Table 1.

Clinical presentation of and host reaction to the more common mycoses

Fungus(i)	Clinical presentation	Host responsea	Comment(s)
Blastomyces dermatitidis	Asymptomatic	Tissue descriptions unavailable	Epidemiologic evidence
	Acute pneumonia	Mixed suppurativeb inflammation	Seen in areas of endemicity
	Chronic pneumonia	Mixed suppurative and granulomatousc inflammation	Most frequently diagnosed
	ARDS	Diffuse alveolar damage	Can be fatal
	Disseminated	Various inflammatory responses depending on immune status	Skin, soft tissue, bone, GU, or CNS is primarily involved
	Cutaneous	Mixed suppurative and granulomatous inflammation	Rare, due to direct cutaneous inoculation
Cryptococcus spp.	Asymptomatic	Minimal reaction	Rare, epidemiologic evidence
	Pneumonia	Predominantly granulomatous inflammation, can have abundant fibrosis	More frequent in immunocompetent individuals
	Cryptococcoma	Granuloma with various degrees of necrosis and fibrosis	More frequent with C. gattii
	Pleural effusion	Various inflammatory responses depending on immune status	More frequent in immunosuppressed patients
	Disseminated	Various inflammatory responses depending on immune status, abundant extracellular yeasts may efface tissue architecture, necrosis may be present	Frequent in immunosuppressed patients; involves the CNS (producing meningitis or cryptococcomas), skin, bones, or other tissues
Histoplasma capsulatum	Asymptomatic	Tissue descriptions not available	Occurs when low numbers of microconidia are inhaled
	Acute pneumonia	Nodules showing vascular necrosis associated with lympho-histiocytic vasculitis and rare granulomatous inflammation	Occurs when high numbers of microconidia are inhaled
	ARDS	Diffuse alveolar damage	Can be fatal
	Mediastinitis	Granulomatous inflammation	Occurs upon initial inhalation of the microconidia
	Chronic pneumonia	Granulomas with various degrees of necrosis and calcification	Can present as a nodule or cavity
	Disseminated	Various inflammatory responses depending on immune status, abundant intracellular yeasts may efface tissue architecture, necrosis may be present	Seen upon initial infection or as reactivation of latent disease in patients with T-cell deficiencies; can involve skin, GI tract, liver, spleen, and bone marrow
Coccidioides immitis/posadasii	Asymptomatic	Tissue descriptions unavailable	Epidemiologic evidence
	Acute pneumonia	Suppurative and granulomatous inflammation	Presents as lobar infiltrates and adenopathy
	Chronic pneumonia	Mixed suppurative (including eosinophils) and granulomatous inflammation with a rim of lymphocytes, Splendore-Höeppli phenomenon likely	Can present as a nodule or cavity
	Disseminated	Various inflammatory responses depending on immune status	Occurs in certain risk groups (those with diabetes, use of steroids, and others); can involve skin, lymph nodes, bones, joints, and CNS
	Cutaneous	Mixed suppurative and granulomatous inflammation	Rare, due to direct cutaneous inoculation
Candida spp.	Superficial infections	Minimal to suppurative inflammation depending on immune status of individual	Skin and mucous membranes of GI and GU tracts in immunocompetent and immunosuppressed individuals
	Invasive disease	Various inflammatory responses depending on immune status, primarily suppurative inflammation with rare granulomas, invasion of blood vessels, necrotizing vasculitis	Occurs primarily as a health care-associated infection (patients with vascular access devices, with recent surgeries, receiving broad-spectrum antibiotics, or immunosuppressed), can involve all organs
Pneumocystis jirovecii	Asymptomatic	Minimal reaction	Has been found in the lungs of children
	Pneumonia	Minimal reaction; rarely atypical reactions such as fibrosis, granulomas, and others	Affects immunosuppressed patients
	Disseminated	Minimal reaction; rarely atypical reactions such as fibrosis, granulomas, and others	Rare, affects immunosuppressed patients
Sporothrix schenckii	Cutaneous	Mixed suppurative (including eosinophils) and granulomatous inflammation, Splendore-Höeppli phenomenon frequent, presence of asteroid bodies, epidermis with pseudoepitheliomatous hyperplasia	Associated with handling contaminated soil or animals, draining lymph nodes are frequently affected
	Disseminated	Various inflammatory responses depending on immune status	Affects bone, joints, meninges, and other organs
Penicillium marneffei	Cutaneous	Mixed suppurative and granulomatous inflammation with various degrees of necrosis	Seen mostly in Southeast Asia
	Disseminated	Various inflammatory responses depending on immune status, may consist only of necrosis and infected macrophages	Seen mostly in Southeast Asia; P. marneffei infection represents the most frequent AIDS-defining illness
Paracoccidioides brasiliensis	Acute pneumonia	Mixed suppurative and granulomatous inflammation	Correlates with hormonal, genetic, immunologic, and nutritional status
	Chronic pneumonia	Mixed suppurative and granulomatous inflammation surrounded by fibrosis	Correlates with hormonal, genetic, immunologic, and nutritional status; if organism is swallowed, can cause GI disease
	Disseminated	Mixed suppurative and granulomatous inflammation, bone may show osteonecrosis	Involvement of bone marrow, adrenal glands, CNS, and other tissues
	Cutaneous	Mixed suppurative and granulomatous inflammation, epidermis with epitheliomatous hyperplasia	Rare, due to direct cutaneous inoculation
Rhinosporidium seeberid	Nose, nasopharynx, ocular areas	Granulomatous inflammation with fibrosis and granulation tissue	Presents as a mass or polyp
	Disseminated	Chronic and granulomatous inflammation	Rare, can involve other mucous membranes or cutaneous sites and internal organs
Aspergillus spp.	Allergic bronchopulmonary aspergillosis	Allergic mucous with eosinophils, Curshmann's spirals, Charcot-Leyden crystals; mucosa with suppurative and granulomatous inflammation, vasculitis, and fibrosis	Hypersensitivity reaction to fungi, most frequently A. fumigatus; seen frequently in patients with cystic fibrosis or steroid-dependent asthma
	Allergic fungal rhinosinusitis	Similar to that for allergic bronchopulmonary aspergillosis	Hypersensitivity reaction to fungi similar to that for allergic bronchopulmonary aspergillosis
	Chronic pulmonary aspergillosis	The wall surrounding the fungus ball consists of fibrosis	Occurs in immunocompetent individuals with a variety of lung conditions (tuberculosis, emphysema, and others) in which the cavity or lesion is colonized and then a “fungus ball” or aspergilloma forms
	Chronic necrotizing pulmonary aspergillosis	The wall surrounding the fungus ball consists of a layer of necrosis, granulation tissue, granulomatous inflammation, and fibrosis	Occurs in immunosuppressed individuals with chronic pulmonary aspergillosis, where the fungus is invading the tissues locally
	Invasive disease	Angioinvasion by hyphae with consequent necrosis or hemorrhage of surrounding tissue	Seen in severely immunosuppressed patients, involves the lungs, CNS, and other tissues
Mucorales genera	Cutaneous	Angioinvasion by hyphae with consequent necrosis or hemorrhage of surrounding tissue; inflammation, if present, is frequently suppurative, less commonly granulomatous, but varies depending on immune status	Necrotic (black) skin lesion in immunosuppressed patients
	Rhinocerebral	Similar to that for cutaneous disease	Particularly frequent in diabetic patients but can occur in any immunosuppressed patient
	Pulmonary	Similar to that for cutaneous disease	Multiple pulmonary nodules and pleural effusions in immunosuppressed patients
	Invasive disease	Similar to that for cutaneous disease	Risk factors include cancer chemotherapy and stem cell transplantation
Entomophthorales	Mucocutaneous	Fibrosis, granulation tissue, mixed eosinophilic and granulomatous inflammation; Splendore-Höeppli phenomenon present	Presents as a mass in immunocompetent individuals, the lesion can be in the GI tract
Hyaline septated molds (Fusarium spp., Scedosporium spp., Trichoderma spp., Paecilomyces spp., and others)	Superficial infections	Mild inflammation	Occur in skin, cornea, and nails; Fusarium spp. are the most common of these organisms in causing superficial infections
Range of diseases similar to that for Aspergillus: allergic, chronic pulmonary, and invasive	Similar to that for Aspergillus	Some organisms have some peculiarities (for example, Scedosporium spp. are associated with pneumonia after near drowning, and Trichoderma spp. have been observed in patients undergoing dialysis)
Dematiaceous fungi (Madurella spp., Fonsecaea spp., Cladophialophora spp., Exophiala spp., Curvularia spp., Bipolaris spp., and others)	Superficial infections	Mild inflammation	Occur in skin, cornea, and nails
	Deep skin infections	Mixed suppurative and granulomatous inflammation with reactive epidermal changes, including pseudoepitheliomatous hyperplasia and draining sinuses	See Table 3
	Range of diseases similar to that for Aspergillus: allergic, chronic pulmonary, and invasive	Similar to that for Aspergillus	Bipolaris and Curvularia are most frequently associated with eosinophilia and allergic sinusitis or allergic bronchopulmonary mycosis, Cladophialophora bantiana is most frequently associated with brain abscesses

^aFungal morphology is presented in Fig. 1, 2, and 3.

^bSuppurative inflammation refers to presence of congestion, edema, necrosis, and an inflammatory infiltrate with a predominance of neutrophils.

^cGranulomatous inflammation refers to presence of epithelioid macrophages including multinucleated giant cells, lymphocytes, and necrosis.

^dR. seeberi is not a fungus but is included for purposes of contrast with fungi that have similar morphology.