Systemic fungal infections

The incidence of systemic fungal infections has increased over the last two decades. An expanded range of antifungal agents are now available. Voriconazole is a broad spectrum triazole. In treatment of invasive aspergillosis, voriconazole was associated with higher survival at 12 weeks compared to starting therapy with amphotericin B deoxycholate. Posaconazole is similar but with a different side effect profile and is a useful alternative. Caspofungin is the first of a new class of intravenous antifungals, the echinocandins. It is active against Candida and Aspergillus, and is as effective with fewer adverse events than amphotericin B in treatment of invasive candidiasis. Anidulafungin and micafungin are similar. The management of invasive candidiasis and aspergillosis is discussed in the light of these new agents. Cryptococcal meningitis remains a leading cause of death in HIV-infected patients in Africa and Asia. Treatment is with amphotericin B plus flucytosine for 2 weeks, followed by fluconazole. Patients with high cerebrospinal fluid opening pressure need serial lumbar punctures. Mucormycosis is a rare but devastating infection in diabetic and neutropenic patients. Rhinocerebral infection presents with orbital swelling, fever and facial pain. Endemic dimorphic fungal infections include histoplasmosis, widespread but common in central USA, and penicilliosis in South East Asia.