Main characteristics and treatment recommendations for the most frequent non-Aspergillus moulds causing lung infections
| Fungal agent | Main species | Microbiological diagnosis [130]# | Treatment¶ | Comments¶ |
| Mucorales [71] | Rhizopus spp., Mucor spp., Rhizomucor spp., Cunninghamella spp., Lichtheimia sp., Apophysomyces spp. | Thick, ribbonlike, non-septate hyphae; no available biomarkers; molecular diagnosis (pan-fungal or quantitative species-specific PCR) | Liposomal amphotericin B 5–10 mg·kg−1 per day (first choice) or isavuconazole (second choice); posaconazole (second line); liposomal amphotericin B combined with echinocandins or posaconazole in severe cases (low evidence) | CT scan showing reverse halo sign, multiple nodes (>10) or pleural effusion; perform surgery whenever feasible; AST is recommended; rigorous glycaemic control; strategies to restore immunity; consider deferasirox in diabetic ketoacidosis; consider hyperbaric oxygen |
| Fusarium spp. [94] | F. solani species complex, F. oxysporum species complex, F. verticillioides, F. fujikuroi | Narrow, septate hyphae with acute angle branching (like Aspergillus spp.); canoe-shaped macroconidia; conidiophores with single or clustered conidia, with potential reniform adventitious conidia; galactomannan and 1,3-β-d-glucan may be positive; positive blood cultures in ∼50% of cases (adventitious sporulation); molecular diagnosis | Liposomal amphotericin B or voriconazole; consider initial combination of both liposomal amphotericin B and voriconazole; adding an echinocandin or terbinafine may be considered in severe cases (very low evidence) | Typically disseminated skin lesions; AST is recommended; perform surgery whenever feasible; strategies to restore immunity; importance of neutropenia recovery |
| Scedosporium spp. [94] | S. apiospermum, S. aurantiacum, S. boydii, S. dehoogii | Narrow, septate hyphae with acute angle branching (like Aspergillus spp.); lateral branching off at 60–70° angle may be observed; annellides with a swollen base and elongated neck; oval conidia with truncated base; distinctive coremia or an ascocarp may be seen; molecular diagnosis | Voriconazole (first line); echinocandins (second line); voriconazole combined with echinocandins or terbinafine in severe cases (low evidence) | Consider performing MRI; resistant to amphotericin B; AST is recommended; perform surgery whenever feasible; strategies to restore immunity |
| Lomentospora prolificans (formerly known as Scedosporium prolificans) [94] | Narrow, septate hyphae with acute angle branching (like Aspergillus spp.); black colour colonies; flask-shaped and annellated conidiogenous cells with a swollen base and elongated neck; smooth olive conidia cluster at the apex; molecular diagnosis | Voriconazole (first line); consider voriconazole combined with terbinafine or/and echinocandins (very low evidence); consider the use of olorofim (current lack of evidence and not commercialised) | Commonly resistant to all available antifungals; AST is recommended; consider performing cranial MRI; perform surgery whenever feasible; strategies to restore immunity | |
| Other hyaline moulds [94] | Paecilomyces spp., Acremonium spp., Rasamsonia spp., Penicillium spp., Trichoderma spp. | Narrow, septate hyphae with acute angle branching (like Aspergillus spp.); some differences between species; molecular diagnosis | Optimal antifungal therapy not established and depends on the isolated species | Importance of molecular diagnosis and AST; perform surgery whenever feasible; strategies to restore immunity |
| Phaeohyphomycetes [94] | Alternaria spp., Exophiala spp., Curvularia spp., Cladosporium spp., Ochroconis spp., Bipolaris spp. | Septate hyphae with dark-pigmented colonies (melanin production); some differences between species; 1,3-β-d-glucan may be positive; molecular diagnosis | Optimal antifungal therapy not established and depends on the isolated species | AST is recommended; perform surgery whenever feasible; strategies to restore immunity |
CT: computed tomography; AST: antifungal susceptibility testing; MRI: magnetic resonance imaging. #: microscopic morphology description is based on direct examination; ¶: due to the very low quality of evidence available, some of these recommendations are based on the personal experience of the authors.