SUBCUTANEOUS MYCOSES

ARNEL. G. BAYOTAS, RMT, AMT, MD, DPSP

Anatomic & Clinical Pathologist
Department of Microbiology
Our Lady of Fatima University

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 At the end of the lecture the
students must be able to:

1.Characterize the fungi causing subcutaneous

mycoses
2.Compare the fungi causing subcutaneous
mycoses in relation to:
a. Important characteristics
b. Clinical presentation
c. Treatment, prevention and control of
infection
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 Subcutaneous Mycoses
Normally reside in soil or on vegetation
Enter the skin or subcutaneous tissue by
TRUMATIC INOCULATION
The lesions become granulomatous and expand
slowly from the area of implantation
Rarely produce systemic and life-threatening
disease

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 Subcutaneous Mycoses
Sporotrichosis
Chromoblastomycosis
Phaeohyphomycosis
Mycetoma

Other uncommon Mycoses

Lobomycosis
Rhinosporodiosis
Subcutaneous mucormycosis
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 SPOROTRICHOSIS
AKA: Gardeners disease
Chronic subcutaneous myocoses with
lymphatic involvement
Become generalized with bones, joints and
other internal organs involvement

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 SPOROTRICHOSIS
Etiology: Sporothrix schenckii
thermally dimorphic fungus that lives on
vegetation
Grows as a mold at ambient temperatures
Branching, septate hyphae and conidia
In tissue or vitro at 3537 C as a small
budding yeast

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 SPOROTRICHOSIS

S. schenckii
grows well on routine agar media
Wrinkled membranous surface
that becomes tan, brown or
black

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 SPOROTRICHOSIS
S. schenckii
Microscopic:
Mold form consists of narrow, hyaline, septate
hyphae that produce abundant oval conidia borne
on delicate sterigmata
The yeast form consists of spheric, oval, or
elongated (cigar-shaped) yeastlike cells, with
single or (rarely) multiple buds

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 Mold phase of Sporothrix schenckii

Rosette or daisy petal formation on

conidiophores
Medical microbiology / Patrick R. Murray, Ken S. Rosenthal, Michael A. Pfaller.
 Yeast form of S. schenckii

(cigar-shaped yeast-like cells)

Medical microbiology / Patrick R. Murray, Ken S. Rosenthal, Michael A. Pfaller.
 SPOROTRICHOSIS
Pathogenesis & Clinical Findings
Conidia or hyphal fragments are introduced into
the skin by trauma
The initial lesion is located on the extremities
Lymphocutaneous- 75%
Granulomatous nodule that may progress to
form a necrotic or ulcerative lesion

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 Classic lymphocutaneous form of
sporotrichosis

(From Chandler FW, Watts JC: Pathologic diagnosis of fungal

infections, Chicago, 1987, American Society for Clinical Pathology Press.)
 SPOROTRICHOSIS
Diagnostic Laboratory Tests
Cultures of infected pus or tissue
S. schenckii grows within 2 to 5 days
Yeast at 35 C and molds at 25 C
Laboratory confirmation is by converting the
mycelial growth to the yeast form by subculture at
37
Immunologically through the use of the exoantigen test

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 SPOROTRICHOSIS
Sporotrichosis cigar-shaped Asteroid body in sporotrichosis. The
spheric yeastlike cells are surrounded
yeast cells in tissue at 370C by Splendore-Hoeppli material

From Connor DH, et al: Pathology of

http://dermpathindia.org/ infectious diseases, Stamford, Conn, 1997,
Appleton & Lange.)
 Lymphocutaneous sporotrichosis
Treatment
Classic treatment - oral potassium iodide in
saturated solution ,given daily for 3-4 weeks
Itraconazole current treatment of choice
Fluconazole
Amphotericin B systemic disease

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 Chromoblastomycosis (chromomycosis)

Subcutaneous mycotic infection caused by

traumatic inoculation by dematiaceous fungi
(naturally pigmented):
Phialophora verrucosa
Fonsecaea pedrosoi
Rhinocladiella aquaspersa
Fonsecaea compacta
Cladophialophora carrionii

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Chromoblastomycosis (chromomycosis)

Morphology & Identification

Colonies are compact, deep brown to black,
and develop a velvety, often wrinkled surface
Identified by their modes of CONIDIATION
In tissue produces spherical brown cells (4
12 m in diameter) termed muriform or
sclerotic bodies or medler bodies

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 Chromoblastomycosis (chromomycosis)

Colonies:

o Compact, deep
brown to black
with velvety,
often wrinkled
surface
http://www.angelfire.com/
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 Chromoblastomycosis (chromomycosis)

Brown-pigmented muriform cell, or Medlar body, of

chromoblastomycosis
From Connor DH, et al: Pathology of infectious diseases, Stamford, Conn, 1997, Appleton & Lange.
Phialophora
verrucosa

Conidia
produced
from flask-
shaped
phialides with
cup-shaped
collarettes Phialophora verrucosa showing flask-shaped
phialide (A) with distinct collarette (B) and conidia
(C) near its tip
 Chromoblastomycosis
Cladophialophora
(Cladosporium)
Produces branching
chains of conidia by
distal (acropetalous)
budding
C. carrionii - elongated
conidiophores with long,
branching chains of oval
conidia

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 Chromoblastomycosis
Rhinocladiella
aquaspersa
Lateral or terminal
conidia from a
lengthening
conidiogenous cell
a sympodial process
conidia are elliptical
to clavate
AGB/NOV.2014 http://atlasmicologico.blogspot.com/
 Chromoblastomycosis
Fonsecaea
Polymorphic genus
Phialides
Chains of blastoconidia, similar to
Cladosporium species
Sympodial, rhinocladiella-type conidiation
F. Pedrosoi - short branching chains of
blastoconidia as well as sympodial conidia
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Fonseca
pedrosoi

Short
branching
chain of
conidia
and
sympodial
conidia http://commons.wikimedia.org/
 Chromoblastomycosis
Fonsecaea compacta
Spherical blastoconidia , with a broad
base connecting the conidia
Blastoconidia is smaller and more
compact than those of F. pedrosoi

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Fonseca
compacta

Almost
spherical
blasto-
conidia with
broad base
connecting
the conidia
http://labmed.ucsf.edu/
 Chromoblastomycosis
Pathogenesis & Clinical Findings
Introduced into the skin by TRAUMA (legs
or feet)
Primary lesion becomes verrucous and wart-
like with extension along the draining
lymphatics

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 Chromoblastomycosis

From Connor DH, et al: Pathology of infectious diseases, Stamford, Conn, 1997, Appleton & Lange
 Complications:
1. Elephantiasis due to
fibrosis of lymph
channels
2. Disseminated
disease or satellite
lesions
 Chromoblastomycosis
Diagnostic Laboratory Tests
Microscopic exam:
Tissue scrapings or biopsies + 10% KOH
LOOK for SCLEROTIC BODIES (Diagnostic)
Culture : Inhibitory mold agar or Sabouraud's agar with
antibiotics
Dematiaceous fungi is identified by: CONIDIAL
STRUCTURES
Pathogenic species unable to grow at 37 C & digest
gelatin
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Sclerotic bodies from the tissue of a patient
with chromoblastomycosis

(From Velasques LF, Restrepo A: Chromomycosis in the toad (Bufo marinus)

 Chromoblastomycosis
Treatment
Surgical excision with wide margins is the
therapy of choice for small lesions
Chemotherapy with flucytosine or itraconazole
for larger lesions
Terbinafine , Posaconazole
Local applied heat

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PHAEOHYPHO-MYCOSIS
Phaeohyphomycosis

Disseminated form of
chromomycosis

Immunocompromised
patients, patients with poorly
controlled diabetes or with
 Etiologic agents: dematiaceous
fungi (Exophiala jeanselmei,
Phialophora richardsiae,
Bipolaris spicifera, Wangiella
dermatitidis)

Alternaria sp. & Curvularia

sp. may cause systemic
disease
Characterized by
presence of darkly
pigmented septate
hyphae in tissue
 Phaeohyphomycotic cyst most
common itraconazole or
flucytosine

Cerebral phaeohyphomycosis
o Leading cause is
Cladophialophora bantiana
o Brain abscess usually fatal
amphotericin B and
Phaeohyphomycosis due to Exophialla spinifera. www.mold.ph
 Mycetoma
A chronic subcutaneous infection induced by
traumatic inoculation of saprophytic species of
fungi or actinomycetous bacteria
Clinical features:
Local swelling and interconnectingoften
drainingsinuses that contain granules
(microcolonies of agent)
Actinomycetoma - actinomycete
Eumycetoma (maduromycosis, Madura foot)-
fungus
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 EUMYCOTIC MYCETOMA
Etiologic agents:
Pseudallescheria boydii
Madurella mycetomatis
Madurella grisea
Exophiala jeanselmei
Acremonium falciforme

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 EUMYCOTIC MYCETOMA
Morphology & Identification
P. boydii Prevalence sp. in U.S.
Ascospores in culture
Agent of pseudallescheriasis
E jeanselmei & Madurella species -
dematiaceous molds
Identified by mode of conidiation

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 EUMYCOTIC MYCETOMA
Morphology & Identification
Color of Mycetoma granules:
P boydii and A falciforme WHITE
M grisea and E jeanselmei BLACK
M. mycetomatis - DARK RED TO BLACK
GRANULE

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 EUMYCOTIC MYCETOMA

Mycetoma granule of Compact dematiaceous hyphae and

Curvularia geniculata chlamydoconidia embedded in
cement-like substance.
Medical microbiology / Patrick R. Murray, Ken S. Rosenthal, Michael A. Pfaller.
 Eumycotic Actinomycotic Mycetoma
Mycetoma

True fungi o Nocardia brasiliensis, A.

More common in Africa madurae
Slower disease o Tropical & sub-tropical
progression countries
Bone involvement less o Faster disease
extensive progression
Thick filaments in the o Extensive bone
granules involvement
o Thin filaments in the
granules
 Mycotic granules
Eumycotic granules Actinomycotic granules

septate hyphae and branched filaments

chlamydoconidia gram-positive
PAS & GMS beaded rods
positive hyphae

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 Mycetoma
Pathogenesis & Clinical Findings
Traumatic inoculation with saprophytic sp. or
actinomycetous bacteria
Pathologic features:
suppuration and abscess formation, granulomas, and
the formation of draining sinuses containing the
granules spread to muscle & bone tissues

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 Mycetoma
Diagnostic Laboratory Tests
DEMONSTRATION OF GRAINS or
GRANULES by 20% KOH, H.E, GMS
Color
Texture
Size
Presence of hyaline or pigmented hyphae or
bacteria
Culture on appropriate media
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 Mycetoma
Treatment
surgical debridement or excision and
chemotherapy
P boydii - topical nystatin or miconazole
Madurella infections - Itraconazole,
ketoconazole, & amphotericin B
E jeanselmei - flucytosine
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LOBOMYCOSIS
 Lobos disease, keloidal
blastomycosis,
lacaziosis

Etiologic agent:
Lacazia loboi (formerly
 Intracellular, within
macrophage vacuoles

With melanin-containing
cell wall resist
digestion by macrophage
chronic infection
 Usually in sites of minor trauma

Zoonotic; human-to-human
transmission not demonstrated

Dissemination within an
individual via lymphatics or
autoreinfection
 I.P. : months to years

Small papules or pustules that

may be pruritic or may present
with burning sensation
regression and scarring
oLesion never disappears

oOften keloidal
http://emedicine.medscape.com/
 Diagnosis:
microscopic
examination of
scrapings from lesion
stained with KOH or
calcofluor white
Characteristic histologic appearance of the organism. Courtesy of Dr. Roberto
Baruzzi, Sao Paulo, Brazil.

http://emedicine.medscape.com/
 Treatment:

oSurgical excision

oClofazimine +
itraconazole
RHINOSPORIDIOSIS
 Etiologic agent:
Rhinosporidium seeberi
(Protist eukaryotic organism)

India & Sri Lanka; males

with frequent contact
with fresh water pools
 Chronic granulomatous
infection of the mucous
membranes

Usually manifests as vascular

friable polyps that arise from
the nasal mucosa or external
structures of the eye.
Diagnosis:

Microscopic examination of
smears of macerated tissue or
histology of prepared biopsy
sample sections
Gomori methenamine silver
stain, PAS, H & E
Sporangia of Rhinosporidium seeberi within nasal polyp (periodic
acid-Schiff [PAS] stain). http://emedicine.medscape.com/
Treatment:

Surgical excision

Long term treatment with

dapsone for patients with
multi-site disease
 SUBCUTANEOUS
ENTOMOPHTHOROMYCOSIS
AKA: Subcutaneous mucormycosis
Etiologic agent: Mucormycetes of the order
Entomophthorales
Conidiobolus coronatus - facial area in adults
Basidiobolus ranarum (haptosporus) proximal limbs in
children
Traumatic implantation of fungus

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 Subcutaneous
Subcutaneous zygomycosis caused entomophthoromycosis caused
by Conidiobolus coronatus by Basidiobolus ranarum

From Chandler FW, Watts JC: Pathologic diagnosis of fungal infections,

Chicago, 1987, American Society for Clinical Pathology Press.
 Clinical Syndromes
Basidiobolus ranarum Conidiobolus coronatus
Disk-shaped Confined to rhinofacial
rubbery, movable area
mass, expand Firm & painless facial
locally and ulcerate swelling involving
nasal bridge , facial area
Shoulder, pelvis, and orbit
hips and thighs No intracranial
extension, bec. of lack
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angioinvasion
 SUBCUTANEOUS
ENTOMOPHTHOROMYCOSIS
Morphology
hyphal elements are sparse
and often fragmented
Granulomatus inflammatory
responses rich in
eosinophils
Thin walled and poorly
stained hyphal fragments

Broad hyphal fragments surrounded

by eosinophilic Splendore-Hoeppli
material
From Chandler FW, Watts JC: Pathologic diagnosis of fungal infections, Chicago, 1987, American
Society for Clinical Pathology Press
 SUBCUTANEOUS
ENTOMOPHTHOROMYCOSIS
Treatment
Itraconazole
oral potassium iodide in
saturated solution
Facial reconstructive surgery
Summary of Common Agents of Subcutaneous Mycoses
Disease Etiologic Agent(s) Typical Morphology Usual Host Reaction
in Tissue

Sporotrichosis Sporothrix schenckii Pleomorphic, spheric Mixed suppurative

to oval or cigarshaped and
yeasts, 2-10m granulomatous
diameter Splendore-
with single or multiple Hoeppli material
(rare) buds surrounds
fungus (asteroid body)

Chromoblastomycosis Cladophialophora Large, 6-12m Mixed suppurative

(Cladosporium) diameter, spheric, and
carrionii thick-walled, brown granulomatous
Fonsecaea compacta muriform Pseudoepitheliomatou
Fonsecaea pedrosoi cells (sclerotic bodies) s
Phialophora with hyperplasia
verrucosa septations along one
Rhinocladiella spp. or two planes;
Exophiala spp. pigmented hyphae
MJAP/May2007 may be present
Summary of Common Agents of Subcutaneous Mycoses
Disease Etiologic Agent(s) Typical Morphology Usual Host Reaction
in Tissue

Eumycotic mycetoma Phaeoacremonium Granules, 0.2 to Suppurative with

spp. several mm multiple
Fusarium spp. diameter, composed of abscesses, fibrosis,
Aspergillus nidulans broad and sinus
Scedosporium (2-6m), hyaline tracts; Splendore-
apiospermum (pale granules) Hoeppli
Madurella spp. or dematiaceous material
Exophiala jeanselmei (black granules),
among others septate hyphae that
branch and
form chlamydoconidia
Subcutaneous Basidiobolus Short, poorly stained Eosinophilic abscesses
entomophthoromycosis ranarum hyphal and
(haptosporus) fragments, 6-25m granulation tissue,
Conidiobolus diameter, Splendore-
coronatus nonparallel sides, Hoeppli material
pauciseptate, around
random branches
MJAP/May2007
Summary of Common Agents of Subcutaneous Mycoses
Disease Etiologic Agent(s) Typical Morphology Usual Host Reaction
in Tissue

Subcutaneous Exophiala jeanselmei Pigmented (brown) Subcutaneous cystic

phaeohyphomycosis Wangiella hyphae, 2-6m or solid
dermatitidis diameter, branched or granulomas; overlying
Bipolaris spp. unbranched, epidermis
Alternaria spp. often constricted at rarely affected
Chaetomium spp. prominent
Curvularia spp. septations, yeast forms
Phialophora spp. and
among others chlamydoconidia may
be present

Data from Chandler FW, Watts JC: Pathologic diagnosis of fungal infections, Chicago, 1987, American
Society for Clinical Pathology Press; and Connor DH, etal: Pathology of infectious diseases, vol 2,
Stamford, Conn, 1997, Appleton & Lange.
Summary of Common Agents of Subcutaneous Mycoses
Disease Etiologic Agent(s) Typical Morphology Usual Host Reaction
in Tissue

Lacaziosis Lacazia loboi (Loboa Spheric, budding Granulomatous

(Lobomycosis) loboi) yeasts, 5-12m
diameter,
that form chains of
cells connected by
tubelike structures;
secondary budding
may be present
Rhinosporidiosis Rhinosporidium Large sporangia (100- Nonspecific chronic
seeberi (aquatic 350m diameter) inflammatory or
protistan parasite of with granulomatous
the thin walls (3-5m)
Mesomycetozoa that enclose numerous
clade) endospores (6-8m
diameter) with a zonal
distribution
Data from Chandler FW, Watts JC: Pathologic diagnosis of fungal infections, Chicago, 1987, American
Society for Clinical Pathology Press; and Connor DH, etal: Pathology of infectious diseases, vol 2,
Stamford, Conn, 1997, Appleton & Lange.
 References:
Medical microbiology / Patrick R. Murray, Ken S. Rosenthal,
Michael A. Pfaller.
Jawetz, Melnick, & Adelberg's Medical Microbiology, Twenty-
Fourth Edition

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