Updated: 5/16/2021

Fungal Infections

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  • summary
    • Cutaneous fungal infections of the hand are usually mild and are broken into 4 types: cutaneous, subcutaneous, deep and systemic.
    • Diagnosis is made by careful history and physical exam and confirmed with positive fungi cultures.
    • Treatment is generally oral antifungal antibiotics with deep infections requiring surgical debridement.
  • Epidemiology 
    • Incidence
      • Most common subcutaneous infection of the hand is sporotrichosis
    • Demographics
      • onychomycosis is more common in middle-aged women
    • Risk factors
      • more common to have fungal infection in macerated skin areas (skin folds)
      • Candida more prevalent in patients working in moist environments or under water.
      • immunocompromised patients at risk for Deep infections
  • Etiology
    • Pathophysiology
      • Depends on fungus species 
        • Candida species are responsible for chronic or recurrent paronychia and found in moist environments
        • Sporothrix schenckii that is found in plants and soil.
  • Classification
    • Infections divided into three categories
      • cutaneous
        • includes nail bed infections (onychomycosis)
      • subcutaneous
        • includes sporothrix schenckii from rose thorn prick
      • deep
        • orthopaedic manifestation
          • tenosynovial
          • septic arthritis
          • osteomyelitis
        • organisms include
          • endemic
            • coccidiomycosis
            • histoplasmosis
            • blastomycosis
          • opportunistic include
            • candidiasis
            • mucormycosis
            • cryptococcocis
            • asperfillosisi
        • requires surgical debridement
  • Onychomycosis
    • Introduction
      • defined as fungal infection in vicinity of nail bed (cutaneous)
      • most common organisms are
        • trichophyton rubrum
          • a destructive nail plate infection
        • candida
          • chronic infection of nail fold
    • Treatment
      • topic antifungal treatment & nail plate removal
        • indications
          • first line of treatment
      • systemic griseofulvin or ketoconazole
        • indications
          • recalcitrant cases
  • Sporothrix schenckii
    • Introduction
      • Sporothrix schenckii a common soil organism
      • a subcutaneous infection
      • rose thorn in classic mechanism of subcutaneous transmission
    • Presentation
      • physical exam
        • will show local ulceration (papule) at site of penetration
        • with time additional lesions form in region on lymphatic vessels
        • may show proximal lymph node involvement
    • Evaluation
      • S schenckii isolated at room temperature on Sabouraud dextrose agar
    • Treatment
      • oral itraconazole for 3 to 6 months
        • indications
          • mainstay of treatment
        • has replaced potassium iodide due to side effects which included
          • thyroid dysfunction
          • rash
          • GI symptoms
  • Coccidiomycosis
    • Introduction
      • found in southwest arid regions (e.g., new mexico)
      • often a deep infection
    • Presentation
      • manifestations include
        • subclinical pulmonary involvement
        • orthopaedic manifestations
          • synovitis
          • arthritis
          • periarticular osteomyelitis
    • Treatment
      • amphotericin B & surgical debridement
  • Histoplasmosis
    • Introduction
      • histoplasma capsulatum infection
      • found in Mississippi River Valleys and Ohio
    • Presentation
      • usually subclinical
      • often found incidentally on CXR
      • may present with tenosynovial infection
    • Evaluation
      • diagnosed by skin testing
    • Treatment
      • amphotericin B & surgical debridement / tenosynovectomy
  • Prognosis
    • usually resolve spontaneously
    • may have serious infection in immunocompromised host

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Evidence (3)
EXPERT COMMENTS (2)
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