Paeds · infectious-diseases
Fungal infections in immunocompetent and immunocompromised children
Also known as Paediatric mycoses · Invasive candidiasis in children · Invasive aspergillosis in children · Pneumocystis jirovecii pneumonia in children · Mucormycosis in children · Tinea capitis · Oral candidiasis (thrush) in children
Fellowship topic on fungal infections in children: the medically important fungi as yeasts (Candida, Cryptococcus, Malassezia), moulds (Aspergillus, Mucorales, dermatophytes), dimorphics and Pneumocystis; the superficial and mucocutaneous disease of the immunocompetent child (oral thrush, napkin candidiasis, tinea capitis, tinea corporis) and the invasive disease of the immunocompromised child (candidaemia, invasive aspergillosis, Pneumocystis pneumonia, mucormycosis, cryptococcosis, neonatal invasive candidiasis); neutrophil-versus-hyphae and T-cell-versus-Pneumocystis host defence and the breach points of central lines, neutropenia, total parenteral nutrition, broad-spectrum antibiotics, steroids, HIV and prematurity; blood-culture and non-culture diagnostics (beta-D-glucan, galactomannan, CT halo sign, biopsy histopathology, CSF cryptococcal antigen); the tiered antifungal armamentarium from topical azoles to oral griseofulvin and terbinafine to intravenous echinocandins, liposomal amphotericin B and voriconazole, with line removal, surgical debridement and reversal of immunosuppression; prophylaxis with fluconazole, caspofungin and trimethoprim-sulfamethoxazole; and ANZ, UK, US and Canada guidance.
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Red flags
- Persistent febrile neutropenia beyond four to seven days on broad-spectrum antibiotics is invasive fungal disease until proven otherwise — add empirical antifungal therapy (an echinocandin or liposomal amphotericin B) and image the chest and sinuses; delaying therapy in the neutropenic child raises mortality with every day
- A necrotic black palatal or nasal eschar with facial pain in a diabetic, neutropenic or transplant child is rhino-orbito-cerebral mucormycosis — a surgical and medical emergency needing urgent imaging, high-dose liposomal amphotericin B and aggressive surgical debridement within hours
- Hypoxaemia out of proportion to the chest X-ray in the HIV-exposed infant or the immunosuppressed child is Pneumocystis jirovecii pneumonia — start high-dose intravenous trimethoprim-sulfamethoxazole and adjunctive steroids for hypoxaemia before the confirmatory bronchoalveolar lavage returns
- Candidaemia in a child with a central line demands line removal, daily blood cultures to clearance, a minimum two-week antifungal course after the first negative culture, and fundoscopy to detect retinal seeding — leaving the line in place prolongs the bacteraemia and seeds retina, heart and bone
- A boggy, tender, purulent scalp mass in a child is a kerion (inflammatory tinea capitis) — treat with oral griseofulvin or terbinafine, not incision and drainage; topical antifungals alone fail because the hair follicle is infected
Life stages
Care settings
Clinical exam formats
Board mappings
- General Paediatrics and Infectious Diseases: superficial and invasive fungal infection in children — clinical recognition, topical and systemic antifungals, and host-risk stratification
- Neonatology: neonatal invasive candidiasis — line-related disease, amphotericin B therapy and prevention
- Renewed curriculum — Infectious diseases and Immunology: invasive candidiasis, aspergillosis, Pneumocystis and mucormycosis in the immunocompromised child; non-culture diagnostics and tiered antifungal therapy
- Oncology support and transplant medicine: antifungal prophylaxis, empirical therapy in febrile neutropenia and reversal of immunosuppression
- General Paediatrics: oral thrush, napkin candidiasis, tinea capitis and tinea corporis — diagnosis and topical or oral therapy
- Acute and oncology care: the persistent febrile neutropenic child — empirical antifungal therapy, imaging and source control
- Long Case / Structured discussion: a neutropenic oncology child with invasive fungal disease, or a neonate with line-related candidiasis — diagnosis, antifungal therapy, complications and prevention
- Communication station: explaining invasive fungal disease, central-line removal, prophylaxis and the duration of therapy to a family
- Level 2 / 3 — Infection: superficial and invasive fungal disease in children; clinical features, complications, antifungal therapy and prevention
- Immunology and oncology support: antifungal prophylaxis, empirical therapy in febrile neutropenia and the immunocompromised host
- Foundation of Practice (FOP): oral candidiasis, tinea capitis and tinea corporis — clinical features, the annular-plaque differential and topical versus oral therapy
- Applied Knowledge in Practice (AKP): invasive candidiasis, aspergillosis, Pneumocystis and mucormycosis — host-risk stratification, diagnostics and tiered antifungal therapy
- History-taking and management: the persistent febrile neutropenic child or the neonate with line-related sepsis
- Communication: explaining invasive fungal disease, line removal, prophylaxis and duration of therapy to a family
- General Pediatrics Content Outline — fungal infection: diagnosis, topical and systemic treatment and prevention
- Infectious Diseases and Neonatology: invasive candidiasis, aspergillosis, Pneumocystis and mucormycosis — host-risk tiering, diagnostics and antifungal therapy
- Dermatology: tinea capitis, tinea corporis and oral candidiasis as common paediatric presentations
- Patient Care: diagnosis and tiered management of fungal infection across age, depth and immune status
- Medical Knowledge: yeast-versus-mould biology, host-defence tiers, antifungal pharmacology and drug-interaction monitoring
- Systems-Based Practice and Population Health: antifungal prophylaxis, stewardship and equitable access to diagnosis and therapy
- Medical Expert: superficial and invasive fungal disease in children — diagnosis, antifungal therapy and prevention
- Health Advocate and Collaborator: antifungal prophylaxis and the prevention of neonatal line-related candidiasis
- Communicator: explaining invasive fungal disease, line removal and prophylaxis to families
One kingdom, two worlds — immunocompetent versus immunocompromised
Immunocompetent child
Immunocompromised child
"Neutrophils kill hyphae, T-cells hold Pneumocystis, macrophages eat spores." A fall in neutrophils (chemotherapy, leukaemia, marrow failure) opens the door to invasive Candida and Aspergillus. A failure of T-cell immunity (HIV, transplant, chronic steroids) opens the door to Pneumocystis and the dimorphic fungi. When both fall — the stem-cell transplant patient on calcineurin inhibitors — every fungal door is open. Hold the host tier in mind at the first encounter and you will never give a cream to a child who needs amphotericin. [14] [2]
Overview & Definition
Picture a six-month-old brought to the clinic with white plaques on her tongue and a fretful, scaly scalp in a toddler in the next room. Both are common, everyday fungal infections of childhood — one a superficial yeast, one a dermatophyte — and both clear with a topical gel or an oral course. Now picture the child two beds away on the oncology ward, febrile for a week with no neutrophils and a central line in situ. The same kingdom of organisms that caused a harmless plaque in the clinic is now a life-threatening invasive disease. Recognising where any child sits on that spectrum — well host with superficial disease, or immunocompromised host with invasive disease — is the single judgement the fellowship examiner probes. [2] [14]
The medically important fungi are eukaryotic organisms that fall, clinically, into four groups. The yeasts — Candida, Cryptococcus and Malassezia — are single-celled and reproduce by budding. The moulds — Aspergillus, the Mucorales, and the dermatophytes that cause tinea — grow as branching hyphae. The dimorphic fungi (Histoplasma, Blastomyces, Coccidioides, Talaromyces) grow as moulds in the environment and as yeasts in tissue. And Pneumocystis jirovecii, once classified as a protozoan, is a fungus that behaves like an opportunistic pneumonitis of the T-cell-deficient host. Knowing which group an organism belongs to points to the host defence that contains it and the antifungal that kills it. [6] [14]
The clinician's job has two halves, and the second is what the fellowship rewards. The superficial half is to recognise the common mucocutaneous presentations — thrush, napkin candidiasis, tinea — and treat them with topical agents or a short oral course, while never missing the immunocompromised host in whom a "minor" fungal infection is the first clue to a deeper defect. The invasive half is to recognise the immunocompromised child at the point of breakdown — the persistent febrile neutropenia, the necrotic nasal eschar, the hypoxaemia out of proportion to the X-ray — and treat with the right intravenous antifungal, the right source control, and the right reversal of immunosuppression. [1] [7]
References14ShowHide
- [1]Fisher BT; Zaoutis T; Dvorak CC; et al Effect of Caspofungin vs Fluconazole Prophylaxis on Invasive Fungal Disease Among Children and Young Adults With Acute Myeloid Leukemia. JAMA, 2019.PMID 31688884
- [2]Fisher BT; Zaoutis TE; Xiao R; et al Comparative Effectiveness of Echinocandins vs Triazoles or Amphotericin B Formulations as Initial Directed Therapy for Invasive Candidiasis in Children. J Pediatric Infect Dis Soc, 2021.PMID 34374424
- [3]Fisher BT; Boge CLK; Xiao R; et al Multicenter Prospective Study of Biomarkers for Diagnosis of Invasive Candidiasis in Children and Adolescents. Clin Infect Dis, 2022.PMID 35134165
- [4]Kilpatrick R; Scarrow E; Hornik C; et al Neonatal invasive candidiasis: updates on clinical management and prevention. Lancet Child Adolesc Health, 2022.PMID 34672994
- [5]Kaufman DA; Mukhopadhyay S Neonatal Invasive Fungal Infections: Epidemiology, Microbiology, and Controversies in Practice. Clin Perinatol, 2025.PMID 39892954
- [6]Warris A; Lehrnbecher T; Roilides E; et al ESCMID-ECMM guideline: diagnosis and management of invasive aspergillosis in neonates and children. Clin Microbiol Infect, 2019.PMID 31158517
- [7]Cornely OA; Alastruey-Izquierdo A; Arenz D; et al Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. Lancet Infect Dis, 2019.PMID 31699664
- [8]Fleece D; Gaughan JP; Aronoff SC Griseofulvin versus terbinafine in the treatment of tinea capitis: a meta-analysis of randomized, clinical trials. Pediatrics, 2004.PMID 15520113
- [9]Stern A; Green H; Paul M; et al Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients. Cochrane Database Syst Rev, 2014.PMID 25269391
- [10]Perfect JR; Dismukes WE; Dromer F; et al Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis, 2010.PMID 20047480
- [11]Gifford A; Jayawardena N; Carlesse F; et al Pediatric Cryptococcosis. Pediatr Infect Dis J, 2024.PMID 38241632
- [12]Leung AKC; Hon KL; Leong KF; et al Tinea Capitis: An Updated Review. Recent Pat Inflamm Allergy Drug Discov, 2020.PMID 31906842
- [13]Takpradit C; Wangkittikal C; Rungmaitree S; et al Antifungal Prophylaxis with Posaconazole versus Fluconazole in Children with Neutropenia Following Allogeneic Hematopoietic Stem Cell Transplantation. J Blood Med, 2021.PMID 34354383
- [14]Tissot F; Agrawal S; Pagano L; et al ECIL-6 guidelines for the treatment of invasive candidiasis, aspergillosis and mucormycosis in leukemia and hematopoietic stem cell transplant patients. Haematologica, 2017.PMID 28011902