Fusarium (Fusariosis)

Epidemiology

Risk Factors

Neutropenia (see Neutropenia, Neutropenia)

Mycology

Fusarium Species

Fusarium Oxysporum
Fusarium Proliferatum
Fusarium Solani Complex
Fusarium Verticillioides

Diagnosis

Serum (1,3)-β-D-Glucan (see Serum (1–3)-β-D-Glucan, Serum (1-3)-β-D-Glucan)

May Be Helpful

Pathology

All Hyaline Molds Appear Similar by Microscopic Examination with Sepated, Nonpigmented Hyphae and 45 Degree Angle Branching:
- Hyaline Molds
  - Acremonium (see Acremonium, Acremonium)
  - Aspergillus (see Aspergillus, Aspergillus)
  - Fusarium
  - Lomentospora (see Lomentospora Prolificans, Lomentospora Prolificans)
  - Paecilomyces (see Paecilomyces, Paecilomyces)
  - Scedosporium (see Scedosporiosis, Scedosporiosis)
- Culture is Required to Distinguish the Species

Clinical Manifestations

Dermatologic Manifestations

Cellulitis (see Cellulitis, Cellulitis)
- Epidemiology
  - May Occasionally Occur in Immunocompetent Host at a Site of Skin Breakdown (Due to Trauma, Burns, or Preexisting Onychomycosis)
  - More Commonly Occurs in Immunocompromised Host
    - Skin Involvement May Occur Secondary to Hematogenous Dissemination
- Physiology
  - In Immunocompromised Hosts, May Result in Hematogenous Dissemination
- Clinical-Immunocompetent Host
  - Skin Involvement is Typically Localized
- Clinical-Immunocompromised Host
  - Erythematous Papular or Nodular Painful Skin Lesions (see Papular-Nodular Skin Lesions, Papular-Nodular Skin Lesions)
    - May Involve Any Site: most common on the extremities
    - Skin Lesions Evolve Rapidly (Over Days)
    - Skin Lesions May Simultaneously Manifest at Different Stages of Evolution (Papules, Nodules, and Necrotic Ulcers)
    - Skin Lesions May Manifest Central Necrosis: mimicking that seen in ecthyma gangrenosum
    - Myalgias May Occur Concomitantly in 15% of Cases (Clin Infect Dis, 2002) [MEDLINE]: suggests underlying muscle Involvement
  - Bullae Occur Very Rarely
  - Lymphangitic Spread May Be Observed
Onychomycosis (see Onychomycosis, Onychomycosis)
- Epidemiology: may occur in immunocompetent host
Interdigital Intertrigo
- Epidemiology: may occur in immunocompetent host
Skin Abscess (see Skin Abscess, Skin Abscess)
- Epidemiology: may occur in an immunocompetent host at a site of skin breakdown (due to trauma, burns, or preexisting onychomycosis)
- Clinical: localized skin involvement
Skin Ulcer (see Mucocutaneous Ulcers, Mucocutaneous Ulcers)
- Epidemiology: may occur in an immunocompetent host at a site of skin breakdown (due to trauma, burns, or preexisting onychomycosis)
- Clinical: localized skin involvement
Tinea Pedis (see Dermatophytosis, Dermatophytosis)
- Epidemiology: may occurs in immunocompetent host

Gastroenterologic Manifestations

Alimentary Toxic Aleukia
- Epidemiology:
  - Associated with Outbreak Related to Consumption of Fusarium-Contaminated Wheat Flour in the Soviet Union in the 1930’s-1940’s
- Physiology
  - Trichothecene T-2 Mycotoxin from Fusarium Sporotrichoides was Found to Be Etiologic
Peritonitis (see Peritonitis, Peritonitis)
- Epidemiology: may occasionally occur in immunocompetent host

Neurologic Manifestations

Brain Abscess (see Brain Abscess, Brain Abscess)
- Epidemiology
  - May Occasionally Occur in Immunocompetent Host
  - More Commonly Occurs in Immunocompromised Host

Ophthalmologic Manifestations

Endophthalmitis (see Endophthalmitis, Endophthalmitis)
- Epidemiology
  - May Occasionally Occur in Immunocompetent Host
  - More Commonly Occurs in Immunocompromised Host
Keratomycosis/Mycotic Keratitis (see Keratitis, Keratitis)
- Epidemiology: may occur in immunocompetent host

Otolaryngologic Manifestations

Chronic Sinusitis (see Chronic Rhinosinusitis, Chronic Rhinosinusitis)
- Epidemiology
  - May Occasionally Occur in Immunocompetent Host
  - More Commonly Occurs in Immunocompromised Host with or without Coexisting Pneumonia
    - Sinus Involvement May Occur Secondary to Hematogenous Dissemination
- Physiology
  - In Immunocompromised Hosts, Angioinvasion is Common and Hematogenous Dissemination May Occur
- Clinical
  - In Immunocompromised Hosts, Clinical Findings Mimic Those Seen in Aspergillus Sinusitis: including nasal discharge, nasal obstruction, mucosal necrosis, periorbital cellulitis, and paranasal cellulitis

Pulmonary Manifestations

Cavitary Lung Lesions/Pneumonia (see Cystic-Cavitary Lung Lesions, Cystic-Cavitary Lung Lesions and Pneumonia, Pneumonia)
- Epidemiology
  - May Occasionally Occur in Immunocompetent Host
  - More Commonly Occurs in Immunocompromised Host: lung involvement is common in invasive infection (with the lung involved in approximately 50% of cases)
  - In Immunocompromised Hosts, Lung Involvement May Be the Presenting Manifestation (i.e. Primary Lung Involvement) or May Become Infected Due to Hematogenous Dissemination (Often Bilaterally)
Lung Nodules (see Lung Nodule or Mass, Lung Nodule or Mass)
- Epidemiology
  - May Occasionally Occur in Immunocompetent Host
  - More Commonly Occurs in Immunocompromised Host: lung involvement is common in invasive infection (with the lung involved in approximately 50% of cases)
- Diagnosis
  - Chest CT (see Chest Computed Tomography, Chest Computed Tomography)
    - Halo Sign May Be Present (see Chest Computed Tomography-Halo Sign, Chest Computed Tomography-Halo Sign)
    - Nodules May Cavitate

Renal Manifestations

Cystitis (see Urinary Tract Infection, Urinary Tract Infection)
- Epidemiology: may occasionally occur in immunocompetent host

Rheumatologic Manifestations

Myositis (see Myositis, Myositis)
- Epidemiology
  - Occurs in Immunocompromised Host
Osteomyelitis (see Osteomyelitis, Osteomyelitis)
- Epidemiology: may occasionally occur in immunocompetent host
Septic Arthritis (see Septic Arthritis, Septic Arthritis)
- Epidemiology
  - May Occasionally Occur in Immunocompetent Host
  - More Commonly Occurs in Immunocompromised Host

Disseminated Fusariosis

Epidemiology
- Occurs in Immunocompromised (Typically Neutropenic) Host
- Disseminated Fusarium Infection is the Most Common Clinical Manifestation in Immunocompromised Patients (Accounting for 70% of Cases)
Clinical
- Fever (see Fever, Fever)
- Fungemia (see Blood Culture, Blood Culture)
  - Fungemia Typically Occurs in the Setting of Disseminated Disease (Although Cases Originating from Central Venous Catheters May Manifest Fungemia without Organ Involvement)
  - Blood Cultures are Positive in Approximately 40% of Disseminated Fusarium Cases: due to the fact that Fusarium sporulates in vivo, facilitating hematogenous dissemination
- Generalized Skin Lesions
- Secondary Organ Involvement Due to Hematogenous Dissemination
  - Cellulitis
  - Pneumonia
  - Sinusitis

Treatment

Azole Antifungals (see Azole Antifungals, Azole Antifungals)

Agents
- Voriconazole (see Voriconazole, Voriconazole): may be used for disseminated Fusariosis
  - Terbinafine (see Terbinafine, Terbinafine): some small studies suggest that this can be used with voriconazole to provide synergy
- Isavuconazole (Cresemba) (see Isavuconazole, Isavuconazole): limited experience
- Posaconazole (XXX) (see xxxx, xxxx): limited experience

Liposomal Amphotericin B (see Amphotericin, Amphotericin)

Effective

Echinocandins (see Echinocandins, Echinocandins)

Ineffective

References

Fusarium allergic fungal sinusitis. J Allergy Clin Immunol. 1993;92(4):624 [MEDLINE]
Taxonomy, biology, and clinical aspects of Fusarium species. Clin Microbiol Rev. 1994;7(4):479 [MEDLINE]
Cutaneous infection by Fusarium species in healthy and immunocompromised hosts: implications for diagnosis and management. Clin Infect Dis. 2002;35(8):909 [MEDLINE]
Emerging fungi. Infect Dis Clin North Am. 2006;20(3):563 [MEDLINE]
Fusarium infections in immunocompromised patients. Clin Microbiol Rev. 2007;20(4):695 [MEDLINE]
Fusariosis. Semin Respir Crit Care Med. 2015 Oct;36(5):706-14 [MEDLINE]