IM26.26-27 | Fungal Infections: Candidiasis and Aspergillosis — Summary & Reflection

KEY TAKEAWAYS

Candida — mucocutaneous:
- Oral thrush: clotrimazole troches or fluconazole 100 mg/day × 7d
- Oesophageal candidiasis (AIDS-defining): fluconazole 200 mg/day × 14–21d (systemic, not topical)
- VVC: topical clotrimazole × 3–7d or fluconazole 150 mg single dose

Candida — invasive: first-line = IV echinocandin (caspofungin/micafungin); CVC removal mandatory; duration ≥14 days from first negative culture; check fundal examination (endophthalmitis).

ABPA: hypersensitivity to Aspergillus in asthma/CF; central bronchiectasis + elevated IgE + eosinophilia; treat: prednisolone + itraconazole.

CPA/aspergilloma: post-TB cavity + fungal ball (air crescent on CT) + elevated Aspergillus IgG; haemoptysis = main risk; treat: voriconazole/itraconazole long-term ± surgical resection.

IPA: neutropenic + halo sign on CT + positive galactomannan = probable IPA; treat: voriconazole IV/oral (gold standard); isavuconazole alternative; mortality 50–90%.

Key antifungals: fluconazole (Candida, oral/IV), echinocandins (invasive Candida, fungicidal, CVC biofilm), voriconazole (Aspergillus first-line, IPA), L-AmB (mucormycosis, broadest spectrum, nephrotoxicity lower than conventional AmB).

REFLECT

The rise of invasive fungal infections in India mirrors the expansion of immunocompromised populations — HIV, transplant recipients, haematological malignancy patients, and patients on biological agents. The 2021 COVID-associated mucormycosis epidemic — with over 40,000 cases in India in 6 months — was at least partly driven by indiscriminate corticosteroid use, hyperglycaemia, and prolonged hospitalisation during the Delta wave. As a physician, you will encounter patients who are immunocompromised due to underlying disease or the medications you prescribe — corticosteroids, immunosuppressants, biological agents like rituximab and natalizumab. Reflect on what precautions — antifungal prophylaxis, monitoring, patient education, glycaemic control — should be routinely considered whenever you initiate immunosuppressive therapy. How does the risk of invasive fungal infection factor into the risk-benefit analysis when prescribing high-dose corticosteroids for conditions such as ARDS, SLE flare, or severe asthma?