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Pt SD Congestive heart failure with itraconazole Pt SD congestive heart failure 5 images PtSD1 CT scan Jan 14, PtSD2  CT scan2 Jan 14, PtSD3 CT scan3 Jan 14, PtSD2 Congestive heart failure with Itraconazole Chest x ray Jan 14, PtSD2 Congestive heart failure with Itraconazole Chest x ray May14
PtSD1 CT scan Jan 14, PtSD2  CT scan2 Jan 14, PtSD3 CT scan3 Jan 14, PtSD2 Congestive heart failure with Itraconazole Chest x ray Jan 14, PtSD2 Congestive heart failure with Itraconazole Chest x ray May14 Pt SD Congestive heart failure with itraconazole Pt SD congestive heart failure 5 images

This 63 year old woman with a lung nodule, probably caused by Aspergillus, was treated with itraconazole 300mg daily. After 3 weeks, she noticed dizziness and her blood pressure was reduced at 100/60.  A week later, she was complaining of headaches, feeling unwell and fluctuating blood pressure. Her BP was 133/62 and pulse 90/min and regular. Her thyroid replacement therapy was excessive and so reduced, as was her itraconazole dose, although subsequent itraconazole levels were in the therapeutic range. Six days later she was admitted to hospital very breathless with bilateral pleural effusions. Itraconazole was stopped.

Her CXR shows bilateral effusions, probable cardiac enlargement and some upper lobe vessel fullness in the lungs. The CT scan confirms bilateral flexural effusions, with associated consolidated lung and fluid in the fissure on the right. The heart is enlarged and right ventricle dilated. In May, all had resolved and she is left with a nodule in the left lower lobe.

Spore catches (from Cunningham DD, Microscopic Examination of Air, 1873):
Spore catches (from Cunningham DD, Microscopic Examination of Air, 1873):

Cunningham, D.D. 1873. Microscopic examination of air. Govt. of India Publication, Calcutta.

Sporetrap circa 1873
Sporetrap circa 1873

Cunningham, D.D. 1873. Microscopic examination of air. Govt. of India Publication, Calcutta.

KOH preparation of a respiratory fluid showing wide non-septate hyphae, typical of a Zygomycete. KOH preparation of a respiratory fluid showing wide non-septate hyphae, typical of a Zygomycete.
KOH preparation of a respiratory fluid showing wide non-septate hyphae, typical of a Zygomycete. KOH preparation of a respiratory fluid showing wide non-septate hyphae, typical of a Zygomycete.
BAL specimen showing hyaline, septate hyphae consistent with Aspergillus, stained with KOH BAL specimen showing hyaline, septate hyphae consistent with Aspergillus, stained with KOH
BAL specimen showing hyaline, septate hyphae consistent with Aspergillus, stained with KOH BAL specimen showing hyaline, septate hyphae consistent with Aspergillus, stained with KOH
BAL specimen showing hyaline, septate hyphae consistent with Aspergillus, stained with Blankophor BAL specimen showing hyaline, septate hyphae consistent with Aspergillus, stained with Blankophor
BAL specimen showing hyaline, septate hyphae consistent with Aspergillus, stained with Blankophor BAL specimen showing hyaline, septate hyphae consistent with Aspergillus, stained with Blankophor
Mucous plug examined by light microscopy with KOH Mucous plug examined by light microscopy with KOH, showing a network of hyaline branching hyphae typical of Aspergillus, from a patient with ABPA.
Mucous plug examined by light microscopy with KOH Mucous plug examined by light microscopy with KOH, showing a network of hyaline branching hyphae typical of Aspergillus, from a patient with ABPA.
Corneal scraping stained with lactophenol cotton blue Corneal scraping stained with lactophenol cotton blue showing beaded septate hyphae not typical of either Fusarium spp or Aspergillus spp, being more consistent with a dematiceous (ie brown coloured) fungus
Corneal scraping stained with lactophenol cotton blue Corneal scraping stained with lactophenol cotton blue showing beaded septate hyphae not typical of either Fusarium spp or Aspergillus spp, being more consistent with a dematiceous (ie brown coloured) fungus
Corneal scrape with lactophenol cotton blue Corneal scrape with lactophenol cotton blue shows separate hyphae with Fusarium spp or Aspergillus spp.
Corneal scrape with lactophenol cotton blue Corneal scrape with lactophenol cotton blue shows separate hyphae with Fusarium spp or Aspergillus spp.
Specimens taken from nails
Specimens taken from nails

The quality of the specimen taken is a major factor in success or otherwise of microscopy and culture. Having a specimen taken should be painless apart from occasional slight discomfort when subungual specimens are taken. The figure shows the appropriate sites from which nail specimens should be obtained.

Skin scraping showing filamentous hyphae with blankophor.
A filamentous fungus in the CSF of a patient with meningitis A filamentous fungus in the CSF of a patient with meningitis that grew Candida albicans in culture subsequently.
A filamentous fungus in the CSF of a patient with meningitis A filamentous fungus in the CSF of a patient with meningitis that grew Candida albicans in culture subsequently.
Transmission electron micrograph of a C. neoformans Transmission electron micrograph of a C. neoformans cell seen in CSF in an AIDS patients with remarkably little capsule present. These cells may be mistaken for lymphocytes.
Transmission electron micrograph of a C. neoformans Transmission electron micrograph of a C. neoformans cell seen in CSF in an AIDS patients with remarkably little capsule present. These cells may be mistaken for lymphocytes.
India ink preparation of CSF India ink preparation of CSF showing multiple yeasts with large capsules, and narrow buds to smaller daughter cells, typical of C. neoformans
India ink preparation of CSF India ink preparation of CSF showing multiple yeasts with large capsules, and narrow buds to smaller daughter cells, typical of C. neoformans
Histological staining PAS-stain. An example of Aspergillus fumigatus.
Histological staining PAS-stain. An example of Aspergillus fumigatus.

PAS-stainAn example of Aspergillus fumigatus in a patient with chronic granulomatous disease showing a 45 degree branching hypha within a giant cell. Rather bulbous hyphal ends are also seem, which is sometimes found in Aspergillus spp. infections, histologically. x800

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