This is a lung biopsy from an immunocompromised individual w | Figure 1

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This is a lung biopsy from an immunocompromised individual with an underlying hematologic process. It shows numerous fungal hyphae in a background of necrosis. The main point of this post is to communicate to pathologists that when they see this process in any immunocompromised individual they should immediately contact the treating physician. Often, the pathologist seeing the biopsy picks up organisms way before the microbiology lab can report positive cultures. I find that picking up the phone and calling the physician directly is the best method, but you can use whatever is best for you and whatever is quickest. Delay in such cases can be catastrophic. The next question is the identity of these hyphae. I think these fungi are septate and show narrow-angle branching. Organisms with this morphology in the lungs are most commonly Aspergillus. However, Pseudallescheria and Fusarium can look very similar. Many publications in the literature have noted similar problems. My practice is to never diagnosed Aspergillus purely on the basis of morphologic findings. My diagnosis generally reads something like “Necrosis (fungal hyphae present)”, and I explain the rest in a detailed comment. I also try to address the issue of invasive, non-invasive or semi-invasive as morphology can be very helpful to tell these apart. Differentiating Aspergillus-type fungi from Mucor-type fungi (Mucor, Absidia, Rhizopus) can also be challenging. There is no easy answer, because morphology is not always straightforward. I am usually more definitive with fungal yeasts such as Histoplasma or Cryptococcus or Blastomyces.

Bottom line: treat ANY fungi in an immunocompromised individual as a critical value, and pick up the phone.

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