322.4 📋 章末速記 Summary

322.4.1 🔑 一句話總結

Pulmonary fungal infections 分 opportunistic + endemic / geographic；opportunistic：(1) PCP (HIV CD4 < 200 or 免疫抑制) — TMP-SMX + steroids if PaO2 ≤ 70；(2) Aspergillus IPA (neutropenia, transplant, COVID-19 CAPA, influenza IAPA) — halo + air crescent + galactomannan，isavuconazole / voriconazole first-line (SECURE 2016)；(3) Mucormycosis (DKA, iron overload, COVID-19 CAM India outbreak 2021) — non-septate 90° broad hyphae，liposomal amphotericin + surgical debridement；(4) Cryptococcus (HIV + CNS most) — serum CrAg，amphotericin + flucytosine → fluconazole；endemic mycoses：histoplasmosis (Ohio/Mississippi)、coccidioidomycosis (SW US)、blastomycosis (river valleys)、paracoccidioides (Brazil)、talaromyces marneffei (SE Asia + HIV + umbilicated skin papules)；多 self-limited in immunocompetent，severe / disseminated 需 amphotericin → azole consolidation；newer antifungals 2023-2024：rezafungin (long-acting echinocandin), ibrexafungerp (oral glucan synthase), olorofim (azole-resistant Aspergillus), fosmanogepix (broad)。

322.4.2 💊 治療精要

  • PCP：TMP-SMX 15-20 mg/kg (TMP) IV/PO div q6-8h × 21 d；alternatives: pentamidine, atovaquone, clindamycin + primaquine；steroids if HIV + PaO2 ≤ 70 or A-a ≥ 35
  • IPA：isavuconazole (Cresemba) or voriconazole first-line；liposomal amphotericin for refractory；duration ≥ 6-12 weeks；combination + surgery for severe
  • mucormycosis：liposomal amphotericin B high-dose + surgical debridement + reverse DKA / iron overload + multidisciplinary
  • cryptococcosis：amphotericin + flucytosine × 2 wk (induction) → fluconazole 400-800 × 8 wk (consolidation) → fluconazole 200 × ≥ 1 yr (maintenance)
  • histoplasmosis severe：amphotericin → itraconazole × 12 months
  • coccidioidomycosis severe：amphotericin → fluconazole；meningitis lifelong fluconazole
  • talaromyces marneffei：amphotericin → itraconazole × 10 weeks；HIV ART
  • PCP prophylaxis HIV CD4 < 200：TMP-SMX (preferred)；dapsone, atovaquone, pentamidine inhaled alternatives

322.4.3 🎯 盧醫師的考前提醒

  1. PCP HRCT 經典：bilateral ground-glass opacities + perihilar predominance with periphery sparing；LDH 升 + β-D-glucan ↑
  2. PCP 治療 + steroid 指徵：TMP-SMX 21 d；HIV + PaO2 ≤ 70 mmHg or A-a gradient ≥ 35 → 加 prednisone 40 BID × 5 d → 40 daily × 5 d → 20 daily × 11 d
  3. Aspergillus IPA：halo sign (early) → air crescent (late, neutrophil recovery)；serum + BAL galactomannan；isavuconazole (SECURE 2016) = voriconazole 效，less toxic + interactions
  4. CAPA + IAPA：COVID-19 + influenza ICU 患者 + steroids 增 IPA risk；early detection (BAL galactomannan) + treatment 重要
  5. mucormycosis 三大 risk：DKA、iron overload (hemochromatosis, deferoxamine)、neutropenia / transplant；COVID-19 CAM India 2021 epidemic（DM + steroids + O2 + ICU）
  6. mucor 顯微特徵：broad non-septate hyphae 90° branching（vs Aspergillus septate 45°）；voriconazole 無效
  7. Lady Windermere syndrome (Ch320 MAC) vs mucormycosis 鑑別 important
  8. endemic mycoses 地理分布：histo (Ohio/Mississippi)、cocci (SW US Arizona/California)、blasto (river valleys + Great Lakes)、paracocci (Brazil)、talaromyces marneffei (SE Asia + HIV + 台灣 returning traveler)
  9. talaromyces marneffei 特徵：HIV + SE Asia exposure + umbilicated skin papules (mimics molluscum) + pancytopenia + hepatosplenomegaly + LAD；treatment amphotericin → itraconazole × 10 wk
  10. β-D-glucan limits：pan-fungal except Cryptococcus + Mucorales NEGATIVE（重要 differential — 不能 rule out 這兩個）