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Sexua I ly Tra nsmitted I nfections Mucormycosis XEY POIilT' Mucormycosis (former$ zygomycosis) is the third most fre- o Because laboratory studies are nonspecific, diagnosing quent cause of invasive fungal infections in immunocompro- mucormycosis relies on a high index of suspicion in a mised persons. Patients with diabetes mellitus, neutropenia, host with appropriate risk factors and evidence of tissue and iron overload states (including deferoxamine administra- invasion. tion) are particularly at risk. The most common mucormycetes o Treatment of mucormycosis requires reversing any are Rhizopus arrhizus and Mucor species. These fungi are predisposing condition, extensive surgical removal of commonly found in the environment on decaying organic affected tissue, and initial antifungal therapy with high- debris and soil. dose liposomal amphotericin B. Infection is acute and rapidly fatal, even with early diag- nosis and treatment. Major blood vessels are invaded, with ensuing ischemia, necrosis, and infarction of adjacent tis- sues. Mucormycosis has five major clinical forms: (t) rfri Sexually Transmitted nocerebral (Figure 2O); (2) pulmonary; (3) abdominal, pelvic, gastric, gastrointestinal; (4) primary cutaneous; and (5) lnfestions disseminated. lntrodustion Because laboratory studies are nonspecific, diagnosis Sexually transmitted infections (STIs) occur most commonly relies on a high index of suspicion in a host with appropriate in adolescents, young adults, and men who have sex with men risk factors and evidence of tissue invasion. Serologic tests and (MSM). Most infections are asymptomatic, so a detailed sexual blood cultures offer no diagnostic benefit. history including sexual practices, is imperative to under- Treatment requires reversal of any predisposing condi- standing individual risk. STI risk factors include a new partner, tions, extensive surgical removal of affected tissue, and early more than one current partner, a partner with an STI, or a antifungal therapy. Initial treatment is high-dose liposomal partner who has concurrent partners. Particularly high risk amphotericin B, with de-escalation to posaconazole or isavu- populations include persons attending STI clinics and MSM. conazole. If amphotericin B is not tolerated, initial therapy The U.S. Preventive Services Task Force (USPSTF) recommends with one of the azoles is warranted. Mortality rates remain as behavioral counseling to reduce the likelihood of acquiring high as 6O%to B0%, even with therapy. STIs in sexually active adolescents and in adults at increased risk. Unrecognized or inadequately treated STIs are a prevent- able cause of infertility in women. The World Health Organization and the CDC provide evidence-based guidelines for the evaluation and management of STIs; the CDC guide- lines are recommended for use in the United States. Any patient diagnosed with an STI should be evaluated for other STIs, including HIV and receive risk reduction counseling.

Mucormycosis XEY POIilT' Mucormycosis (former$ zygomycosis) is the third most fre- o Because laboratory studies are nonspecific, diagnosing quent cause of invasive fungal infections in immunocompro- mucormycosis relies on a high index of suspicion in a mised persons. Patients with diabetes mellitus, neutropenia, host with appropriate risk factors and evidence of tissue and iron overload states (including deferoxamine administra- invasion. tion) are particularly at risk. The most common mucormycetes o Treatment of mucormycosis requires reversing any are Rhizopus arrhizus and Mucor species. These fungi are predisposing condition, extensive surgical removal of commonly found in the environment on decaying organic affected tissue, and initial antifungal therapy with high- debris and soil. dose liposomal amphotericin B. Infection is acute and rapidly fatal, even with early diag- nosis and treatment. Major blood vessels are invaded, with ensuing ischemia, necrosis, and infarction of adjacent tis- sues. Mucormycosis has five major clinical forms: (t) rfri Sexually Transmitted nocerebral (Figure 2O); (2) pulmonary; (3) abdominal, pelvic, gastric, gastrointestinal; (4) primary cutaneous; and (5) lnfestions disseminated. lntrodustion Because laboratory studies are nonspecific, diagnosis Sexually transmitted infections (STIs) occur most commonly relies on a high index of suspicion in a host with appropriate in adolescents, young adults, and men who have sex with men risk factors and evidence of tissue invasion. Serologic tests and (MSM). Most infections are asymptomatic, so a detailed sexual blood cultures offer no diagnostic benefit. history including sexual practices, is imperative to under- Treatment requires reversal of any predisposing condi- standing individual risk. STI risk factors include a new partner, tions, extensive surgical removal of affected tissue, and early more than one current partner, a partner with an STI, or a antifungal therapy. Initial treatment is high-dose liposomal partner who has concurrent partners. Particularly high risk amphotericin B, with de-escalation to posaconazole or isavu- populations include persons attending STI clinics and MSM. conazole. If amphotericin B is not tolerated, initial therapy The U.S. Preventive Services Task Force (USPSTF) recommends with one of the azoles is warranted. Mortality rates remain as behavioral counseling to reduce the likelihood of acquiring high as 6O%to B0%, even with therapy. STIs in sexually active adolescents and in adults at increased risk. Unrecognized or inadequately treated STIs are a prevent- able cause of infertility in women. The World Health Organization and the CDC provide evidence-based guidelines for the evaluation and management of STIs; the CDC guide- lines are recommended for use in the United States. Any patient diagnosed with an STI should be evaluated for other STIs, including HIV and receive risk reduction counseling. Ch I a mydi a trach o m ati s I nfecti o n Chlamydia trachomotis is the most commonly reported bac- terial STI in the United States. Screening of all sexually active women younger than 25 years is recommended. Women aged 25 years and older should be screened if they have STI risk fac- tors. The USPSTF concluded that evidence is insufficient to support routine screening in men; the CDC recommends screening men in settings or populations with high prevalence or burden of disease (MSM, STI clinics). Nucleic acid amplification testing (NAAT) is preferred for screening and diagnosis. First-catch urine (for men and FIGURE 20. This patientpresented with a caseof a periorbitalfungalinfection women) and endocervical (for women) or urethral (for men) known as mucormycosis, a dangerous invasive fungal infection frequently swabs can be used. NAAT of urine samples for C. trachomatis occurring in patients with uncontrolled diabetes in ketoacidosis or severely and -l{eisseria gonorrhoeae has been shown to have a sensitiv- immunocompromised patients such as solid organ or hematopoietic stem cell ity and specificity near$ identical to tests obtained from ure- transplantation recipients. The most common form of infection tends to affect the regions of the eye and nose, with penetration into the central nervous system thral and endocervical samples. Chlamydia may cause (rhinocerebralform). oropharyngeal and rectal infection, and these sites should be

Ch I a mydi a trach o m ati s I nfecti o n Chlamydia trachomotis is the most commonly reported bac- terial STI in the United States. Screening of all sexually active women younger than 25 years is recommended. Women aged 25 years and older should be screened if they have STI risk fac- tors. The USPSTF concluded that evidence is insufficient to support routine screening in men; the CDC recommends screening men in settings or populations with high prevalence or burden of disease (MSM, STI clinics). Nucleic acid amplification testing (NAAT) is preferred for screening and diagnosis. First-catch urine (for men and FIGURE 20. This patientpresented with a caseof a periorbitalfungalinfection women) and endocervical (for women) or urethral (for men) known as mucormycosis, a dangerous invasive fungal infection frequently swabs can be used. NAAT of urine samples for C. trachomatis occurring in patients with uncontrolled diabetes in ketoacidosis or severely and -l{eisseria gonorrhoeae has been shown to have a sensitiv- immunocompromised patients such as solid organ or hematopoietic stem cell ity and specificity near$ identical to tests obtained from ure- transplantation recipients. The most common form of infection tends to affect the regions of the eye and nose, with penetration into the central nervous system thral and endocervical samples. Chlamydia may cause (rhinocerebralform). oropharyngeal and rectal infection, and these sites should be 44

Fungal lnfections suspected cases in which the serum antibody and urinary Blastomycosis antigen assay result is negative. Blastomyces dermatitidis is a dimorphic, round, budding Asymptomatic and mild pulmonary histoplasmosis typi yeast. In the United States, blastomycosis is found primarily cally resolve without treatment. Antifungal therapy is recom- along the Mississippi and Ohio River valleys but can be found mended for severe or disseminated disease. Itraconazole is the as far north as Wisconsin and Minnesota and as far south as agent of choice; therapy duration is 6 to 12 weeks for acute Florida. Infection occurs by inhalation of conidia and mani- infection and t2 months for chronic cavitary pulmonary infec- fests initially as a primary pulmonary infection (acute or tion. For severe lung disease and disseminated infection, lipo- chronic pneumonia). Occasionally, a chest radiograph shows a somal amphotericin B should be used initially, followed by spiculated nodular appearance that may be mistaken for lung de-escalation to oral itraconazole. cancer. Rarely, dissemination occurs and produces extrapul KEY POIT{TS monary disease (osteomyelitis or skin infection). . Histoplasmo urinary antigen assay has a sensitivi[z and Diagnosis can be made by direct fungal stain of clinical specificiff of greater than 85% in acute and dissemi- specimens (sputum, tissue, or purulent material) and con- nated infection but less than 50o1, in chronic infection. firmed by culture or serologr for BlostomAces antibodies. o Itraconazole is the antifungal agent of choice for most Urinary antigen testing is also available. The preferred treat- patients with histoplasmosis; liposomal amphotericin B ment for mild to moderate infection is itraconazole. Liposomal should be used initially for patients with severe lung amphotericin B is recommended for CNS, severe pulmonary disease and disseminated infection. and disseminated infections.

suspected cases in which the serum antibody and urinary Blastomycosis antigen assay result is negative. Blastomyces dermatitidis is a dimorphic, round, budding Asymptomatic and mild pulmonary histoplasmosis typi yeast. In the United States, blastomycosis is found primarily cally resolve without treatment. Antifungal therapy is recom- along the Mississippi and Ohio River valleys but can be found mended for severe or disseminated disease. Itraconazole is the as far north as Wisconsin and Minnesota and as far south as agent of choice; therapy duration is 6 to 12 weeks for acute Florida. Infection occurs by inhalation of conidia and mani- infection and t2 months for chronic cavitary pulmonary infec- fests initially as a primary pulmonary infection (acute or tion. For severe lung disease and disseminated infection, lipo- chronic pneumonia). Occasionally, a chest radiograph shows a somal amphotericin B should be used initially, followed by spiculated nodular appearance that may be mistaken for lung de-escalation to oral itraconazole. cancer. Rarely, dissemination occurs and produces extrapul KEY POIT{TS monary disease (osteomyelitis or skin infection). . Histoplasmo urinary antigen assay has a sensitivi[z and Diagnosis can be made by direct fungal stain of clinical specificiff of greater than 85% in acute and dissemi- specimens (sputum, tissue, or purulent material) and con- nated infection but less than 50o1, in chronic infection. firmed by culture or serologr for BlostomAces antibodies. o Itraconazole is the antifungal agent of choice for most Urinary antigen testing is also available. The preferred treat- patients with histoplasmosis; liposomal amphotericin B ment for mild to moderate infection is itraconazole. Liposomal should be used initially for patients with severe lung amphotericin B is recommended for CNS, severe pulmonary disease and disseminated infection. and disseminated infections. XEY POIilT5 . Blastomycosis occurs by inhalation of Blastomyces der- Coccidioidomycosis mqtitidis conidia and manifests initially as a primary Coccidioides is a dimorphic fungus that exists as a mold in the pulmonary infection; diagnosis is made by direct fungal environment. There are two species: C. immitis refers to isolates stain of clinical specimens and confirmed by culture, from California, and C. posadasii refers to isolates from all other urinary antigen testing, or serologr for Blastomyces endemic areas, including Arizona, New Mexico, western Texas, antibodies. northern Mexico, and parts of Central and South America. In . The preferred treatment for mild to moderate blastomy- endemic areas, the annual risk of infection is approximately 3% cosis is itraconazole, with liposomal amphotericin B for most persons, although the risk of infection (and dissemina used for central nervous system, severe pulmonary and tion) is greater in those who are pregnant, younger than 5 years disseminated infections. or older than 50 years, or of African, Filipino (and possibly other Asian), and Native American ancestry. Infection is usually acquired by inhalation of aerosolized arthroconidia; the fungus then begins its dimorphic change in Sporotrichosis the lungs and becomes a yeast cell. Several clinical syndromes Sporothrix schenckii is a dimorphic fungus found most often are seen in coccidioidomycosis and may manifest as acute or in soil, plants, or plant debris. Although found worldwide, chronic pulmonary infection, cutaneous infection (-40%), or most reported infections are from North and South America meningitis (-39'2,). and Japan. Infection occurs after direct contact with plants, Diagnosis is straightforward in endemic areas and usually such as roses and sphagnum moss. Direct inoculation of the is based on clinical manifestations and confirmatory testing by organism into the skin or subcutaneous tissue manifests as a mycologic culture of affected tissue, histopathologic evalua- fixed, "plaque-like" cutaneous sporotrichosis or as lymphocu- tion of tissue, and serologz for Coccidioides antibodies. taneous sporotrichosis. Extracutaneous infection (osteoarticu- Fluconazole is the first-line treatment for symptomatic lar, pulmonary ocular, or disseminated) can occur in patients infection. In patients with meningitis, fluconazole is contin- who are immunocompromised. ued for life. In patients who do not respond to azoles, intrathe- Diagnosis requires cuiture of the organism from affected cal amphotericin B may be an alternative. tissues. Treatment is with itraconazole.

XEY POIilT5 . Blastomycosis occurs by inhalation of Blastomyces der- Coccidioidomycosis mqtitidis conidia and manifests initially as a primary Coccidioides is a dimorphic fungus that exists as a mold in the pulmonary infection; diagnosis is made by direct fungal environment. There are two species: C. immitis refers to isolates stain of clinical specimens and confirmed by culture, from California, and C. posadasii refers to isolates from all other urinary antigen testing, or serologr for Blastomyces endemic areas, including Arizona, New Mexico, western Texas, antibodies. northern Mexico, and parts of Central and South America. In . The preferred treatment for mild to moderate blastomy- endemic areas, the annual risk of infection is approximately 3% cosis is itraconazole, with liposomal amphotericin B for most persons, although the risk of infection (and dissemina used for central nervous system, severe pulmonary and tion) is greater in those who are pregnant, younger than 5 years disseminated infections. or older than 50 years, or of African, Filipino (and possibly other Asian), and Native American ancestry. Infection is usually acquired by inhalation of aerosolized arthroconidia; the fungus then begins its dimorphic change in Sporotrichosis the lungs and becomes a yeast cell. Several clinical syndromes Sporothrix schenckii is a dimorphic fungus found most often are seen in coccidioidomycosis and may manifest as acute or in soil, plants, or plant debris. Although found worldwide, chronic pulmonary infection, cutaneous infection (-40%), or most reported infections are from North and South America meningitis (-39'2,). and Japan. Infection occurs after direct contact with plants, Diagnosis is straightforward in endemic areas and usually such as roses and sphagnum moss. Direct inoculation of the is based on clinical manifestations and confirmatory testing by organism into the skin or subcutaneous tissue manifests as a mycologic culture of affected tissue, histopathologic evalua- fixed, "plaque-like" cutaneous sporotrichosis or as lymphocu- tion of tissue, and serologz for Coccidioides antibodies. taneous sporotrichosis. Extracutaneous infection (osteoarticu- Fluconazole is the first-line treatment for symptomatic lar, pulmonary ocular, or disseminated) can occur in patients infection. In patients with meningitis, fluconazole is contin- who are immunocompromised. ued for life. In patients who do not respond to azoles, intrathe- Diagnosis requires cuiture of the organism from affected cal amphotericin B may be an alternative. tissues. Treatment is with itraconazole. KTY POII{TS XEY POII{TS . Coccidioidomycosis should be suspected clinically in . Sporotrichosis is an infection of cutaneous and lym- endemic areas and may be confirmed by a mycologic phocutaneous tissues usually caused by direct contact culture of affected tissues, histopathologic evaluation of with plants; extracutaneous infection can occur in tissue, or serologz for Coccidioides antibodies. immunocompromised persons. . Fluconazole is first-line treatment for symptomatic coc- o Itraconazole is the preferred treatment for cutaneous cidioidomycosis infection. and lymphocutaneous sporotrichosis.

KTY POII{TS XEY POII{TS . Coccidioidomycosis should be suspected clinically in . Sporotrichosis is an infection of cutaneous and lym- endemic areas and may be confirmed by a mycologic phocutaneous tissues usually caused by direct contact culture of affected tissues, histopathologic evaluation of with plants; extracutaneous infection can occur in tissue, or serologz for Coccidioides antibodies. immunocompromised persons. . Fluconazole is first-line treatment for symptomatic coc- o Itraconazole is the preferred treatment for cutaneous cidioidomycosis infection. and lymphocutaneous sporotrichosis. 43