

Hematogenous SeedingHematogenous Seeding Multiple Micro-abscessesMultiple Micro-abscesses

Chronic Renal InfectionChronic Renal Infection Unilateral, Ascending SeedingUnilateral, Ascending Seeding Perinephric Abscess or BezoarPerinephric Abscess or Bezoar

Efficacy of Funguria Efficacy of Funguria TreatmentTreatment

No Affect on MortalityNo Affect on Mortality Resolution of FunguriaResolution of Funguria

No Treatment 76%No Treatment 76% Catheter Removal 35%Catheter Removal 35% Fluconazole or Amphotericin B 50%Fluconazole or Amphotericin B 50%

Fungal UTI Treatment Fungal UTI Treatment GuidelinesGuidelines

Symptomatic UTISymptomatic UTI Fluconazole 400mg x 1, then 200mg/day x Fluconazole 400mg x 1, then 200mg/day x

1313 Amphotericin B 0.3-0.7 mg/kg/day IV x 1-7Amphotericin B 0.3-0.7 mg/kg/day IV x 1-7 Flucytosine 25mg/kg/day PO x 5-7Flucytosine 25mg/kg/day PO x 5-7

Asymptomatic UTIAsymptomatic UTI Only Treat if NeutropenicOnly Treat if Neutropenic

Perinephric AbscessPerinephric Abscess Surgical Drainage + Systemic AntifungalSurgical Drainage + Systemic Antifungal

Candida VulvovaginitisCandida Vulvovaginitis

EpidemiologyEpidemiology Increased Estrogen Increased Estrogen

LevelsLevels AntibioticsAntibiotics CorticosteroidsCorticosteroids Diabetes MellitusDiabetes Mellitus HIVHIV IUDIUD DiaphragmDiaphragm

Clinical Clinical ManifestationsManifestations ItchItch DischargeDischarge DyspareuniaDyspareunia DysuriaDysuria Vaginal IrritationVaginal Irritation

Candida Vulvovaginitis Candida Vulvovaginitis DiagnosisDiagnosis

Vulvar Erythema and SwellingVulvar Erythema and Swelling Vaginal Erythema and White, Curd-like Vaginal Erythema and White, Curd-like

DischargeDischarge Budding Yeast with or without Budding Yeast with or without

Pseudohyphae on Wet Mount or KOH Pseudohyphae on Wet Mount or KOH Prep of Vaginal SecretionsPrep of Vaginal Secretions

Candida Vulvovaginitis Candida Vulvovaginitis TreatmentTreatment

Fluconazole 150mg x 1Fluconazole 150mg x 1Repeat q 72 hours Repeat q 72 hours

for Complicated Casesfor Complicated Cases

Candida Osteoarticular Candida Osteoarticular InfectionsInfections

EpidemiologyEpidemiology Hematogenous Hematogenous

SpreadSpread TraumaTrauma Intraarticular InjectionIntraarticular Injection SurgerySurgery Injection Drug UseInjection Drug Use Native > Prosthetic Native > Prosthetic

JointsJoints Months-Years after Months-Years after

InsultInsult

Clinical Clinical Manifestations Manifestations PainPain Decreased Range of Decreased Range of

MotionMotion

Candida Osteoarticular Candida Osteoarticular InfectionsInfections

DiagnosisDiagnosis Candidemia in 50-Candidemia in 50-

60%60% WBC WNLWBC WNL ESRESR Erosion on Xray or Erosion on Xray or

MRIMRI Culture of Infected Culture of Infected

SiteSite

TreatmentTreatment Systemic TherapySystemic Therapy

Amphotericin B 0.5-Amphotericin B 0.5-1mg/kg/day x 2-3 1mg/kg/day x 2-3 weeksweeks

then then Fluconazole Fluconazole 400mg/day x 6-12 400mg/day x 6-12 monthsmonths

I & DI & D Remove ProsthesisRemove Prosthesis

Candida MediastinitisCandida Mediastinitis EpidemiologyEpidemiology

Thoracic SurgeryThoracic Surgery Prior Antibiotic Prior Antibiotic

TherapyTherapy Time from Insult to Time from Insult to

Infection 11 DaysInfection 11 Days Range 6 - 100Range 6 - 100

Hematogenous Hematogenous SpreadSpread

Mortality Rate 55%Mortality Rate 55%

Clinical Clinical ManifestationsManifestations Chest Wall Chest Wall

ErythemaErythema Chest Wall Chest Wall

DrainageDrainage FeverFever Sternal InstabilitySternal Instability

TreatmentTreatmentAmphotericin B 0.7 – 1.0 mg/kg dailyAmphotericin B 0.7 – 1.0 mg/kg daily

Fluconazole 400mg dailyFluconazole 400mg dailySurgical DrainageSurgical Drainage

Fungal MeningitisFungal Meningitis

Ventricular Drainage DevicesVentricular Drainage Devices Ventriculoperitoneal ShuntVentriculoperitoneal Shunt Ventriculoatrial ShuntVentriculoatrial Shunt

CraniotomyCraniotomy Hematogenous SpreadHematogenous Spread CSFCSF

Low GlucoseLow Glucose High ProteinHigh Protein

Candidal MeningitisCandidal Meningitis

C. Albicans > C. Paraspilosis > C. TropicalisC. Albicans > C. Paraspilosis > C. Tropicalis ImmunosuppressedImmunosuppressed Fever, Nuchal Rigidity, Altered MS, Fever, Nuchal Rigidity, Altered MS,

HeadacheHeadache Culture CSFCulture CSF Micro-abscesses on MRIMicro-abscesses on MRI Amphotericin B + FlucytosineAmphotericin B + Flucytosine Follow up LP in 1 WeekFollow up LP in 1 Week

Coccidiodal MeningitisCoccidiodal Meningitis

C. Immitis > C. PosadasiiC. Immitis > C. Posadasii Southwestern USSouthwestern US HeadacheHeadache

Persistent or Progressively WorseningPersistent or Progressively Worsening Unusual SeverityUnusual Severity Nausea/VomittingNausea/Vomitting Blurred VisionBlurred Vision Mental Status ChangeMental Status Change

+Culture or Anti-Coccidioidal Antibodies in CSF+Culture or Anti-Coccidioidal Antibodies in CSF Untreated 95% MortalityUntreated 95% Mortality Fluconazole 400-1000mg/day PO IndefinitelyFluconazole 400-1000mg/day PO Indefinitely Intrathecal Amphotericin B for NonrespondersIntrathecal Amphotericin B for Nonresponders

Cryptococcal MeningitisCryptococcal Meningitis

C. NeoformansC. Neoformans InhalationInhalation ImmunosuppressedImmunosuppressed Headache, Fever, Lethargy, Mental Status Headache, Fever, Lethargy, Mental Status

Changes, Memory LossChanges, Memory Loss CSF Culture, India Ink, Cryptococcal Antigen CSF Culture, India Ink, Cryptococcal Antigen

AssayAssay Fatal if UntreatedFatal if Untreated Amphotericin B + Flucytosine x 2 WeeksAmphotericin B + Flucytosine x 2 Weeks

Followed with 3 – 6 months of Fluconazole POFollowed with 3 – 6 months of Fluconazole PO Intrathecal for NonrespondersIntrathecal for Nonresponders

Follow up LP in 2 WeeksFollow up LP in 2 Weeks

FungemiaFungemia ImmunosuppressedImmunosuppressed

Hematologic Hematologic MalignanciesMalignancies

Transplant RecipientsTransplant Recipients ChemotherapyChemotherapy

ICUICU TraumaTrauma BurnsBurns Central LinesCentral Lines TPNTPN ABXABX HemodialysisHemodialysis Abdominal Surgical Abdominal Surgical

ProceduresProcedures GI Tract Perforations GI Tract Perforations

and Anastomotic Leaksand Anastomotic Leaks

Hematogenous SpreadHematogenous Spread C. Albicans C. Albicans

C. Galbrata C. Galbrata C. Parapsilosis C. Parapsilosis C. TropicalisC. TropicalisC. KruseiC. Krusei

Candidemia Clinical Candidemia Clinical ManifestationsManifestations

FeverFever SepsisSepsis Skin LesionsSkin Lesions Eye LesionsEye Lesions Muscle AbscessesMuscle Abscesses Multiorgan System FailureMultiorgan System Failure

Candidemia Diagnosis and Candidemia Diagnosis and TreatmentTreatment

DiagnosisDiagnosis + Blood Cultures+ Blood Cultures Biopsy of Involved Biopsy of Involved

SitesSites

TreatmentTreatment Ophthalmologic Ophthalmologic

ExamExam Catheter RemovalCatheter Removal Systemic AntifungalSystemic Antifungal

Fluconazole 800mg Fluconazole 800mg x1, then 400mg QD x1, then 400mg QD x 14 Days after -BCx 14 Days after -BC

Caspofungin for C. Caspofungin for C. Krusei and C. Krusei and C. GalbrataGalbrata

QuestionsQuestions

1.1. The mortality rate associated with The mortality rate associated with fungal endocarditis is:fungal endocarditis is:

a) < 10%a) < 10%

b) 20-30%b) 20-30%

c) 30-40%c) 30-40%

d) > 50%d) > 50%

QuestionsQuestions

2.2. 67y/o female admitted to the ICU with 67y/o female admitted to the ICU with sepsis. Broad spectrum antibiotics were sepsis. Broad spectrum antibiotics were initiated. She continues to decline. Blood initiated. She continues to decline. Blood cultures finally grow Candida Albicans. cultures finally grow Candida Albicans. After initiating the appropriate After initiating the appropriate antifungal, you:antifungal, you:a) Consult Opthalmologya) Consult Opthalmologyb) Consult GIb) Consult GIc) Consult Orthopedicsc) Consult Orthopedicsd) Consult Psychiatryd) Consult Psychiatry

QuestionsQuestions

3.3. All of the following are susceptible All of the following are susceptible to Fluconazole except:to Fluconazole except:

a) C. Albicansa) C. Albicans

b) C. Kruseib) C. Krusei

c) C. Parapsilosisc) C. Parapsilosis

d) C. Tropicalisd) C. Tropicalis