Page 1834 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 129: Dermatologic Conditions 1303

FUNGAL INFECTIONS
■ DISSEMINATED CANDIDIASIS

During the past two decades, the incidence of candidemia in patients in
ICUs has soared from 1.5 to 60 infections per 10,000 adult ICU admis-
sions and from 23 to 123 infections per 10,000 neonatal ICU admissions.
Even with antifungal therapy, the mortality rate approaches 30%. Most
cases occur in patients who have central venous lines. Candida species
on the skin of the patient or caregivers can insinuate their way into
these catheters, adhere to the inside of the tubing, and form biofilms.
124
Disseminated candidiasis presents with the characteristic widespread
papules and pustules. In neutropenic patients with candidiasis, the
skin lesions may not develop until the white count begins to recover.
125
Neutropenia and immunosuppression are the greatest risk factors for
disseminated candidiasis. The differential diagnosis includes steroid-
induced acne, which may develop in conjunction with chemotherapy. FIGURE 129-38. Blastomycosis. A well-demarcated plaque with violaceous, rolled
In steroid-induced acne, the pustules arise from the hair follicle, are all borders and verrucous surface. (Used with permission of Dr Diana Bolotin.)
in the same stage of development, and tend to concentrate on the face,
shoulders, and upper trunk.
Diagnosis can be attempted by culturing the blood, the pustule
contents, or tissue obtained from a skin biopsy, but the yield may be
as low as 50%. Biopsy specimens may be stained with periodic acid-
Schiff (PAS) or silver methenamine stain to visualize yeast forms. There
is a need for better technology to identify disseminated candidiasis.
Detection of anti-Candida antibodies, Candida metabolites, Candida
DNA, or the release of β-glucan into the blood has not proven to be of
general clinical use thus far. 126
■ DEEP FUNGAL INFECTIONS

Deep cutaneous fungal infections are uncommon in the immunocompe-
tent host. Opportunistic infections occur in patients who are immuno-
compromised by malignancies, systemic agents, or medical conditions.
Hematogenous seeding to the skin from the lung is the most common route
for aspergillosis (Fig. 129-37), histoplasmosis, blastomycosis (Fig. 129-38),
cryptococcosis, and zygomycosis (Fig. 129-39). Direct inoculation
127
may occur but is less common. Lesions present as inflammatory pap-
ules, plaques, nodules, and ulcerations. Differentiation cannot be made
on clinical grounds alone. Umbilicated papules resembling lesions of
molluscum contagiosum are characteristically seen in disseminated
cryptococcosis, but they have also been reported in disseminated his-
toplasmosis. Biopsy and culture of the lesions is imperative. Histologic

FIGURE 129-39. Disseminated mucormycosis: a well-defined necrotic plaque with
FIGURE 129-37. Disseminated aspergillosis: a well-defined, necrotic plaque on the surrounding erythema on the anterior arm (A), and multiple small necrotic papules on dorsal
anterior chest. (Used with permission of Dr Bernhard Ortel.) hands (B). (Used with permission of Dr Keyoumars Soltani.)

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