Fungal Infections

Patients whose immunity is impaired are succeptible to systemic fungal
infections. In CLL they are particilarly a risk following treatment with steroids,
fludarabine or Campath.

Candida usually shows itself as mouth ulcers or painful swallowing, but can
be a cause of an unexplained fever or disordered liver function tests. It is
nowadays much less of a problem than previously because of the widespread use
of fluconazole.

Aspergillus is rather more serious and is resistant to treatment with
fluconazole. It tends to cause unexplained fevers and pneumonias. Typically a
neutropenic patient with a fever will be first treated with antibiotics tailored
to kill gram negative bacteria like E. coli or Pseudomonas and if the fever
persists after 48 hours and the patient has a line inserted treatment for a gram
positive bacterium, like staphylococcus will be started. If the fever is no
better after 96 hours then fungus is suspected and treatment started. It can
be difficult to determine whether a fungus is present, blood tests are not
very good, though a CT chest may be helpful.

The standard treatment is amphotericin B. Unfortunately this tends to induce
kidney damage. Gold standard treatment is therefore liposomal amphotericin
(ambisome) which is much less toxic and therefore can be given in larger
doses. There are two newer drugs, voriconazole and capsofungin. All three of these
more effective drugs are very expensive.

There is a lot more that could be said. This is only a brief summary