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\author{gnvr (Guenevere)}
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  /Title (fungal-diseases-of-the-lung-des-jardins.pdf)
  /Creator (Cheatography)
  /Author (gnvr (Guenevere))
  /Subject (Fungal Diseases of the Lung (Des Jardins) Cheat Sheet)
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    \vspace{-2pt}\large{\bf{\textcolor{DarkBackground}{\textrm{Fungal Diseases of the Lung (Des Jardins) Cheat Sheet}}}} \\
    \normalsize{by \textcolor{DarkBackground}{gnvr (Guenevere)} via \textcolor{DarkBackground}{\uline{cheatography.com/147429/cs/34811/}}}
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  \mymulticolumn{1}{p{5.377cm}}{\bf\textcolor{white}{Cheat Sheet}}  \\
   \vspace{-2pt}Published 21st October, 2022.\\
   Updated 21st October, 2022.\\
   Page {\thepage} of \pageref{LastPage}.
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\begin{tabularx}{8.4cm}{p{0.8 cm} x{7.2 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Anatomic Alterations of the Lungs}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{{\emph{Chronic restrictive pulmonary disorder}}}}} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{When fungal spores are inhaled, they may reach the lungs and germinate.} \tn 
% Row Count 3 (+ 2)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{The spores produce a {\bf{frothy, yeast-like}} substance that leads to an inflammatory response.} \tn 
% Row Count 5 (+ 2)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{Polymorphonuclear leukocytes and macrophages move into the infected area and engulf the fungal spores.} \tn 
% Row Count 8 (+ 3)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{The pulmonary capillaries dilate, the interstitium fills with fluid, and the alveolar epithelium swells with {\bf{edema fluid}}.} \tn 
% Row Count 11 (+ 3)
% Row 5
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Regional lymph node involvement}} commonly occurs during this period.} \tn 
% Row Count 13 (+ 2)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Because of the inflammatory reaction, the alveoli in the infected area eventually become {\bf{consolidated}}.} \tn 
% Row Count 16 (+ 3)
% Row 7
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{Airway secretions may also develop at this time.} \tn 
% Row Count 17 (+ 1)
% Row 8
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{In {\bf{severe cases}}, tissue necrosis, {\bf{granulomas}}, and cavity formation may be seen.} \tn 
% Row Count 19 (+ 2)
% Row 9
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{During the healing process, {\bf{fibrosis}} and {\bf{calcification}} of the lung parenchyma ultimately replace the granulomas.} \tn 
% Row Count 22 (+ 3)
% Row 10
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{In response to the fibrosis and occasional calcification, the lung tissue retracts and becomes firm.} \tn 
% Row Count 24 (+ 2)
% Row 11
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{The {\bf{apical}} and {\bf{posterior}} {\bf{segments of the upper lobes}} are most commonly involved.} \tn 
% Row Count 26 (+ 2)
% Row 12
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Anatomic changes are similar to those seen in TB.} \tn 
% Row Count 27 (+ 1)
% Row 13
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{\{\{ac\}\}{\bf{Major pathologic or structural changes}}} \tn 
% Row Count 28 (+ 1)
% Row 14
\SetRowColor{LightBackground}
 & •	 Alveolar consolidation \tn 
% Row Count 29 (+ 1)
% Row 15
\SetRowColor{white}
 & •	 Alveolar-capillary destruction \tn 
% Row Count 30 (+ 1)
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\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Anatomic Alterations of the Lungs (cont)}}  \tn
% Row 16
\SetRowColor{LightBackground}
 & •	 Caseous tubercles or granulomas \tn 
% Row Count 1 (+ 1)
% Row 17
\SetRowColor{white}
 & •	 Cavity formation \tn 
% Row Count 2 (+ 1)
% Row 18
\SetRowColor{LightBackground}
 & •	 Fibrosis and secondary calcification of the lung parenchyma \tn 
% Row Count 4 (+ 2)
% Row 19
\SetRowColor{white}
 & •	 Bronchial secretions \tn 
% Row Count 5 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
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\begin{tabularx}{8.4cm}{x{2.64 cm} x{5.36 cm} }
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\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Etiology and Epidemiology}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Fungal spores of various types are widely distributed throughout the {\bf{air}}, {\bf{soil}}, {\bf{fomites}}, and {\bf{animals}}, and even exist in the {\bf{{\emph{normal flora of humans}}}}.} \tn 
% Row Count 4 (+ 4)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{300 fungal species may be linked to disease in animals} \tn 
% Row Count 6 (+ 2)
% Row 2
\SetRowColor{LightBackground}
In plants & fungal disease is the most common cause of death and destruction \tn 
% Row Count 9 (+ 3)
% Row 3
\SetRowColor{white}
In humans & most exposures to fungal pathogens do {\emph{not}} lead to overt infection because humans have a relatively high resistance to them \tn 
% Row Count 14 (+ 5)
% Row 4
\SetRowColor{LightBackground}
Human fungal disease & {\bf{{\emph{mycotic disease}}}} or {\bf{{\emph{mycosis}}}} \tn 
% Row Count 16 (+ 2)
% Row 5
\SetRowColor{white}
 & caused by {\bf{primary or "true" fungal pathogens}} that exhibit some degree of virulence or by opportunistic \tn 
% Row Count 21 (+ 5)
% Row 6
\SetRowColor{LightBackground}
 & or {\bf{secondary pathogens}} that take advantage of a weakened immune defense system \tn 
% Row Count 25 (+ 4)
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\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Primary Pathogens {[}Histoplasmosis{]}}}  \tn
% Row 0
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\mymulticolumn{2}{x{8.4cm}}{{\bf{HISTOPLASMOSIS}}} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
 & •	 {\bf{{\emph{Ohio Valley Fever}}}} \tn 
% Row Count 2 (+ 1)
% Row 2
\SetRowColor{LightBackground}
 & •	 most common fungal infection in the United States \tn 
% Row Count 4 (+ 2)
% Row 3
\SetRowColor{white}
 & •	 dimorphic fungus {\bf{{\emph{Histoplasma capsulatum}}}} \tn 
% Row Count 6 (+ 2)
% Row 4
\SetRowColor{LightBackground}
 & •	 prevalence of histoplasmosis is especially high along the major river valleys of the Midwest and South (e.g., in Ohio, Michigan, Illinois, Mississippi, Missouri, Kentucky, Tennessee, Georgia, and Arkansas) \tn 
% Row Count 14 (+ 8)
% Row 5
\SetRowColor{white}
 & •	 On the basis of skin test surveys it is estimated that {\bf{80\% to 90\%}} of the population throughout these areas shows signs of previous infection \tn 
% Row Count 20 (+ 6)
% Row 6
\SetRowColor{LightBackground}
{\emph{H. capsulatum}} & •	 commonly found in soils enriched with bird excreta, such as the soil near chicken houses, pigeon lofts, barns, and trees where starlings and blackbirds roost \tn 
% Row Count 26 (+ 6)
% Row 7
\SetRowColor{white}
 & •	 may be carried by bats \tn 
% Row Count 27 (+ 1)
% Row 8
\SetRowColor{LightBackground}
 & •	 an individual acquires the infection by inhaling the fungal spores that are released when the soil from an infected area is disturbed \tn 
% Row Count 32 (+ 5)
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\vfill
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\begin{tabularx}{8.4cm}{x{2.16 cm} x{5.84 cm} }
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\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Primary Pathogens {[}Histoplasmosis{]} (cont)}}  \tn
% Row 9
\SetRowColor{LightBackground}
 & •	incubation period for the infection is approximately 17 days \tn 
% Row Count 3 (+ 3)
% Row 10
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{When the {\emph{H. capsulatum}} organism reaches the alveoli at body temperature, it converts from its {\bf{{\emph{mycelial form (mold)}}}} to a {\bf{parasitic yeast form}}.} \tn 
% Row Count 7 (+ 4)
% Row 11
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Only about 40\% of those infected demonstrate symptoms, and only about 10\% of these patients are ill enough to consult a physician.} \tn 
% Row Count 10 (+ 3)
% Row 12
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{Depending on the individual's immune system, the disease may take one of the following forms:} \tn 
% Row Count 12 (+ 2)
% Row 13
\SetRowColor{LightBackground}
 & •	{\bf{asymptomatic primary histoplasmosis}} \tn 
% Row Count 14 (+ 2)
% Row 14
\SetRowColor{white}
 & •	 {\bf{acute symptomatic pulmonary histoplasmosis}} \tn 
% Row Count 16 (+ 2)
% Row 15
\SetRowColor{LightBackground}
 & •	 {\bf{chronic histoplasmosis}} \tn 
% Row Count 18 (+ 2)
% Row 16
\SetRowColor{white}
 & •	 {\bf{disseminated histoplasmosis}} \tn 
% Row Count 20 (+ 2)
% Row 17
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\emph{Asymptomatic histoplasmosis}}} \tn 
% Row Count 21 (+ 1)
% Row 18
\SetRowColor{white}
 & •	 most common form of histoplasmosis \tn 
% Row Count 23 (+ 2)
% Row 19
\SetRowColor{LightBackground}
 & •	 Normally it produces no signs or symptoms in otherwise healthy individuals who become infected. \tn 
% Row Count 27 (+ 4)
% Row 20
\SetRowColor{white}
 & •	 The only residual sign of infection may be a small, healed lesion of the lung parenchyma or calcified hilar lymph nodes. \tn 
% Row Count 32 (+ 5)
\end{tabularx}
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\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{2.16 cm} x{5.84 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Primary Pathogens {[}Histoplasmosis{]} (cont)}}  \tn
% Row 21
\SetRowColor{LightBackground}
 & •	 patient will have a positive {\bf{histoplasmin skin test}} result \tn 
% Row Count 3 (+ 3)
% Row 22
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{{\emph{Acute symptomatic pulmonary histoplasmosis}}} \tn 
% Row Count 4 (+ 1)
% Row 23
\SetRowColor{LightBackground}
 & •	 occur in otherwise healthy individuals who have had an intense exposure to {\emph{H. capsulatum}} \tn 
% Row Count 8 (+ 4)
% Row 24
\SetRowColor{white}
 & •	 Depending on the number of spores inhaled, the individual signs and symptoms may range from mild to serious illness. \tn 
% Row Count 13 (+ 5)
% Row 25
\SetRowColor{LightBackground}
 & •	 Mild signs and symptoms include fever, muscle and joint pain, headache, dry hacking cough, chills, chest pain, weight loss, and sweats. \tn 
% Row Count 18 (+ 5)
% Row 26
\SetRowColor{white}
 & •	 People who have inhaled a large number of spores may develop a severe acute pulmonary syndrome, a potentially life-threatening condition in which the individual becomes extremely short of breath. \tn 
% Row Count 25 (+ 7)
% Row 27
\SetRowColor{LightBackground}
 & •	 This is often referred to as {\bf{{\emph{spelunker's lung}}}} because it frequently develops after excessive exposure to bat excrement stirred up by individuals exploring caves. \tn 
% Row Count 31 (+ 6)
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\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{2.16 cm} x{5.84 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Primary Pathogens {[}Histoplasmosis{]} (cont)}}  \tn
% Row 28
\SetRowColor{LightBackground}
 & •	 During this phase of the disease, the patient's chest radiograph generally shows single or multiple infection sites resembling those associated with pneumonia. \tn 
% Row Count 6 (+ 6)
% Row 29
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{{\emph{Chronic pulmonary histoplasmosis}}} \tn 
% Row Count 7 (+ 1)
% Row 30
\SetRowColor{LightBackground}
 & •	 Infiltration and cavity formation in the upper lobes of one or both lungs. \tn 
% Row Count 10 (+ 3)
% Row 31
\SetRowColor{white}
 & •	 often affects people with an underlying lung disease such as {\bf{emphysema}} \tn 
% Row Count 13 (+ 3)
% Row 32
\SetRowColor{LightBackground}
 & •	 most commonly seen in middle-aged white men who smoke \tn 
% Row Count 15 (+ 2)
% Row 33
\SetRowColor{white}
 & •	 {\bf{Signs and symptoms}} include fatigue, fever, night sweats, weight loss, productive cough, and hemoptysis—similar to signs and symptoms of tuberculosis. \tn 
% Row Count 21 (+ 6)
% Row 34
\SetRowColor{LightBackground}
 & •	 Often the infection is self-limiting. \tn 
% Row Count 23 (+ 2)
% Row 35
\SetRowColor{white}
 & •	 In some patients, however, progressive destruction of lung tissue and dissemination of the infection may occur. \tn 
% Row Count 27 (+ 4)
% Row 36
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\emph{Disseminated histoplasmosis}}} \tn 
% Row Count 28 (+ 1)
% Row 37
\SetRowColor{white}
 & •	 either self-limited histoplasmosis or chronic histoplasmosis \tn 
% Row Count 31 (+ 3)
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\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Primary Pathogens {[}Histoplasmosis{]} (cont)}}  \tn
% Row 38
\SetRowColor{LightBackground}
 & •	 most often seen in very young or very old patients with compromised immune systems \tn 
% Row Count 3 (+ 3)
% Row 39
\SetRowColor{white}
 & •	 Even though the macrophages can remove the fungi from the bloodstream, they are unable to kill the fungal organisms. \tn 
% Row Count 8 (+ 5)
% Row 40
\SetRowColor{LightBackground}
 & •	 As a result, disseminated histoplasmosis can affect nearly any part of the body, including eyes, liver, bone marrow, skin, adrenal glands, and intestinal tract. \tn 
% Row Count 14 (+ 6)
% Row 41
\SetRowColor{white}
 & •	 Depending on which body organs are affected, the patient may develop anemia, pneumonia, pericarditis, meningitis, or adrenal insufficiency and ulcers of the mouth, tongue, or intestinal tract. \tn 
% Row Count 21 (+ 7)
% Row 42
\SetRowColor{LightBackground}
 & •	 If untreated, disseminated histoplasmosis is usually fatal. \tn 
% Row Count 24 (+ 3)
% Row 43
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{\{\{ac\}\}{\bf{Screening and Diagnosis}}} \tn 
% Row Count 25 (+ 1)
% Row 44
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Fungal culture}}} \tn 
% Row Count 26 (+ 1)
% Row 45
\SetRowColor{white}
 & •	 gold standard for detecting histoplasmosis \tn 
% Row Count 28 (+ 2)
% Row 46
\SetRowColor{LightBackground}
 & •	 A small amount of blood, sputum, or tissue from a lymph node, lung, or bone marrow is cultured. \tn 
% Row Count 32 (+ 4)
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\vfill
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\begin{tabularx}{8.4cm}{x{2.16 cm} x{5.84 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Primary Pathogens {[}Histoplasmosis{]} (cont)}}  \tn
% Row 47
\SetRowColor{LightBackground}
 & •	 The disadvantage of this test is that it takes time for the fungus to grow—4 weeks or longer. \tn 
% Row Count 4 (+ 4)
% Row 48
\SetRowColor{white}
 & •	 not the test of choice in cases of disseminated histoplasmosis \tn 
% Row Count 7 (+ 3)
% Row 49
\SetRowColor{LightBackground}
 & •	 Treatment delays in patients may prove fatal. \tn 
% Row Count 9 (+ 2)
% Row 50
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Fungal stain}}} \tn 
% Row Count 10 (+ 1)
% Row 51
\SetRowColor{LightBackground}
 & •	 a tissue sample, which may be obtained from sputum, bone marrow, lungs, or a skin lesion, is stained with dye and examined under a microscope for {\emph{H. capsulatum}} \tn 
% Row Count 16 (+ 6)
% Row 52
\SetRowColor{white}
 & •	 A positive test result is 100\% accurate. \tn 
% Row Count 18 (+ 2)
% Row 53
\SetRowColor{LightBackground}
 & •	 e. The disadvantage of this test is that obtaining a sputum sample can be difficult, and obtaining a sample from other sites requires invasive procedures. \tn 
% Row Count 24 (+ 6)
% Row 54
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Serology}}} \tn 
% Row Count 25 (+ 1)
% Row 55
\SetRowColor{LightBackground}
 & •	 checks blood serum for antigens and antibodies \tn 
% Row Count 27 (+ 2)
% Row 56
\SetRowColor{white}
 & •	 When an individual is exposed to histoplasmosis spores (antigens), the body's immune system produces antibodies (proteins) to react to the histoplasmosis antigens. \tn 
% Row Count 33 (+ 6)
\end{tabularx}
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\columnbreak
\begin{tabularx}{8.4cm}{x{2.16 cm} x{5.84 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Primary Pathogens {[}Histoplasmosis{]} (cont)}}  \tn
% Row 57
\SetRowColor{LightBackground}
 & •	 Tests that check for histoplasmosis antigen and antibody reactions are relatively fast and fairly accurate. \tn 
% Row Count 4 (+ 4)
% Row 58
\SetRowColor{white}
 & •	 False-negative results, however, may occur in people who have compromised immune systems or who are infected with other types of fungi. \tn 
% Row Count 9 (+ 5)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
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\begin{tabularx}{8.4cm}{x{3.2 cm} x{4.8 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Primary Pathogens {[}Coccidioidomycosis{]}}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Coccidioidomycosis}}} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
 & •	 caused by inhalation of the spores of {\bf{{\emph{Coccidioides immitis}}}}, which are spherical fungi carried by wind-borne dust particles \tn 
% Row Count 7 (+ 6)
% Row 2
\SetRowColor{LightBackground}
 & •	 endemic in hot, dry regions \tn 
% Row Count 9 (+ 2)
% Row 3
\SetRowColor{white}
 & •	 .In the United States, coccidioidomycosis is especially prevalent in California, Arizona, Nevada, New Mexico, Texas, and Utah. \tn 
% Row Count 15 (+ 6)
% Row 4
\SetRowColor{LightBackground}
 & •	 About 80\% of the people in the San Joaquin Valley have positive coccidioidin skin-test results. \tn 
% Row Count 20 (+ 5)
% Row 5
\SetRowColor{white}
 & •	 "{\bf{California fever}}," "{\bf{Desert rheumatism}}," "{\bf{San Joaquin Valley Disease}}," and "{\bf{Valley Fever}}." \tn 
% Row Count 26 (+ 6)
% Row 6
\SetRowColor{LightBackground}
 & •	 isolated in these regions from soils, plants, and a large number of vertebrates \tn 
% Row Count 30 (+ 4)
\end{tabularx}
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\begin{tabularx}{8.4cm}{x{3.2 cm} x{4.8 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Primary Pathogens {[}Coccidioidomycosis{]} (cont)}}  \tn
% Row 7
\SetRowColor{LightBackground}
 & •	 When {\emph{C. immitis}} spores are inhaled, they settle in the lungs, begin to germinate, and form round, thin-walled cells called {\bf{spherules}}. \tn 
% Row Count 6 (+ 6)
% Row 8
\SetRowColor{white}
 & •	 The spherules, in turn, contain endospores that make more spherules (the spherule-endospore phase). \tn 
% Row Count 11 (+ 5)
% Row 9
\SetRowColor{LightBackground}
 & •	 The disease usually takes the form of an acute, primary, selflimiting pulmonary infection with or without systemic involvement. \tn 
% Row Count 17 (+ 6)
% Row 10
\SetRowColor{white}
 & •	 Some cases, however, progress to disseminated disease. \tn 
% Row Count 20 (+ 3)
% Row 11
\SetRowColor{LightBackground}
{\bf{Clinical manifestations}} & •	 absent in about 60\% of the people who have a positive skin-test result \tn 
% Row Count 24 (+ 4)
% Row 12
\SetRowColor{white}
 & •	 40\%: cold-like symptoms such as fever, chest pain, cough, headaches, and malaise are often present. \tn 
% Row Count 29 (+ 5)
% Row 13
\SetRowColor{LightBackground}
 & •	 In uncomplicated cases, patients generally recover completely and enjoy lifelong immunity. \tn 
% Row Count 33 (+ 4)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{3.2 cm} x{4.8 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Primary Pathogens {[}Coccidioidomycosis{]} (cont)}}  \tn
% Row 14
\SetRowColor{LightBackground}
 & •	 In approximately 1:200 cases, however, the primary infection does not resolve and progresses with varied clinical manifestations. \tn 
% Row Count 6 (+ 6)
% Row 15
\SetRowColor{white}
 & •	 Chronic progressive pulmonary disease is characterized by nodular growths called {\bf{{\emph{fungomas}}}} and cavity formation in the lungs. \tn 
% Row Count 12 (+ 6)
% Row 16
\SetRowColor{LightBackground}
 & •	 Disseminated coccidioidomycosis occurs in about 1:6000 exposed persons. \tn 
% Row Count 16 (+ 4)
% Row 17
\SetRowColor{white}
 & •	 When this condition exists, the lymph nodes, meninges, spleen, liver, kidney, skin, and adrenals may be involved. \tn 
% Row Count 21 (+ 5)
% Row 18
\SetRowColor{LightBackground}
 & •	 The skin lesions (e.g., bumps on the face and chest) are commonly accompanied by arthralgia or arthritis, especially in the ankles and knees. This condition is commonly called "{\bf{desert bumps}}," "{\bf{desert arthritis}}," or "{\bf{desert rheumatism}}." \tn 
% Row Count 32 (+ 11)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{3.2 cm} x{4.8 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Primary Pathogens {[}Coccidioidomycosis{]} (cont)}}  \tn
% Row 19
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Screening and Diagnosis}}} \tn 
% Row Count 1 (+ 1)
% Row 20
\SetRowColor{white}
 & •	 The diagnosis of coccidioidomycosis can be made by direct visualization of distinctive spherules in microscopy of the patient's sputum, tissue exudates, biopsies, or spinal fluid. \tn 
% Row Count 9 (+ 8)
% Row 21
\SetRowColor{LightBackground}
 & •	 The diagnosis can be further supported by blood tests that detect antibodies to the fungus or from a culture of the organism from infected fluid or tissue. \tn 
% Row Count 16 (+ 7)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{p{0.8 cm} x{7.2 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Primary Pathogens {[}Blastomycosis{]}}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Blastomycosis}}} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
 & •	 "{\bf{Chicago disease}}," {\bf{Gilchrist's disease}}, and {\bf{North American blastomycosis}} \tn 
% Row Count 4 (+ 3)
% Row 2
\SetRowColor{LightBackground}
 & •	 caused by {\bf{{\emph{Blastomyces dermatitidis}}}} \tn 
% Row Count 6 (+ 2)
% Row 3
\SetRowColor{white}
 & •	 occurs in people living in the south-central and midwestern United States and in Canada \tn 
% Row Count 9 (+ 3)
% Row 4
\SetRowColor{LightBackground}
 & •	 The infection occurs in 1 to 2 of every 100,000 people in these areas. \tn 
% Row Count 12 (+ 3)
% Row 5
\SetRowColor{white}
 & •	 Cases also have been reported in Central America, South America, Africa, and the Middle East. \tn 
% Row Count 15 (+ 3)
% Row 6
\SetRowColor{LightBackground}
 & •	 {\emph{B. dermatitidis}} inhabits areas high in organic matter, such as forest soil, decaying wood, animal manure, and abandoned buildings. \tn 
% Row Count 19 (+ 4)
% Row 7
\SetRowColor{white}
 & •	 most common among pregnant women and middle-aged African-American men \tn 
% Row Count 22 (+ 3)
% Row 8
\SetRowColor{LightBackground}
 & •	 The disease also is found in dogs, cats, and horses. \tn 
% Row Count 24 (+ 2)
% Row 9
\SetRowColor{white}
 & •	 Primary portal of entry of {\emph{B. dermatitidis}} is the {\bf{lungs}}. \tn 
% Row Count 26 (+ 2)
% Row 10
\SetRowColor{LightBackground}
 & •	 The acute clinical manifestations resemble those of acute histoplasmosis, including fever, cough, hoarseness, joint and muscle aches, and, in some cases, {\bf{pleuritic pain}}. \tn 
% Row Count 31 (+ 5)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{p{0.8 cm} x{7.2 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Primary Pathogens {[}Blastomycosis{]} (cont)}}  \tn
% Row 11
\SetRowColor{LightBackground}
 & •	 Unlike in histoplasmosis infection, however, the {\bf{cough is frequently productive}}, and the {\bf{sputum is purulent}}. \tn 
% Row Count 4 (+ 4)
% Row 12
\SetRowColor{white}
 & •	 Acute pulmonary infections may be self-limiting or progressive. \tn 
% Row Count 6 (+ 2)
% Row 13
\SetRowColor{LightBackground}
 & •	 When the condition is progressive, {\bf{nodules}} and {\bf{abscesses}} develop in the lungs. \tn 
% Row Count 9 (+ 3)
% Row 14
\SetRowColor{white}
 & •	 Extrapulmonary lesions commonly involve the skin, bones, reproductive tract, spleen, liver, kidney, or prostate gland. \tn 
% Row Count 13 (+ 4)
% Row 15
\SetRowColor{LightBackground}
 & •	 The {\bf{skin lesions}} may, in fact, be the {\emph{first signs of the disease}}. \tn 
% Row Count 16 (+ 3)
% Row 16
\SetRowColor{white}
 & •	 It often begins on the face, hands, wrists, or legs as subcutaneous nodules that erode to the skin surface. \tn 
% Row Count 20 (+ 4)
% Row 17
\SetRowColor{LightBackground}
 & •	 {\bf{Yeast dissemination}} also may cause arthritis and osteomyelitis, and involvement of the central nervous system causes headache, convulsions, coma, and mental confusion. \tn 
% Row Count 25 (+ 5)
% Row 18
\SetRowColor{white}
 & •	 Standardized serologic testing procedures for blastomycosis are not available, and neither is an accurate {\bf{{\emph{blastomycin skin test}}}}. \tn 
% Row Count 29 (+ 4)
% Row 19
\SetRowColor{LightBackground}
 & •	 The diagnosis of blastomycosis can be made from direct visualization of the yeast in sputum smears, or the fungus can be cultured. \tn 
% Row Count 33 (+ 4)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{2.56 cm} x{5.44 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Opportunistic Pathogens}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Opportunistic yeast pathogens such as {\bf{{\emph{Candida albicans}}}}, {\bf{{\emph{Cryptococcus neoformans}}, and {\bf{}}Aspergillus}}* also are associated with lung infections in certain patients.} \tn 
% Row Count 4 (+ 4)
% Row 1
\SetRowColor{white}
{\bf{{\emph{C. albicans}}}} & •	 Occurs as normal flora in the oral cavity, genitalia, and large intestine. \tn 
% Row Count 7 (+ 3)
% Row 2
\SetRowColor{LightBackground}
 & •	 infection of the mouth, or {\bf{thrush}}, is characterized by a white, adherent, patchy infection of the mouth, gums, cheeks, and throat. \tn 
% Row Count 13 (+ 6)
% Row 3
\SetRowColor{white}
 & •	 In patients with HIV infection, {\emph{C. albicans}} often causes infection of the mouth, pharynx, vagina, skin, and lungs \tn 
% Row Count 18 (+ 5)
% Row 4
\SetRowColor{LightBackground}
{\bf{{\emph{C. neoformans}}}} & •	 Proliferates in the {\bf{high nitrogen content of pigeon droppings}} and is readily scattered into the air and dust. \tn 
% Row Count 23 (+ 5)
% Row 5
\SetRowColor{white}
 & •	 Today, {\bf{{\emph{Cryptococcus}}}} is most often seen in patients with HIV infection and persons undergoing steroid therapy \tn 
% Row Count 28 (+ 5)
% Row 6
\SetRowColor{LightBackground}
{\bf{{\emph{Aspergillus}}}} & •	 {\bf{most pervasive}} of all fungi \tn 
% Row Count 30 (+ 2)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{2.56 cm} x{5.44 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Opportunistic Pathogens (cont)}}  \tn
% Row 7
\SetRowColor{LightBackground}
 & •	 found in soil, vegetation, leaf detritus, food, and compost heaps \tn 
% Row Count 3 (+ 3)
% Row 8
\SetRowColor{white}
 & •	 Persons breathing the air of granaries, barns, and silos are at greatest risk. \tn 
% Row Count 7 (+ 4)
% Row 9
\SetRowColor{LightBackground}
 & •	 usually occurs in the lungs where it may present in the form of {\bf{allergic bronchopulmonary aspergillosis}}, a form of asthma. \tn 
% Row Count 12 (+ 5)
% Row 10
\SetRowColor{white}
 & •	 It is almost always an opportunistic infection and poses a serious threat to patients with HIV infection. \tn 
% Row Count 17 (+ 5)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{OVERVIEW}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{\{\{ac\}\}{\bf{CLINICAL DATA OBTAINED AT THE PATIENT'S BEDSIDE}}} \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{{\bf{The Physical Examination}}} \tn 
% Row Count 3 (+ 1)
% Row 2
\SetRowColor{LightBackground}
{\bf{Vital Signs}} & Increased Respiratory Rate (Tachypnea) \tn 
% Row Count 5 (+ 2)
% Row 3
\SetRowColor{white}
 & •	Stimulation of peripheral chemoreceptors \tn 
% Row Count 8 (+ 3)
% Row 4
\SetRowColor{LightBackground}
 & •	Decreased lung \seqsplit{compliance–increased} ventilatory rate relationship \tn 
% Row Count 12 (+ 4)
% Row 5
\SetRowColor{white}
 & •	Pain, anxiety, fever \tn 
% Row Count 14 (+ 2)
% Row 6
\SetRowColor{LightBackground}
 & Increased Heart Rate (Pulse) and Blood Pressure \tn 
% Row Count 17 (+ 3)
% Row 7
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Chest Pain, Decreased Chest Expansion}}} \tn 
% Row Count 18 (+ 1)
% Row 8
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Cyanosis}}} \tn 
% Row Count 19 (+ 1)
% Row 9
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Digital Clubbing}}} \tn 
% Row Count 20 (+ 1)
% Row 10
\SetRowColor{LightBackground}
{\bf{Peripheral Edema and Venous Distention}} & Because polycythemia and cor pulmonale are associated with severe fungal disease of the lungs, the following may be seen: \tn 
% Row Count 27 (+ 7)
% Row 11
\SetRowColor{white}
 & •	Distended neck veins \tn 
% Row Count 29 (+ 2)
% Row 12
\SetRowColor{LightBackground}
 & •	Pitting edema \tn 
% Row Count 30 (+ 1)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{OVERVIEW (cont)}}  \tn
% Row 13
\SetRowColor{LightBackground}
 & •	Enlarged and tender liver \tn 
% Row Count 2 (+ 2)
% Row 14
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Cough, Sputum Production, and Hemoptysis}}} \tn 
% Row Count 3 (+ 1)
% Row 15
\SetRowColor{LightBackground}
{\bf{Chest Assessment Findings}} & •	Increased tactile and vocal fremitus \tn 
% Row Count 5 (+ 2)
% Row 16
\SetRowColor{white}
 & •	Dull percussion note \tn 
% Row Count 7 (+ 2)
% Row 17
\SetRowColor{LightBackground}
 & •	Bronchial breath sounds \tn 
% Row Count 9 (+ 2)
% Row 18
\SetRowColor{white}
 & •	Crackles, wheezing \tn 
% Row Count 11 (+ 2)
% Row 19
\SetRowColor{LightBackground}
 & •	Pleural friction rub (if process extends to pleural surface) \tn 
% Row Count 15 (+ 4)
% Row 20
\SetRowColor{white}
 & •	Whispered pectoriloquy \tn 
% Row Count 17 (+ 2)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{2.48 cm} x{5.52 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{General Management of Fungal Disease}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{Amphotericin B}} & •	treatment of choice for most fungal infections \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
 & •	However, because of the high incidence of nephrotoxicity associated with amphotericin B, the {\bf{{\emph{azole}}}} antifungal agents now serve as an excellent alternative. \tn 
% Row Count 9 (+ 7)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{Although {\bf{ketoconazole}} was the first agent in this class, it has largely been replaced with {\bf{fluconazole}} and {\bf{itraconazole}}.} \tn 
% Row Count 12 (+ 3)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{In addition, a new class of antifungals known as the {\bf{{\emph{echinocandins}}}} is now available.} \tn 
% Row Count 14 (+ 2)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{\{\{ac\}\}{\bf{Respiratory Care Treatment Protocols}}} \tn 
% Row Count 15 (+ 1)
% Row 5
\SetRowColor{white}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Oxygen Therapy Protocol}}} \tn 
% Row Count 16 (+ 1)
% Row 6
\SetRowColor{LightBackground}
 & •	used to treat hypoxemia, decrease the work of breathing, and decrease myocardial work \tn 
% Row Count 20 (+ 4)
% Row 7
\SetRowColor{white}
 & •	Because of the hypoxemia associated with the fungal pulmonary condition, supplemental oxygen may be required. \tn 
% Row Count 25 (+ 5)
% Row 8
\SetRowColor{LightBackground}
 & •	Because of the alveolar consolidation produced by a fungal disorder, capillary shunting may be present. \tn 
% Row Count 29 (+ 4)
% Row 9
\SetRowColor{white}
 & •	Hypoxemia caused by capillary shunting is often refractory to oxygen therapy. \tn 
% Row Count 32 (+ 3)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{2.48 cm} x{5.52 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{General Management of Fungal Disease (cont)}}  \tn
% Row 10
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Bronchopulmonary Hygiene Therapy Protocol}}} \tn 
% Row Count 1 (+ 1)
% Row 11
\SetRowColor{white}
 & •	Because of the excessive production and accumulation of mucus sometimes associated with fungal disease, a number of bronchial hygiene treatment modalities may be used to enhance the mobilization of bronchial secretions. \tn 
% Row Count 10 (+ 9)
% Row 12
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{8.4cm}}{{\bf{Mechanical Ventilation Protocol}}} \tn 
% Row Count 11 (+ 1)
% Row 13
\SetRowColor{white}
 & •	may be necessary to provide and support alveolar gas exchange and eventually return the patient to spontaneous breathing \tn 
% Row Count 16 (+ 5)
% Row 14
\SetRowColor{LightBackground}
 & •	Because acute ventilatory failure is occasionally seen in patients with severe fungal disease, continuous mechanical ventilation may be required. \tn 
% Row Count 22 (+ 6)
% Row 15
\SetRowColor{white}
 & •	Continuous mechanical ventilation is justified when the acute ventilatory failure is thought to be reversible. \tn 
% Row Count 27 (+ 5)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}


% That's all folks
\end{multicols*}

\end{document}