Table 1.

Clinical Manifestations, Diagnosis, and Initial Treatment of Invasive Fungal Disease

	Organism	Invasive fungal disease	Diagnostic testing	Treatmenta,b	Common species
Yeast	Candida spp.	Bloodstream infection	• Blood culture • Diagnostic imaging to assess for dissemination • Ophthalmologic examc	• Echinocandin for total of 14 days after clearance of candidemiad • Removal of central venous catheter should be considered
		Disseminated disease	• Blood culture • Diagnostic imaging • Ophthalmologic examc • Tissue biopsy for culture and histopathology	• Choice of therapy depends on the site of infection • Duration of treatment dependent on treatment of underlying condition • Ocular infections: triazolese • CNS infections: liposomal AmB	C. albicans C. parapsilosis C. tropicalis C. glabrataf
		Hepatosplenic candidiasis	• Blood culture, • Liver/spleen imaging (US and/or CT) • Tissue biopsy for culture and histopathology	• Echinocandin or liposomal AmB • Consider corticosteroid therapyg
	Trichosporon spp.	Disseminated disease	• Blood culture • Tissue biopsy for culture and histopathology	• Voriconazole +/− liposomal AmB • Removal of central venous catheter should be considered	T. asahii  T. mucoides
	Cryptococcus spp.	Pulmonary disease Bloodstream infection Meningoencephalitis	• Blood culture • Lumbar puncture for CSF analysis and culture • Cryptococcal antigen in serum and CSF • Tissue biopsy for culture and histopathology	• CNS infections: liposomal AmB plus flucytosine used for induction, then maintenance therapy with fluconazole • Extraneural infections: fluconazole	C. neoformans C. gattii
Molds	Aspergillus spp.	Isolated cutaneous nodule	• Serum galactomannan • Serum β-D-glucan • Diagnostic imaging • Tissue biopsy for culture, histopathology, and molecular testing	• Voriconazole • Surgical resection	A. fumigatus A. flavus A. terreus A. nigerf A. lentulusf
		Disseminated or organ-invasive disease	• Serum galactomannan • Serum β-D-glucan • Diagnostic imaging • Tissue biopsy for culture, histopathology, and molecular testing • Bronchoalveolar lavage for culture and galactomannan testing	• Voriconazole • Surgical resection, if localized disease • Consider G-CSF and/or granulocyte transfusionsh
	• Fusarium spp.	• Cutaneous disease • Pulmonary disease • Diseminated disease	• Tissue biopsy for culture, histopathology, and molecular testing • Diagnostic imaging	Voriconazole • Surgical resection, if localized disease	F. solani species complex
	Mucorales order	Disseminated or organ-invasive disease	• Similar to diagnostic workup for invasive aspergillosisi	• Liposomal AmB • Surgical resection, if localized disease • Consider G-CSF and/or granulocyte transfusionsh	Rhizopus spp. Mucor spp. Lichthiemia spp. Cunninghamella spp.

^aDefinitive therapy should be tailored based upon final organism identification and susceptibility testing

^bIn addition to antifungal therapy, every attempt at immune reconstitution should be made

^cFor neutropenic patients, eye examination should be done after recovery from neutropenia

^dStep-down therapy using a triazole antifungal can be performed for clinically stable patients with susceptible isolates and clearance of candidemia

^eFor ocular candidiasis, intravitreal injection of AmB deoxycholate or voriconazole is recommended

^fPossess intrinsic resistance to triazole antifungals

^gShort-term treatment with corticosteroids can be considered for patients with persistent high fevers

^hFor patients with potential for neutrophil recovery

ⁱGalactomannan and 1,3-β-D-glucan assays are not useful for detecting Mucorales molds