Fungus Culture With Reflex to Rapid Identification

CPT: 87101
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Test Details

Use

Isolate and identify fungi. Blood: establish the diagnosis of fungal infections including fungemia, fungal endocarditis, and disseminated mycosis in patients at risk for fungal infections.

Limitations

Blood: A single (or even multiple) negative fungal blood culture does not exclude disseminated fungal infection. If disseminated or deep fungal infection is strongly suspected despite repeatedly negative blood cultures, biopsy of the appropriate tissue and/or bone marrow aspiration for sections and fungus culture should be considered.

Stool: Use of this test is generally limited to detection of Candida. Stool cultures have a low yield and are not recommended for the isolation of systemic fungi; however, Histoplasma capsulatum is recovered from the stool of AIDS patients with disseminated infection.

Methodology

Culture and reflex identification

Additional Information

Blood: Fungemia can be a complication of venous or arterial catheterization, hyperalimentation, the acquired immunodeficiency syndrome (AIDS), and therapy with steroids, antineoplastic drugs, radiation, or broad spectrum antimicrobial agents. Intravenous drug abusers are prone to Candida endocarditis. Although many fungal species, including Histoplasma capsulatum, Coccidioides immitis, and Cryptococcus neoformans are recoverable from blood cultures, the most common cause of fungemia is Candida albicans followed by other Candida sp, including Candida glabrata. Fungemia represents a failure of the host defense system. Fungemia may be precipitated by contamination of an indwelling catheter or, in the critically ill and immunocompromised patient, contamination of the gastrointestinal and less frequently the urinary tract.1 In a review of 356 patients with neoplastic disease, Candida sp was recovered in 7% of neutropenic patients.

In the potentially immunocompromised host, a temperature of 38.5°C (101°F) for more than two hours, which is not associated with the administration of a pyrogenic drug (chemotherapy), indicates the presence of infection until proven otherwise. In these patients, characteristic signs and symptoms are frequently absent. A careful physical examination, including mouth, anus, and genitalia, may reveal the site of infection. Therapy must be instituted as soon as appropriate specimens are collected. Most infections in these patients are caused by gram-negative organisms (eg, E coli, Pseudomonas sp, Klebsiella sp ) and by S aureus; however, fungi and other usually nonpathogenic organisms must be considered significant.2

Rarely, blastospores (budding yeast structures) and pseudohyphae can be seen by examination of Wright-stained venous peripheral blood smears. This technique may allow early diagnosis and therapy before culture results are available.3

Eye: The more common causes of keratomycosis include Fusarium solani, Candida albicans, Aspergillus fumigatus, Curvularia sp, Aspergillus flavus, other species of Aspergillus, Penicillium, Paecilomyces, Fusarium, and many other species.4 A keratomycosis-like clinical presentation may also be encountered caused by Nocardia asteroides and Mycobacterium fortuitum. Keratomycosis is a rare complication of contact lens use.5

Sinus: Fungal sinusitis has been increasingly recognized in otherwise healthy teenagers who often present with a history of recurrent sinusitis, asthma, and/or polyps. At surgery, material is consistently described as thick peanut butter-like or pistachio pudding-like. Dematiaceous fungi are the most common cause.

Skin: Candida sp may colonize skin. Clinical diagnosis of Candida infection involves consideration of predisposing factors such as occlusion, maceration altered cutaneous barrier function. Signs of Candida infection include bright erythema, fragile papulopustules, and satellite lesions.6 Patients with defects in T-lymphocyte responses, such as AIDS patients or individuals being treated with antineoplastic drugs, are especially susceptible to many fungal infections including superficial mycoses.7,8 See tables.

Selection of Specimens for the Diagnosis of Superficial Mycosis and Dermatomycosis

Diagnosis

Specimen of Choice

Superficial Mycoses

Piedra

Hair

Tinea nigra

Skin scraping

Pityriasis versicolor

Skin scraping

Dermatomycoses (Cutaneous Mycoses)

Onychomycosis

Nail scraping

Tinea capitis

Hair (black dot)

Tinea corporis

Skin scraping

Tinea pedis

Skin scraping

Tinea cruris

Skin scraping

Candidiasis

Thrush

Scraping of oral white patches

Diaper dermatitis

Scraping of pustules at margin

Paronychia

Scraping skin around nail

Cutaneous candidiasis

Scraping of pustules at margin

Erosio interdigitalis blastomycetia (coinfection with gram-negative rods)

Scrapings of interdigital space

(routine culture also)

Congenital candidiasis

Scraping of scales, pustules and cutaneous debris, cultures of umbilical stump, mouth, urine, and stool

Mucocutaneous candidiasis

Scraping of affected area

Selection of Specimens for the Diagnosis of Systemic and Subcutaneous Mycosis

Diagnosis

Specimen of Choice

in Order of Usefulness

Systemic Mycoses

Aspergillosis

Sputum

Bronchial aspirate

Biopsy (lung)

Blastomycosis

Skin scrapings

Abscess drainage (pus)

Urine

Sputum

Bronchial aspirate

Candidiasis

Sputum

Bronchial aspirate

Blood

Cerebrospinal fluid

Urine

Stool

Coccidioidomycosis

Sputum

Bronchial aspirate

Cerebrospinal fluid

Urine

Skin scrapings

Abscess drainage (pus)

Cryptococcosis

Cerebrospinal fluid

Sputum

Abscess drainage (pus)

Skin scraping

Urine

Mucomycosis / phycomycosis / zygomycosis

Sputum

Bronchial aspirate

Biopsy (lung)

Paracoccidioidomycosis

(South American blastomycosis)

Skin scrapings

Mucosal scrapings

Biopsy (lymph nodes)

Sputum

Bronchial aspirate

Subcutaneous Mycoses

Chromomycosis

Skin scrapings

Biopsy (skin)

Drainage (pus)

Maduromycosis (mycetoma)

Abscess drainage

Biopsy (lesion)

Granules

Sporotrichosis

Drainage (pus)

Abscess drainage

Biopsy (skin, lymph node)

Hair: The leading agent of tinea capitis in the United States is Trichophyton tonsurans. Other dermatophytes such as T violaceum, T mentagrophytes, and Microsporum canis are also recovered routinely. Unlike at the beginning of the 20th century, M audouinii is rarely seen.

Nails: Nail disease can be caused by dermatophytes and nondermatophytes. The leading cause of nail infection is Trichophyton rubrum, but it is not unusual to find T mentagrophytes and T tonsurans. Recovery of dermatophytes from nail can be difficult and careful cleansing, scraping of the diseased nail, and collecting debris under the nail is required. Attributing nail disease to nondermatophytes is more problematic. Fungi such as Fusarium, Scopulariopsis, and some aspergilli are routinely associated with disease, however, Chrysosporium, Paecilomyces, Trichoderma and others may likely represent environmental contamination unless repeatedly isolated in the absence of other pathogens.

Sputum: Deeply coughed sputum, transtracheal aspirate, bronchial washing or brushing, or deep tracheal aspirate are preferred specimens. Oncology patients, transplant patients, and patients with the acquired immunodeficiency syndrome (AIDS) are particularly prone to infection with fungi.8

Primary fungal pulmonary infections include Histoplasma capsulatum, Coccidioides immitis, Cryptococcus neoformans, and Blastomyces dermatitidis. The incidence is largely related to geographic exposure and cases can occur in seemingly normal hosts. Numbers of reports of opportunistic fungal pulmonary infections due to a variety of etiologic agents that are ubiquitous in the environment are being published. Definitive diagnosis depends upon the presence of clinical signs of pulmonary infection, a chest x-ray revealing abnormality such as granuloma; laboratory isolation of a potentially significant organism from a suitable specimen; histologic documentation of tissue invasion by the isolated organism. A list of etiologic agents of pulmonary fungal disease has been compiled.9 In practice a diagnosis sufficient for therapy can frequently be established by observation of hyphae, pseudohyphae, spherules, or yeast cells in tissue sections; recovery of the organism from a normally sterile site; repeated isolation of the same suspect organism from the same or different sites; seroconversion (ie, the development of an immune response to the suspected organism).10Candida and Aspergillus sp are the most frequently isolated fungal organisms; however, they are frequently present as the result of contamination from the patient's normal flora or airborne sources. Their presence may represent colonization rather than invasion. Recovery of Candida from blood is a major adjunct to definitive diagnosis. Even without invasion Aspergillus may cause IgE mediated asthma, allergic alveolitis cell mediated hypersensitivity, mucoid impaction, and bronchocentric granulomatosis.11 Fungal tracheobronchitis has recently been recognized as a pseudomembranous form involving the circumference of the bronchial wall or as multiple or discrete plaques. The plaques or pseudomembranes are composed of necrotic tissue exudate and fungal hyphae.12

Stool: Candida can be isolated in up to 30% of oropharyngeal cultures and 65% of stool cultures; thus, it is a common saprophyte.13 Neonates and adults may develop watery diarrhea due to intestinal overgrowth by yeast that readily responds to specific therapy. Candida may become disseminated in patients with leukopenia, immunosuppressive therapy, AIDS, corticosteroid therapy, phagocytic defects, hyperalimentation, use of broad spectrum antibiotics, and oral contraceptives. Travelers in endemic areas with poor sanitation have also experienced intestinal overgrowth with Candida, although the specific mechanism causing diarrhea is unknown.14

Candida-associated diarrhea is predominantly of the secretory type, characterized by frequent watery stools, usually without blood, mucus, tenesmus, or abdominal pain.15 Overgrowth of Candida sp should be considered when evaluating Clostridium difficile negative cases of antibiotic-associated colitis.16

Urine: Asymptomatic funguria often clears spontaneously; however, candiduria with >15,000 colony forming units/mL of urine and with such evidence of dissemination as elevated serum precipitin antibody titers, is associated with increased mortality.17 Patients with candiduria may or may not have candidemia; positive urine culture for fungi often may be followed by positive blood culture for fungi. Ascending infections occur in patients with diabetes, prolonged antimicrobial therapy, or following instrumentation. Urinary obstruction due to “fungus balls” may occur in diabetes and following renal transplantation. Candiduria associated with hematogenous infections is observed in patients with granulocytopenia, corticosteroid therapy, and with immunosuppression. The source is frequently the gastrointestinal tract or indwelling catheters particular with hyperalimentation.18 A blood fungus culture is useful to define invasive disease; however, proof of invasive Candida infection requires direct cystoscopic or operative visualization, fungus balls, pyelonephritis, or histological evidence of mucosa invasion. Urine is a useful specimen for culture in cryptococcosis, blastomycosis, and candidiasis. The incidence of genitourinary fungal infections is increasing. They are usually associated with broad spectrum antibiotic therapy, corticosteroid therapy, underlying general debility, and AIDS. In addition to Candida, opportunistic pathogens in the genitourinary tract include Aspergillus and Cryptococcus. Endemic pathogens such as Histoplasma, Blastomyces, and Coccidioides are also encountered.19

Mold spores are common in the environment and it is not uncommon for saprophytic environmental fungi to be recovered from respiratory and skin specimens.

Specimen Requirements

Specimen

Biopsy, blood, body fluid, aspirates, bronchoalveolar lavage (BAL), swab of conjunctiva, skin, nails, hair, sputum, stool, throat, tissue, urine, or vaginal

Volume

2 mL or 1 cm3 tissue, 10 mL blood, whole nails, 50 mL body fluid (5 mL CSF), 5 mL aspirates or sputum; skin scrapings may be submitted on Mycosel® media (not supplied by LabCorp)

Container

Sterile screw-capped container for fluid or tissue, green-top (sodium heparin) tube, blood culture bottle, bacterial swab

Patient Preparation

Usual sterile preparation (see Blood Culture, Routine [008300]).

Collection

Biopsy: Surgical specimen in sterile container. A small amount of sterile nonbacteriostatic water should be added to prevent drying.

Body fluid, aspirates: Aspirated material in sterile container.

Eye: For keratitis, scrapings with a Kimura spatula directly inoculated using “C” streaks are best. For conjunctivitis, swabs of conjunctiva are acceptable.

Skin: Cleanse the area with 70% alcohol and collect a portion from the active border of the lesion.

Nails: For all types of onychomycosis, clean the nail area well with 70% alcohol, then, depending on type of nail disease, collect the following:

• Distal subungual: Clip the abnormal nail as close to the proximal edge as possible. Scrape the nail bed and underside of nail plate with a curet. Discard the outermost debris, which likely contains contaminants. Nail clippings are less desirable for culture.

• Proximal subungual: Pare down the normal surface of nail plate in the area of the lunula. Collect white material from the deeper portion of plate.

• White superficial: Scrape the white spots, discarding the outermost surface, which likely contains contaminants. Collect the white areas directly underneath.

Candida infection: Collect material closest to the proximal and lateral nail edges.

Hair: Epilate 10 to 12 hairs and place them in a sterile container.

Stool: Random sample in sterile container.

Swabs: Throat, nose, nasopharynx, and ear swabs are acceptable; material from the ear is better than a swab.

Urine: Clean catch midstream sample in sterile container.

Wound: Aspirate of purulent material or fluid, scraping of lesion border, or swab (least preferred) in sterile container. Swabs cannot be split for other tests.

Avoid contamination of the specimen with commensal organisms as much as possible. Specify the source of the specimen and include any pertinent clinical information. Cultures are incubated one to four weeks (depending on source) before a final negative report is issued.

Storage Instructions

Refrigerate nonsterile respiratory specimens; all others should be maintained at room temperature.

Causes for Rejection

Unlabeled specimen or name discrepancy between specimen and request label; specimen received after prolonged transport (usually more than 72 hours); swab without evidence of specimen present; specimen received after leaking transport container into specimen bag; inappropriate transport device, including syringe with needle. Trach-suction devices will often leak if the cap with tubing is not removed and replaced by a solid cap. This may need to be done by personnel collecting the specimen as the solid cap is usually in with the device. If there is not solid cap, the specimen should be transferred to a leakproof sterile cup with metal cap.

Clinical Information

Special Instructions

If reflex testing is performed, additional charges/CPT code(s) may apply.

Footnotes

1. Dyess DL, Garrison RN, Fry DE. Candida sepsis. Implications of polymicrobial blood-borne infection. Arch Surg. 1985 Mar; 120(3):345-348. 3970669
2. Whimbey E, Kiehn TE, Brannon P, Blevins A, Armstrong D. Bacteremia and fungemia in patients with neoplastic disease. Am J Med. 1987 Apr; 82(4):723-730. 3565430
3. Kates MM, Phair JB, Yungbluth M, et al. Demonstration of Candida in blood smears. Lab Med. 1988; 19:25.
4. Rebell GC, Foster RK. Fungi of keratomycosis. In: Lennette EH, Balows AL, Hausler WJ, et al, eds. Manual of Clinical Microbiology. 3rd ed. Washington, DC: ASM Press;1980.
5. White GL Jr, Thiese SM, Lundergan MK. Contact lens care and complications. Am Fam Physician. 1988 Apr; 37(4):187-192. 3358344
6. McKay M. Cutaneous manifestations of candidiasis. Am J Obstet Gynecol. 1988 Apr; 158(4):991-993. 3364512
7. Herrod HG. Chronic mucocutaneous candidiasis in childhood and complications of non-Candida infection: A report of the Pediatric Immunodeficiency Collaborative Group. J Pediatr. 1990 Mar; 116(3):377-382. 2308026
8. Diamond RD. The growing problem of mycoses in patients infected with the human immunodeficiency virus. Rev Infect Dis. 1991 May-Jun; 13(3):480-486. 1866553
9. Hector RF. Compounds active against cell walls of medically important fungi. Clin Microbiol Rev. 1993 Jan; 6(1):1-21. 8457977
10. Boyars MC, Zwischenberger JB, Cox CS Jr. Clinical manifestations of pulmonary fungal infections. J Thorac Imaging. 1992 Sep; 7(4):12-22. 1404541
11. Fraser RS. Pulmonary aspergillosis: Pathologic and pathogenetic features. Pathol Annu. 1993; 28(Pt 1):231-277. 8416139
12. Clarke A, Skelton J, Fraser RS. Fungal tracheobronchitis. Report of 9 cases and review of the literature. Medicine (Baltimore). 1991 Jan; 70(1):1-14. 1988763
13. Cohen R, Roth FJ, Delgado E, Ahearn DG, Kalser MH. Fungal flora of normal human small and large intestine. N Engl J Med. 1969 Mar 20; 280(12):638-641. 5764842
14. Chretien JH, Garagusi VF. Current management of fungal enteritis. Med Clin North Am. 1982 May; 66(3):675-687. 6281592
15. Gupta TP, Ehrinpreis MN. Candida-associated diarrhea in hospitalized patients. Gastroenterology. 1990 Mar; 98(3):780-785. 2298377
16. Sanderson PJ, Bukhari SS. Candida spp and Clostridium difficile toxin-negative antibiotic-associated diarrhoea. J Hosp Infect. 1991 Oct; 19(2):142-143. 1684608
17. Wong-Beringer A, Jacobs RA, Guglielmo BJ. Treatment of funguria. JAMA. 1992 May 27; 267(20):2780-2785. 1578598
18. Kunin CM, Lipsky BA. Treatment of candiduria. JAMA. 1989; 262:691-692 (question and answer).
19. Frangos DN, Nyberg LM Jr. Genitourinary fungal infections. South Med J. 1986 Apr; 79(4):455-459. 3518068

References

Anaissie EJ, Bodey GP, Kantarjian H, et al. A new spectrum of fungal infections in patients with cancer. Rev Infect Dis. 1989 May-Jun; 11(3):369-378. 2749101
Batra P. Pulmonary coccidioidomycosis. J Thorac Imaging. 1992 Sep; 7(4):29-38. 1404543
Cohn MS. Superficial fungal infections. Topical and oral treatment of common types. Postgrad Med. 1992 Feb 1; 91(2):239-244,249-252. 1738744
Danna PL, Urban C, Bellin E, Rahal JJ. Role of Candida in pathogenesis of antibiotic-associated diarrhoea in elderly inpatients. Lancet. 1991 Mar 2; 337(8740):511-514. 1671890
Elewski BE, Rinaldi MG, Weitzman I. Diagnosis and Treatment of Onychomycosis: A Clinician's Handbook. Calfon, NJ: SynerMed;1995.
Ginsburg CM. Tinea capitis.Pediatr Infect Dis J. 1991 Jan; 10(1):48-49. 2003055
Gray LD, Roberts GD. Laboratory diagnosis of systemic fungal diseases. Infect Dis Clin North Am. 1988 Dec; 2(4):779-803. 3062087
Guerra-Romero L, Telenti A, Thompson RL, Roberts GD. Polymicrobial fungemia: Microbiology, clinical features, and significance. Rev Infect Dis. 1989 Mar-Apr; 11(2):208-212. 2704925
Hay RJ. Fungal skin infections. Arch Dis Child. 1992 Sep; 67(9):1065-1067. 1417045
Meyer RD. Cutaneous and mucosal manifestations of the deep mycotic infections. Acta Derm Venereol Suppl (Stockh). 1986; 121:57-72 (review). 3521177
Rasmussen JE. Cutaneous fungus infections in children. Pediatr Rev. 1992 Apr; 13(4):152-156. 1626010
Rezabek GH, Friedman AD. Superficial fungal infections of the skin diagnosis and current treatment recommendations. Drugs. 1992 May; 43(5):674-682. 1379146
Roy JB, Geyer JR, Mohr JA. Urinary tract candidiasis: An update. Urology. 1984 Jun; 23(6):533-537. 6375071
Saral R. Candida and Aspergillus infections in immunocompromised patients: An overview. Rev Infect Dis. 1991 May-Jun; 13(3):487-492. 1866554
Schuyler MR. Allergic bronchopulmonary aspergillosis. Clin Chest Med. 1983 Jan; 4(1):15-22. 6340924
Tang CM, Cohen J. Diagnosing fungal infections in immunocompromised hosts. J Clin Pathol. 1992 Jan; 45(1):1-5. 1740508
Telenti A, Steckelberg JM, Stockman L, Edson RS, Roberts GD. Quantitative blood cultures in candidemia. Mayo Clin Proc. 1991 Nov; 66(11):1120-1123. 1943243
Ullrich R, Heise W, Bergs C, L'age M, Riecken EO, Zeitz M. Gastrointestinal symptoms in patients infected with human immunodeficiency virus: Relevance of infective agents isolated from gastrointestinal tract. Gut. 1992 Aug; 33(8):1080-1084. 1327982
Urinary tract candidosis. Lancet. 1988 Oct 29; 2(8618):1000-1002 (review). 2902434
Wey SB, Mori M, Pfaller MA, Woolson RF, Wenzel RP. Risk factors for hospital-acquired candidemia: A matched case-control study. Arch Intern Med. 1989 Oct; 149(10):2349-2353. 2802900
Wheat LJ. Systemic fungal infections: Diagnosis and treatment. I. Histoplasmosis. Infect Dis Clin North Am. 1988 Dec; 2(4):841-859 (review). 3062090

LOINC® Map

Order Code Order Code Name Order Loinc Result Code Result Code Name UofM Result LOINC
188573 Fungus Culture W/Rfx Rapid ID 188572 Report Status N/A
188573 Fungus Culture W/Rfx Rapid ID 188574 Fungal Culture W/Rfx 51723-5
188573 Fungus Culture W/Rfx Rapid ID 188586 Reflex to ID N/A
Reflex Table for Reflex to ID
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 188575 Fungal ID by Molecular Methods 188576 Fungus ID 1 (DID) 42805-2
Reflex Table for Reflex to ID
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 188579 Fungal ID by Molecular Methods 188576 Fungus ID 1 (DID) 42805-2
Reflex Table for Reflex to ID
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 188579 Fungal ID by Molecular Methods 188577 Fungus ID 2 (DID) 42805-2
Reflex Table for Reflex to ID
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 188580 Fungal ID by Molecular Methods 188576 Fungus ID 1 (DID) 42805-2
Reflex Table for Reflex to ID
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 188580 Fungal ID by Molecular Methods 188577 Fungus ID 2 (DID) 42805-2
Reflex Table for Reflex to ID
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 188580 Fungal ID by Molecular Methods 188578 Fungus ID 3 (DID) 42805-2
Reflex Table for Reflex to ID
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 188581 Fungal ID by Screening Assays 188582 Fungus ID 1 (SID) 580-1
Reflex Table for Reflex to ID
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 188583 Fungal ID by Screening Assays 188582 Fungus ID 1 (SID) 580-1
Reflex Table for Reflex to ID
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 188583 Fungal ID by Screening Assays 188584 Fungus ID 2 (SID) 17947-3
Reflex Table for Reflex to ID
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 188585 Fungal ID Screen/Molec. Method 188582 Fungus ID 1 (SID) 580-1
Reflex Table for Reflex to ID
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 188585 Fungal ID Screen/Molec. Method 188577 Fungus ID 2 (DID) 42805-2

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