Management of Fungal Pneumonia in Elder People

Introduction:

Pneumonia is one of the common infections caused by bacteria, viruses, or fungi. Fungi can colonize different sites of the body without causing any symptoms but can become opportunistic pathogens, leading to various diseases. Fungal infection usually occurs due to inhalation of spores, or reactivation of a previous asymptomatic infection. Fungal infections are increasing especially in older people due to immunocompromised conditions, various medications, organ transplantations, or aggressive treatment of various malignant diseases.

What Is Fungal Pneumonia?

Inflammation of the lungs due to fluid or pus accumulation caused by a fungal infection is fungal pneumonia. Endemic fungal infections can affect any individual either healthy or immunocompromised, but opportunistic fungal infections affect patients with congenital diseases or immunocompromised people. Fungal pneumonia is rarely seen in healthy people, but fungal organisms can be present in the lungs without causing any symptoms.

What Are the Causes of Fungal Pneumonia?

• Mainly fungal pneumonia or endemic fungal infections occurs due to the inhalation of spores of certain species of fungi such as Coccidiodes, Cryptococcus neoformans, Histoplasma species, Blastomyces species, etc. People working in farms, gardeners, and construction workers are affected by these types of species as they are frequently exposed to dusty environments. Fungal pneumonia due to Cryptococcus species can occur due to exposure to bird or rodent droppings, rotting wood, contaminated soil, etc.

• Opportunistic fungal infections can be hospital-acquired infections (HAI) caused by fungal species such as Candida, Aspergillus, Mucor, Pneumocystis, etc. it may also be due to the weakened immune system caused by medical conditions such as Human immunodeficiency virus (HIV), congenital diseases, malignant diseases, etc. Patients under corticosteroid therapy or recipients of bone marrow or stem-cell transplants can acquire fungal pneumonia through inhalation of air-borne fungal spores or due to blood vessel thrombosis, tissue necrosis, or invasion of fungi into the blood vessels. Fungal pneumonia due to Candida species is rare but may occur in critically ill patients, due to ineffective defense mechanisms of the body.

What Are the Signs and Symptoms of Fungal Pneumonia?

Some of the signs and symptoms of fungal pneumonia include:

• Severe dry cough.

• Fever and fatigue.

• Chest pain and discomfort.

• Difficulty in breathing.

• Headache.

• Hemoptysis (coughing up blood).

• Allergic reactions.

• Muscle and joint pain.

What Are the Risk Factors Associated With Fungal Pneumonia?

• Farmers, construction workers, and gardeners are at a high risk of acquiring fungal infections as they are constantly exposed to soil and animal droppings. Any cuts or puncture wounds can lead to exposure to the fungus.

• Patients suffering from AIDS (Acquired Immunodeficiency syndrome), malignancies, congenital immunodeficiency diseases, chronic lung diseases, autoimmune diseases such as rheumatoid arthritis, lupus erythematosus, etc.

• Patients undergoing organ or stem cell transplants, corticosteroids medications, etc.

How Is Fungal Pneumonia Diagnosed?

Diagnosis of fungal pneumonia is quite challenging as it closely resembles other conditions like upper respiratory infections like the common cold or flu. On physical examination, the patient shows signs of fever, respiratory discomfort, tachycardia, and tachypnea. It can be diagnosed by taking a sample of the mucus coughed by the patient or a small sample of the lung tissue (biopsy) and sent to the laboratory. Blood tests and polymerase chain reactions can also help in the diagnosis of fungal pneumonia. Increased white blood cell (WBC) count may be seen in endemic fungal infections and decreased WBC count, especially neutrophils, is seen in opportunistic fungal infections. Pulse oximetry (to check the blood-oxygen levels) can be done in severe cases as extremely low levels require immediate management. Diagnostic tests include:

• Sputum tests to help determine the presence of the specific fungi or any other cause of the infection.

• Blood culture tests can be advised to rule out the advancement of the infection to other parts of the body and the presence of fungal organisms indicate immediate treatment.

• Chest radiograph shows multiple patchy consolidated nodules, in Aspergillosis infections, the nodules are surrounded by a halo sign (ground glass opacity).

• Computed Tomography of the chest provides a clear and detailed view compared to chest radiographs and helps in early diagnosis, especially in immunocompromised patients. Nodular lung lesions with the halo sign can be clearly observed in CT scans.

• Samples from the pleural fluid (fluid present between the chest wall and the lungs) are collected and screened for the presence of fungi; which is called pleural fluid culture.

• Fiberoptic bronchoscopy is advised in some patients, to obtain the specimens and helps avoid lung biopsy which may be invasive and cause discomfort to the patient.

How Is Fungal Pneumonia Managed in Elderly People?

Fungal pneumonia in elderly people is mainly managed by the administration of antifungal medications. The dosage and method of administration depend on the type, and severity of the infection along with the general health of the patient. Some of the antifungal drugs indicated are:

• Trimethoprim-Sulfamethoxazole: It is also known as Co-trimoxazole and is an effective regimen for treating severe Pneumocystis pneumonia, and is dosed at Trimethoprim 15 to 20 mg/kg/day (milligram per kg per day) and Sulfamethoxazole 75 to 100 mg/kg/day in four divided doses daily for three weeks. It is associated with side effects such as fever and rash.

• Amphotericin B: It is found to be useful in acute cases of fungal pneumonia and is the main treatment of choice in Aspergillosis infections. However, in recent times Voriconazole is preferred based on its superiority.

• Itraconazole: It is a triazole group of drugs and the most common antifungal medication indicated in the treatment of histoplasmosis, blastomycosis, and some cases of fungal pneumonia.

• Fluconazole: It is indicated to prevent fungal pneumonia in patients suffering from HIV infections or patients with organ transplants.

• Oxygen therapy: It may be recommended in some severe cases to restore oxygen levels and facilitate easy breathing. It also loosens the mucus and strengthens the lungs.

• Surgery: Surgical excision of the necrotic tissues is performed in severe cases of fungal pneumonia which does not respond to antifungal treatment and also helps to overcome hemoptysis and pulmonary abscess.

What Are the Complications of Fungal Pneumonia?

Complications associated with fungal pneumonia include:

• Progression of the disease to other parts of the body such as the brain, kidney, heart, eyes, liver, etc. leads to sepsis syndrome and damage to the organs.

• Untreated fungal pneumonia can progress leading to lung abscess or pleural disorders.

• Invasion of the fungal organisms into the blood vessels, resulting in hemoptysis, cerebral infarction, pulmonary infarction, cerebral septic emboli, etc.

• Severe inflammation can hamper breathing leading to reduced oxygen supply and may result in respiratory failure.

• Some of the other complications include chronic pulmonary symptoms, bronchopleural fistula, mediastinal fibromatosis, etc.

How Can Fungal Pneumonia Be Prevented?

Practicing healthy lifestyle habits such as regular exercise, healthy diet, adequate sleep, and avoiding smoking and alcohol which help in maintaining overall health and immunity.

Regular health screenings and vaccinations help maintain good health. Avoiding unhygienic places, and following precautionary measures like washing hands frequently, and wearing masks, gloves, or clothes that cover the body completely while working in the soil, or construction sites.

Conclusion:

Fungal infection of the lungs due to fluid or pus accumulation is fungal pneumonia. It is usually seen in immuno-compromised individuals or patients with stem cell or organ transplants. It is caused due to inhalation of fungal spores or acquired due to opportunistic infections. Fungal pneumonia is usually managed by antifungal therapy or in severe cases by surgery to prevent complications. Lifestyle modifications, regular health screenings, and taking precautionary measures can help in the prevention of fungal pneumonia.