CHAPTER XXIV – THE MEDICALLY IMPORTANT MYCOSES
Treatment
Superficial Mycoses
These are caused by fungi affecting the superficial
layers of the skin such as the stratum corneum and hair.
They are asymptomatic but aesthetically displeasing.
A. Tine versicolor (Pityriasis versicolor)
1. Clinical Features
a. It is a chronic and non-irritating superficial
infection of the stratum corneum occurring
on the chest, upper back, arms, abdomen
and rarely on the face.
b. Lesions are described as superficial
brownish scaly areas on light-skinned
persons and lighter areas on dark-skinned
persons
2. Causative Agent: Malassezia furfur
(Pityrosporum orbiculare – yeast phase)
3. Predisposing Factors:
i. Hot and humid climate
ii. Excessive perspiration
iii. Corticosteroid use
iv. Malnutrition
v. Heredity
4. Other Diseases Caused by M. furfur
a. Disseminated infection in infants, young
children and adults receiving lipid
replacement therapy
b. Folliculitis
c. Possibly seborrheic dermatitis or dandruff
5. Laboratory Diagnosis
Specimen: Skin Scrapings
a. Direct Microscopic Examination
i. 10% KOH
ii. Calcofluor white stain
Appearance: blunt-ended short hyphae
and clusters of spherical spores that
form “spaghetti and meatballs” pattern
b. Wood’s light (ultraviolet radiation of lesions
in a darkened room)
i. Lesions fluoresce golden yellow or
brownish
c. Culture
i. Not required to establish a diagnosis
ii. M. furfur grows on Sabouraund’s
medium overlaid with olive oil; a
related species M. pachydermatis does
not require added lipid for growth
6.
a. Topical application of 2.5% selenium sulfide
for 10 minutes daily for 7 days
b. Topical miconazole and ketoconazole
c. Folliculitis – treated with oral ketoconazole
B. Tinea nigra (Tinea nigra palmaris)
A. Clinical Features
1. Blackish-brown macular patches resembling
faded silver nitrte stain occurring most
frequently on the falms but also on the
soles or elsewhere
2. Lesions are not elevated or scaly
B. Causative Agent: Phaeoannellomyces werneckii
(Cladosporium or Exophiala werneckii)
C. Laboratory Diagnosis
Specimen: Skin Scrapings
1. Direct KOH or calcofluor white
examination
a. Olive or brown-pigmented, branched,
septe hyphae ad budding yeast cells
that are one- or two-celled
b. Older colonies exhibit one- or two-
celled conidia produced by annelids,
that bear successive rings (annelations)
2. Culture (Sabouraud’s medium with and
without antibiotics)
a. Initial colonies are glossy, black, and
yeast-like in appearance
b. With age, colonies become
filamentous with velvety-gray aerial
hyphae
D. Treatment
1. Topical keratolytic solutions of sulfur,
salicylic acid or tincture of iodine
2. Simple shaving of superficial epidermis with
scalpel blade
C. Piedra (Trichosporosis)
A fungal infection of the hair characterized
by hard nodules distributed irregularly along the
length of the shaft which are easily felt by palpation
1. Black Piedra
a. Caused by Piedraia hortai
b. Occurs in tropical areas
c. Crushed nodules in KOH preparation show
numerous oval asci, containing 2-8 aseptae
ascospores; ascospores are spindle-shaped
(fusiform) and have a filament at each pole
 d. Any fungal culture medium lacking Colony usually
Thick-walled, spindle-
membranous with
cycloheximide may be used; colonies are feathery periphery;
shaped, multi septate,
rough-walled
black and composed of hyphae and center of colony white 1
M. canis macroconidia some
chlamydospores to buff over orange- week
with a curved tip;
yellow; lemon-yellow
e. Treatment is by cutting the hair microconidia rarely
or yellow orange
seen
2. White Piedra apron and reverse
Thick-walled rough,
a. Caused by Trichosporon beigelii (T. elliptical
Cinnamon-colored,
cutaneum) 1 multiseptated
M. gypseum powdery colony;
b. Occurs commonly intemperate regions week macroconidia;
reverse light tan
microconidia few or
c. Crushed nodules in KOH preparation show absent
hyaline hyphae and arthrospores Many round to
globose microconidia
d. Culture shows cream-colored, soft colonies
most commonly borne
composed of blastospores and septate Different colonial
in grapelike clusters or
types; white to
hyphae which fragment into arthrospores laterally along the
pinkish, granular and
hyphae; spiral hyphae
e. T. beigelii does not ferment carbohydrates T. mentagro- fluffy varieties; 7-10
in 30% of isolates;
phytes occasional light yellow days
but aerobically utilizes certain substrates periphery in younger
macroconidia are thin-
walled, smooth, club-
f. Treatment is the same cultures, reverse buff
shaped &
to reddish brown
multiseptated;
Cutaneous Mycoses (Dermatomycoses) numerous or rare
depending upon strain
These are fungal infections involving the superficial Colonial types vary Microconidia usually
from white downy to teardrop, most
keratinized tissues of the body such as the skin, hair, and pink granular; rugal commonly borne
nails. They are caused by a group of fungi commonly called folds are common;
2
along sides of the
T. rubrum reverse yellow when hyphae; macroconidia
dermatophytes which breakdown and utilize keratin as a colony is young;
weeks
usually absent but
source of nitrogen but are incapable of penetrating the however, wine red when present are
subcutaneous tissue. The three genera associated with color commonly smooth, thin-walled,
develops with age and pencil-shaped
dermatomycoses include: Microconidia are
teardrop or club-
White, tan to yellow shaped with flat
1. Epidermophyton – affecting skin and nails or rust suede-like to bottoms; vary in size
2. Microsporum – affecting skin and hair powdery; wrinkled but usually larger than
7-14
3. Trichophyton – affecting skin, hair, and nails T. tonsurans with heaped or other dermatophytes;
days
sunken center; balloon forms-aged
reverse yellow to tan pleomorphic
A. Morphology and Identification of Common to rust red microconidia;
macroconidia usually
Dermatophytes
rare
Irregularly heaped,
Hyphae usually sterile;
(Table 24-1. Characteristics of Commonly Isolated smooth white to
T. 2-3 many antler-types
cream colony with
Dermatophytes) schoenleinii
radiating grooves;
weeks hyphae seen (favic
Dermatophy Growth chandeliers)
Colonial Morphology Micromorphology reverse white
tes Rate Port wine to deep Branched, tortuous
Macroconidia large, violet colony, may be hyphae that are
Center of colony tends thing smooth-walled, heaped or flat with 2-3 sterile;
to be folded and is multiseptated, clavate T. violaceum
waxy-glabrous weeks chlamydospores
khaki green; periphery 1 and borne singly or in surface; pigment may commonly aligned in
E. floccosum
is yellow; reverse week clusters of two or be lost on subculture chains
yellowish brown with three; microconidia Microconidia rare;
observable folds are absent; numerous large and teardrop
chlamydospores when seen;
Sterile hyphae; Glabrous to velvety macroconidia
terminal white colonies; rare extremely rare, but
chlamydospores, favic T. stains produce yellow- 2-3 form characteristic
Downy white to
chandeliers, and verrucosum brown color; rugal weeks “rat-tail” types when
salmon pink colony; 2
M. audouinii pectinate bodies; folds with tendency to seen; many
reverse tan to salmon weeks
macroconidia rarely sink into agar surface chlamydospores seen
pink
seen – bizarre-shaped in chains, particularly
is seen; microconidia when colony is
rare or absent incubated at 37°C
 1. Epidermophyton floccosum (see table 24-1) Anthropophilic species produce relatively mild and
2. Microsporum (for colonial and microscopical chronic infections in humans whereas zoophilic
morphologies – see table 24-1) dermatophytes cause more inflammatory and acute
a. M. audouinii infections that respond better to treatment and usually do
i. Infected hair shafts fluoresce yellow-green not recur.
using a Wood’s lamp
2. Transmission
ii. Addition of yeast extract may stimulate
a. Contact with dermatophytes in soil or in
growth and production of macroconidia
animals
iii. Grows poorly on sterile rice grains (rice
b. Anthropophilic species are transmitted by direct
medium)
contact or fomites (ex. Infected hairs on hats,
b. M. canis
caps, combs, or barber clippers)
i. Infected hairs fluoresce bright
yellow-green using a Wood’s lamp
3. Predisposing Factors
ii. Grows well on sterile rice grains
a. Hot, humid climates
c. M. gypseum
b. Crowded living conditions
i. Infected hairs generally do not
c. Increased perspiration
fluoresce using a Wood’s lamp
d. Heavy exposure
3. Trichophyton (infected hair do not fluoresce under
e. Young individuals
a Wood’s lamp)
f. Genetic predisposition
The most common species recovered in the
clinical laboratory are T. rubrum and T. mentagrophytes
4. Clinical Forms of Dermatophytes
hence; they should be differentiated (for colonial and
Cutaneous mycoses are usually referred to as tinea
microscopical morphologies – see table 24-1)
(ringworm) because of the raised circular lesion which has
a. T. rubrum
an outer ring of an active progressing infection with central
i. No specific nutritional requirement
healing within the ring.
ii. Does not perforate hair in vitro (hair baiting
test) Tinea capitis
iii. Does not produce urease a. Site of lesions
b. T. mentagrophytes i. Scalp
i. Produces urease ii. Endothrix – presence of arthroconidia (from
ii. Perforates hair in vitro (hair baiting test) fragmentation of hyphae) within hairshaft but
c. T. tonsurans without destruction of cuticle
i. Growth enhanced by thiamine iii. Ectothrix – presence of arthroconidia (from
d. T. verrucosum fragmentation of hyphae) around or on the
i. Growth enhanced at 35-37C surface of hairshaft with destruction of cuticle
ii. Growth requires thiamine and inositol b. Most commonly isolated organisms
iii. Grows in media with 4% casein and 0.5% i. Epidemic tinea capitis – T. tonsurans, M.
yeast extract audouinii (most important), T. violaceum
iv. Early hydrolysis of casein ii. Non-epidemic tinea capitis – M. canis, T.
e. T. schoenleinii (see table 24-1) verrucosum, M. gypseum
f. T. violaceum c. Manifestation
i. Growth enhanced with thiamine i. T. tonsurans and T. violaceum – endothrix
B. Clinical Infection type of invasion; circular, scaly patches of
1. Natural Habitat of Common Dermatophytes alopecia; stubs of hair remain in the
Anthropophilic Zoophilic Geophilic epidermis of the scalp after the brittle hairs
(humans) (animals) (soil)
E. floccosum M. canis (dogs, cats) M. gypseum have broken off and give the typical “black
M. audouinii T. mentagrophytes var dot” ringworm appearance
T. mentagrophytes var interdigitale mentagrophytes
ii. T. verrucosum – lesions are deep, pustular,
T. rubrum (rodents)
T. schoenleinii T. verrucosum (cattle) and inflammatory; endothrix and ectothric
T. tonsurans T. violaceum type of invasion; may induce a severe
 combined inflammatory and hypersensitivity Tinea pedis (athlete’s foot)
reaction called a kerion. a. Site of lesions
iii. Microsporum species – ectothrix type of i. Feet particularly the toes, webs, and soles
invasion b. Commonly isolated organisms
i. T. rubrum and T. mentagrophytes
Tinea favosa (favus)
ii. E. floccosum
a. Site of lesions
c. Manifestations
i. Scalp
i. Acute; itching, red vesicular lesions
ii. Torso
ii. Chronic; itching, scaling and fissures
b. Causative agent: T. schoenleinii
c. Manifestation Tinea manus
i. Formation of yellowish cup-shaped crusts or A. Site of lesions
scutulae i. Interdigital areas and palm
ii. Extensive alopecia and scarring of the scalp B. Commonly isolated fungi
iii. Mousy odor to scalp a. Same as in tinea pedis
C. Manifestations
Tinea barbae (barber’s itch)
1. Usually associated with tinea pedis
a. Site of lesions
2. Hyperkeratotic (white flakes or vesicular or
i. Bearded area of face and neck
erythematous)
b. Commonly isolated organisms
i. T. rubrum Tinea unguium
ii. T. verrucosum a. Site of lesions
c. Manifestations i. Nails
i. Mild superficial edematous, erythematous b. Commonly isolated dermatophytes
lesions or; i. T. rubrum and T. mentagrophytes
ii. Sever deep pusticular folliculitis ii. E. floccosum
c. Manifestations
Tinea corporis
i. Nails thickened or crumbling distally
a. Site of lesions
ii. White patches on surface or invasive infection
i. Arms
beneath nail plates
ii. Legs
iii. Usually associated with tinea pedis
iii. Torso
b. Commonly isolated fungi Dermatophytid (id reaction)
iv. T. rubrum An allergic response to fungal antigens wherein a
v. M. canis dermatophyte infection in one area (e.g., Tinea pedis) elicits
vi. T. mentagrophytes an allergic reaction elsewhere on the body (e.g., the hands).
c. Manifestations
5. Laboratory Diagnosis
vii. Circular patches with advancing red,
Specimen: skin and nail scrapings, hairs
vesiculated border and central scaling
a. Examination of infected hairs under Wood’s light
viii. Pruritic
b. Microscopic examination using 10-20% KOH (or
Tinea crusis (jock itch) calcofluor white)
a. Site of lesions i. Microsporum species – form dense sheaths
i. Genitocrural folds of spores in a mosaic pattern around the
b. Commonly isolated fungi hair (extothrix)
i. T. rubrum and T. mentagrophytes ii. Trichophyton species – form parallel rows
ii. E. floccosum of spore outside (ectothrix) or inside
c. Manifestations (endothrix) the hair shaft
i. Erythematous scaling lesion in intertriginous iii. T. schoenleinii – favic hairs present
area characteristic air spaces in the hair which
ii. Pruritic are readily filled with fluid in KOH
preparations.
 c. Culture
i. Mycosel
ii. DTM
iii. Cornmeal agar – for production of
macroconidia
iv. Inhibitory mold agar
v. Sabouraud’s agar with antibiotics
d. Id reaction is diagnosed by a negative microscopic
and cultural examination of the reaction site and
finding of dermatophytosis elsewhere on the body
6. Treatment
a. Topical antibiotics such as cream preparations of
tolnaftate, miconazole nitrate, haloprogin,
clotrimazole, econazole, or ciclopirox
b. Oral griseofulvin for long periods – most effective
especially for scalp and nail infections
c. Oral ketoconazole
Subcutaneous Mycoses
These are infections that involve the skin and subcutaneous
tissue which may rarely become systemic or disseminated.
A. Sporotrichosis (Rose gardener’s disease)
1. Causative agent
a. Thermally dimorphic sporothrix schenkii
whose natural habitat is living or dead
vegetation
2. Morphologic and Cultural Characteristics
a. Mycelial phase
i. Colonies are usually small, moist and
white to cream colored which on
further incubation become
membranous and coarsely matted,
wrinkled, with the color becoming
irregularly dark brown or black and the
colony become leathery
ii. Microscopically hyphae are delicate,
septate, exhibit branching and bear
one-celled conidia which are borne
bouquet-like, in clusters from the tips
of single conidiophores
b. Yeast phase
i. Colonies are pasty and grayish
ii. Microscopically they are usually
spherical, oval, singly, or multiply
budding cells but some are fusiform,
elongated or cigar-shaped; asteroids
may also be seen
iii. Mycelial to yeast conversion at 37C in
12-48 hours
3. Transmission
a. Through traumatic inoculation with
contaminated material (e.g., thorn or
splinter, brushing against a tree bark)
b. Inhalation of infectious particles (in
pulmonary sporotrichosis)
4. Clinical Manifestation
a. Lymphocutaneous sporotrichosis (75% of
cases)
i. Lesions appear first in the cutaneous
and subcutaneous tissue and
progressively involve the draining
lymphatics
ii. Initially with a small, movable, non-
tender, subcutaneous nodule develops
but a small ulcer may also be seen
iii. The subcutaneous nodule becomes
discolored and the skin darkens from
red to black which subsequently erupts
to form an ulcer or sporotrichotic
chancre
iv. After a few weeks, the primary lesion
heals and new ones develop
b. Chronic sporotrichosis
i. After the primary lesion, multiple
subcutaneous nodules develop along
the lymphatic channels and become
hard and cordlike
ii. The course is the same and if untreated,
becomes chronic, but may heal
spontaneously
c. Fixed sporotrichosis
i. Presence of only one lesion without
involvement of the lymphatics
ii. Lesion may be ulcerative or appear as a
plaque or rash
d. Pulmonary sporotichosis (rare)
5. Laboratory Diagnosis
Specimen: exudates from unopened
subcutaneous nodules or from open draining
lesions; biopsy material
a. KOH or calcofluor white preparations
b. Special stains
i. PAS
ii. Methenamine silver stain
iii. Fluorescent antibody stain
c. Culture
i. Inhibitory mold agar or
 ii. Sabouraud’s agar with antibiotics
iii. Others
d. Serology
i. Yeast cell agglutination test
ii. Sporotrichin
e. Treatment
i. Oral solution of saturated potassium
iodid (SSKI) – treatment of choice for
cutaneous sporotrichosis (can be
administered topically also)
ii. Amphotericin B, ketoconazole,
dihydroxystilbamidine, griseofulvin and
flucytosine
B. Chromomycosis (Chromoblastomycosis)
This is a chronic fungal infection acquired thru
traumatic inoculation of spores, primarily in the
lower extremities. It is characterized by the
development of a papule at the site of injury that
spreads to form warty or tumor-like lesions
(cauliflower-like). Secondary infection and
ulceration may ensue. Rarely, brain abscess may
occur.
1. Causative Agents
Chromomycosis is caused by
dematiaceous fungi which are imperfect
fungi that produce varying amount of
melanin-like pigments found in the conidia
or hyphae or both.
a. Cladosporium carrionii
b. Phialophora verrucose
c. Fonsecae pedrosoi and F. compacta
2. Cultural Characteristics
a. The dematiacous fungi have similar
characteristics
b. All are slow-growing and produce
heaped-up and slightly folded, darkly
pigmented colonies with a grayish-
velvety appearance; the reverse side of
the colonies is jet black
c. Yeas species are usually pleomorphic
and produce a dark, moist colony
3. Microscopic appearance
a. Cladosporium species
Produce long chains of elliptical conidia
(blastoconidia) borne from erect, tall
branching conidiosphores
b. Phialophora species
Produce short, flask-shaped to tubular
phialides, usually with a well-developed
collarette; clusters of conidia are
produced by the phialides through an
apical pore
c. Fonsecae species
May exhibit Phialophora-type or
Cladosporium-type of sporulation and
also produce lateral or terminal conidia
froma lengthening conidiogenous cell
resembling a series of bend knees
(conidia are produced sympodially)
i. F. pedrosoi – produce conidial
heads
ii. F. compacte – produce more
compact conidial heads
4. Laboratory Diagnosis
Specimens: Scrapings or biopsy from lesions
a. Microscopic examination
i. Scrapings from crusted areas added
to 10% KOH show presence of
muriform or sclerosis bodies, which
appear rounded, brown resembling
copper pennies that exhibit
transverse septations
b. Culture
i. Sabouraud’s with or without
antibiotics
c. Extraction and detection of exoantigens
5. Treatment
a. Flucytosine – the best
b. Amphotericin B and the azoles especialy
itraconazole
C. Phacohyphomycosis
This term refers to infections characterized by
presence of darkly pigmented, septate hyphae in
tissue. Clinical forms vary from solitary
encapsulated cysts in the subcutaneous tissue to
brain abscess.
1. Causative Agents
a. Exophiala jeanselmei
i. Grows early as a black yeast with
dark budding yeast forms seen on
microscopy of culture
b. Phialophora (see above)
c. Wangiella dermatitidis
i. Early form same as that of
Exophiala
ii. Produces conidia by phialides that
lack collarettes
 d. Xylohypha bantiana (Cladosporium
bantianum or Cladosporium trichoides)
i. Cladosporium type of sporulation
ii. Infection usually recognized only at
autopsy
e. Other normally saprophytic
dematiaceous fungi
2. Laboratory Diagnosis
a. Microscopic examination (KOH
preparation)
i. Irregular dark, hyphae, as well as
yeasts and pseudohyphae are seen
in tissue
b. Culture
3. Treatment: same as in Chromomycosis
D. Mycetoma (Madura foot or Maduromycosis)
This is chronic granulomatous infection usually
involving the lower extremities. It is characterized
by swelling, purplish discoloration, tumor-like
deformities of the subcutaneous tissue and multiple
sinus tracts that drain pus containing yellow, red,
white, or black granules. There are two types of
Mycetoma:
Actinomycotic mycetoma
- Caused by Nocardia,
Actinomadura, Streptomyces and
aerobic actinomycetes
Eumycotic mycetoma
- Caused by a true fungi, most
commonly Pseudoallescheria
boydii which is found in soil and
sewage; transmitted via
traumatic inoculation
1. Culural and Microscopic Appearance
a. P. boydii is a hyaline mold (sexual stage)
that grows rapidly as white fluffy colony
that changes to a brownish-gray
(mousey) mycelium; the reverse of the
colony is black
b. The asexual stage is called
Scedosporium apiospermum and
microscopically produces elliptical
(sperm-shaped), single-celled conidia
borne singly from the tips of long or
short conidiosphores (annelophores);
clusters of conidiophores with conidia
produced at the ends are called
coremia
c. P. boydii, microscopically exhibit
cleistothecia, which are sac-like
structures that contain asci and
ascospores; the ascopores are oval and
delicately pointed at each and
resembling conidia of the sexual form
2. Laboratory Diagnosis
a. Macroscopic examination of granules
from lesions are white to yellow
b. Microscopically the granules consist of
loosely arranged, hyaline or pigmented,
intertwined hyphae
3. Treatment
a. Topical nystatin and potassium iodide
b. Amphotericin B and miconazole
E. Rhinosporidiosis
A chronic infection characterized by the
development of polypoid masses of the nasal
mucosa caused by Rhinosporidium seeberi.
1. Laboratory Diagnosis
a. Histologic examination of infected
tissue
i. Reveals epithelial hyperplasia and
cellular infiltrate of neutrophils,
lymphocytes, plasma cells and giant
cells
ii. Large thick-walled sporangia; the
cell wall of the spherule is
multilayered and stains with
mucicarmine
b. Serologic test for rhinosporidial antigen
2. Treatment
a. Topically, surgically and by local
injection of ethylstilbamidine
F. Lobomycosis
A chronic subcutaneous infection of
humans and dolphins caused by Loboa loboi
(Paracoccidiodes loboi).
1. Laboratory Diagnosis
Specimens: Skin scrapings, biopsies or
wet preparations of exudative lesions
a. Direct microscopic examination
i. Large, spherical or oval yeasts that
exhibit multiple budding and form
short chains of three to six or more
yeast cells which are
multinucleated and thick-walled
 b. Histologic examination
i. Granulomatous nodules and
occasional asteroid bodies
ii. Yeasts stain with PAS or
methenamine silver and may be
seen inside macrophages
2. Treatment
a. Sulfa drugs
b. Surgical excision

G. Rhinoentomophthoromycosis
(entomophthoromycosis conidiocolae)
A rare infection of the nasal mucosa caused
by Entomophthora coronate (Conidiobolus
coronatus)

Systemic or Deep Mycoses

These are fungal infections that may involve any of the

internal organs of the body as well as lymph nodes, bone,
subcutaneous tissue, and skin. They are caused by
inhalation of thermally dimorphic fungi which exist in two
phases of growth:

A. Yeast phase, parasitic, invasive or tissue form

a. Takes place at 35-37C
B. Mycelial phase, mold or saprobic form
a. Takes place at room temperature 25-30C

Traditionally, the definitive diagnosis of a dimorphic

fungus has been made by observing both the mold and
yeast form. But now, most laboratories consider the
exoantigen test as the most conclusive method.