Microbiology: Mycology Skin Infection 01 by Dr.

Padla Superficial Mycoses

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BATCH 2014- SY 2011-2012

transcriber: Me want to sleep..o_O

Infection of the outermost layer of the skin [stratum corneum and cuticle of hair] No cellular response because it can t invade living tissues Little to no physical discomfort, they are only dermatologic problems Easily diagnosed and treated Wood s lamp is ONLY a GUIDE where the fungi is growing, NOT a diagnostic test KOH is atransparent medium and for better viewing of fungi, a contrast , such as PARKER BLUE-BLACK ink is added

Superficial Mycoses Pityriasisver sicolor (aka: Tineaflava, Tinea albaold names, according todrpls don t use this, word tineaertains to dermatophy tes) Called AnAn locally

Etiology

Malassezia furfur (Pityrosporu morbiculare) [Recall: this is a basidiomycet es]

Characteristic of etiologic agent Lipophilic [hence, seen in sebaceous glands] Infectious particles: Short hyphae and yeast-like conidia, that is rightfully called phialoconidia

Epidemiolog y Worldwide, usually seen in tropicals (thrives in warm and humid environment) Mostly endogenous NF of skin: 80-90% of Normal individuals

Habitat

Clinical Disease Pathogenesis Character: Variable change in color depending on the skin color of individual: Hyperpigmente d or hypopigmente d macules [or patches when they coalesce] that scale easily giving it a blotchy appearance. This is usually confined to the trunk or proximal parts of the limbs. Pigmentary changes due to: - inhibition of melanin formation by fungal products in the epidermis (hypopigmentation) - enlargement of melanosomes (hyperpigmentation) Infection is from colonized skin It is believed that from commensalism to pathogenic is due to phase change (yeast hyphal forms) MOT: y Person to person y Fomites

Found in areas of the body rich in sebaceo us glands

Specim en of Choice Skin scrapin gs

Laboratory Diagnosis: KOH Diagnostic: spaghetti and meatballs appearance Short, stubby hyphae and clumps of budding yeast cells

Laboratory Treatment Diagnosis: Culture Can t be y topical cultured keratolytic unless olive oil agents or fatty acids y topical azole is used. y good personal hygiene y have a marked tendency to recur and treatment have to be repeated

Others

Wood s lamp: Golden yellow due to Copropor phyrin

Tineanigra (aka: Pytiriasisnig ra)

Phaeannello myceswernec kkii (Exophiliawer neckii) Black Fungi

Brown to black organism because it can produce melanin Halophilic - salt loving Infectious particles: hyphae

America, Asia and Australia Seen in soil, decaying vegetation, trees and sewage Commensal in skin

Lesions seen in palmar and plantar skin

Resembles a silver nitrate stain Well demarcated usually solitary brown to black macules - this take years to appear due to long incubation lesions

Implantation of fungus from contaminated soil, tress, decaying vegetations, sewage MOT: Implantation of fungus after exposure

Skin scrapin gs

Diagnostic: Pigmented [aka: coenocytic, dematiacieous] budding cells and branching septated hyphae and hyphal fragments

y Imidazole y Undecylenic acid

PIEDRA: Black Piedra (aka: tineanigra)

Piedraiahorta Dematiaceous e , keratinolytic fungi Infectious particle: hyphae

Tropical regions: Latin America and Southeast Asia Ususally seen in soil and considered as plant parasite

Scalp hair, eyebro ws and eyelash es

Hair shaft infection sparing the surrounding scalp; it is NOT associated with alopecia. Broken hairs can be found Hard black nodulesmade of fungal elements that are firmly attached to

Through contaminated soil

hair

*pls note that all pigmented hyphae are ALWAYS septated and hence, NOZygomycota(non -septated) is pigmented. Diagnostic: Telemorphic state is seen in hair shaft - Ascostromata or the fruiting body that contains the asci - Ascopores in asci - Asci containing fusiform ascospores with whiplike extension

Anamorphic state in cultures: Slow growing brown to reddish black hyphae with chlamydoconi dium-like cells

Shaving or cropping the infeted hair close to scalp surface

PiedraStone Produced a metallic sound when combing hair. Not associated with alopecia because scalp is not

scalp hairs Nodules: hard carbonaceous consistency visible to naked eyes; stonelike on hair Cream colored, soft, pasty easily detachable granules form a sleeve-like collarette along the infected hair

infected

PIEDRA: White Piedra

Trichosporon asahii Previously known as Trichosporon beigeii

Basidiomycete , yeast-like and forms hyphae and fragment into athroconidia (recall: arthroconidia are rectangular asexual spores) This is produced by thallic(from hyphae itself) or blasticconidio geny Infectious particles: Hyphae, athroconidia

Tropics, temperate climates NF(in small amounts): human skin and mouth

Hairs of heard, mustach e, axilla, and genitals

hair

Diagnostic: Septated hyphae that fragment into arthroconidiawhich rapidly rounds up showing a yeast-like form Blastoconidiamay be present along the hyphae

For Confirmatory Test Not usually done Pasty consistency colonies

Cutting or shaving off affected hairs close to the scalp Imidazoles

Not associated with alopecia because scalp is not infected

Otomycosis *not discussed during our lecture but included in DrPadla s book

Aspergillussp p: Aspergillusni ger Penicillim Mucor Rhizopus

Worldwide Common soil saprophytes which are ubiquitous

Outer ear canal

Present as Pruritus Inflammation Pain Scaling Mass of greyish- white debris resembling a wet blotting paper May also present as fine filaments projecting from the meatal wall. Due to hyphal plug patient may have partial deafness Filamentous fungal ulcers - This can cause scarring and lead to blindness Stromal infiltrates with

exudat es

Hyaline hyphae which may be septate or aseptate

For taxonomic ID

imidazole

Superficial , chronic or subacute infection Can occur as primary infection or mixed with bacteria

Mycotic Keratitis or Keratomyco sis *not discussed during our lecture but

Aspergillusfu migatus Fusarium Penicillium spp. Candida spp.

yeast

World wide Ubiquitous Soil saphropytes: Vegetable, plant matter, sawdust,soilc

Eye: corneal surface

Post traumatic infections following corneal trauma

Corneal scrapin gs

Hyphae, pseudohyphae, and yeast cells

For taxonomic ID

included inDrPadla s book

ontaminate by foreign bodies

feathery margins and these tend to be dry, grey and somewhat elongated above the level of corneal surface Stromal keratitis by Candida spp. More localized and discrete, underlying small ulcerations

Dermatophytoses/ Cutaneous Mycoses/ Tinea/ Ring worm - Any keratin infection of hair, nails and skins caused by dermatophytes - The disease is a result of host reaction to the fungal enzymes released by the fungus during its digestive process - Infection that extend into the epidermis, as well as, invasive hair and nail infection is initiated by the adherence of the fungal elements to the stratum corneum - Germinate and start to colonize the keratinized layer of the skin and/or it s appendages - Systemic spread is rare, doesn t invade living tissues because it is restricted to keratinized layer - Most common human mycoses - Sources of dermatophytes: human, animals and soil MOT:

direct contact to infected hair or epidermal cells of humans or animals o human to human and contact with contaminated objects o animal to human and contact with contaminated animal products o direct exposure to the soil homogenous of closely related organisms that exhibit high degree of specificity for the tissues they colonize keratinophilic fungi o ability to utilize keratin as nitrogen source Three genra: o Trichophyton o Microsporum o Epidermophytonfloccosum o

Dermatophytes Trichophyton Micropsorum Epidermophytonfloccosum

Skin X X X

Hair X X

Nail X X

In anamorphic state, it is classified based on the following: [important in ID of species] o Sporulation patterns o Morphologic features o Nutritional requirements Classification according to ecologic niche o Geophilic  Isolated in soil  M. gypseum o Zoophilic  Associated with animals  Sporadic infection  T. vericosum, M. canis o Anthropophilic  Associated with humans  Common in community  Cause chronic infections  May be difficult to cure  T. rubrum One of the most common infectious agents of humans Prevalence and incidence of disease are difficult to determine because they are not reportable Some are endemic in certain countries Pathogenicity o important determinants of the occurrence of the disease/  Age  Sex  ethnic group  culture and social habits

Certain individuals have natural resistance to dermatophyte infection o Infection is by trauma and direct contact o Occurs in areas in the body with excessive moisture o Crowded living conditions o Host immune status o Infection is always possible but it is easily curable o Infectious particle:  hyphae CLINICAL MANIFESTATION o Hair Infection  Kerion(inflammatory type), gray patch, scarring and alopecia o Nail Infection  Thickened, deformed, friable, discolored and ungualdebris o Skin Infection  Circular, dry, erythematous, scaly, itchy lesions LABORATORY DIAGNOSIS: o Confirmatory testing: Culture o Diagnosis by fungal elements demonstrated in clinical specimen o ID by morphology o Specimen of choice  Skin scrapings y For all dermatophytes  Nail scrapings y For trichophyton and E. flocossum  Hair stubs(including roots) y For Trichophyton and Microsporum o KOH:  Direct microscopic examination willONLYconfirm the diagnosis of fungal infection and will NOT ID the fungi y Direct microscopic examination means Direct examination on specimen collected(hair, nail, skin) o

cutaneous lesions and nails y Branching hyaline septate hyphae y Note that there is NO black fungi dermatophytes and hence, NO dermatiaceous hyphae  Hair y Endothrix invasion o Spores inside the infected hair shaft y Ectothrix invasion o Spores surrounding the hair shaft; athrospores may be seen inside and outside the hairshaft o Started as endothrix and got out of the hair infected the outside cuticle y Ectothrix and endothrix is NOT seen in T. schoenleinii [favus etiologic agent- more on this later] o It appears as degenerated hyphal elements coursing throughout the hair shaft and considered diagnostic for this fungi  Contrast for better viewing: parker blue-black ink WOOD s LAMP:  Bright greenish yellow fluorescence due to metabolite pteridine y RECALL: Supf Mycoses: M. furfur will appear golden yellow due to Coproporphyrin CULTURE:  For ID of specific etiologic agents y To know the source of infection and prognosis  Selective media contains: y Ex. Dermatophyte test medium[DTM]

Contents: o Cycloheximide  Suppress saprophytic fungi o Chloramphenicol  Inhibit bacteria contaminants  SDA is not used to prevent growth of unnecessary contaminants  Cultural characteristic is very variable and unreliable in ID of species  After growing the fungi on a selective medium, ID will be done by microscopic examination. y Classification will be based on type and characteristics of conidia y Note that Microscopic examination is done on isolates from the selective media that will show very distinct strudcture giving clue to the ID of the causative agent o Confirmatory test  T. mentagrophytesvs T. rubrum  Hair Penetration test y - production of wedge shaped or cone like area (+) for T. mentagrophyte  Urease test y easier to do y (+) red-pink for T. mentagrophytes Dermatophyte ID reaction y Typical cutaneous lesions in patients with dermatophyte infection from which no fungi can be recovered or demonstrated Allergic reactions to the infection, often precipitated by treatment to dermatophytes These secondary lesions will not respond to topical treatment but will disappear with successful treatment of the primary infection

Features of Tineacapitis Organism Hair invasion M. canis ECTOTHRIX M. auduoinii ECTOTHRIX T. tonsurans endothrix T. violaceum endothrix T. soudanense endothrix T. schoenleinii endothrix T. verrucosum ECTOTHRIX

Wood s light (+) (+) (-) (-) (-) (+) (-)

Source Cat, dog Man Man Man Man Man cattle

Genra and Disease Genus Disease Tricophyton Tineacapitis Tineacorporis Tine cruris Tineabarbae Tineaunguium Tineapedis Microsporum Tineacapitis Tineacorporis Epidermophyton Tineacruris Tineaunguium Tineapedis

Tissue involved Hair, skin, nails

Transmission Human to human Animal to human

Scalp hair, skin

Skin, nails

Human to human Animal to human Soil to human STRICTLY human to human

DESCRIPTION OF SPECIES Genus TRICHOPHYTON

MACROCONIDIA Usually rare, smooth, pencilshaped, thin- walled, normally contain 3-8 cells

MICROCONIDIA Few to numerous, round to oval, borne singly or in grapelike clusters

Sexual form Ascomycetes Sexual: athroderma Inhabits soil humans, animal Ascomycetes Sexual: athroderma Inhabits soil humans, animal Ascomycetes

Infectious particle Hyphae

MICROSPORUM

Numerous, rough, multicellular ehinulate(spiny) and spindle shaped, thick or thin walled, usually contain 3-7 cells

Few, club-shaped, borne singly

Hyphae

OTHERS Some species don t produce conidia; ID by special techniques, including biochemical assays Bright green in UV light

EPIDERMOPHYTONflocossum Numerous, smooth, club-shaped, thin-walled, contain 2-4 cells

ABSENT

Hyphae

Mostly anthropophilic

Dermatophytic Diseases Disease Etiology Tineabarbae beard Tinea Barber s itch Bearded areas of face and neck Trichophyton and Microsporum

Clinical Disease Acute, localized, pustular folliculitis which soon resembles a kerion Kerion- refers to inflammatory type of infection

Epidemiology Worldwide Tropical and subtropical rural areas

Tineacapitis head

Zoophilic Highly contagious Patches of hair loss(alopecia), inflammation and scaling infection of the - When condition has resolved, there may be areas of permanent scalp hair hair loss Trichophyton Microsporumaudouinii Microsporum- Grey patches covered with scales develop with broken stumps of most common the infected hair cause in children Lusterless and chalky due to high amount of athroconidia; this is very infectious and can be easily distributed in the Rare in adults; a environment childhood - Ecothrix (observed microscopically) disease T. violaceumand T. tonsurans - Endothrix and breaking off at the surface leaving stumps that look like black dots in the follicles - *endothrix infection will always indicate that the pathogen is anthropophilicin origin - Black dot type tineacapitis[T. tonsurans] M. canis - Greater inflammatory reaction - Cause kerion type tineacapitis y In Greek honeycomb y Caused by spores of animal origin y A severe inflammatory type characterizes by boggy, tumid, suppurating mass studded with pustules and broken hair

Worldwide Common in tropics This is a childhood disease - Rare in adults because of change in fatty acid constituents of sebum around the time of puberty Postpubertal sebum are fungistatic Animal to human transmission also occurs

Laboratory Diagnosis Direct microscopic Examination - Hyaline septate hyphae Culture Wood s light (UV >365nm): M. canisand M. auduoini - yellow green fluorescence T. schoenleinii - grey-green flourescence Direct microscopic examination Culture

Treatment Systemic griseofulvin, clipping, or shaving the beard

DOC: Systemic griseofulvin

Tineacorporis body Ring worm

Infection of the smooth or bare parts of skin Microsporum - Predominant cause in children Trichophyton E. floccosum

T. schoenleinii - Affects mainly the scalp and is characterized by scutula (yellow cup-shaped discs/crustings around the hair follicle with peculiar mousy odor) and cicatricial alopecia - Favus type tineacapitis - Degenerated hyphal elements that areendothrix - It has bores and when infected hair is submerged under water, air bubbles moving through the channels Typically during early infection, well defined, circular (annular), erythematous, scaly, vesiculo-pustular lesions with an active border and central healing. During late infection, lesions may coalesce and enlarge without central healing to form a solid, papulo-squamous plaques pruritus *tineaimbricata - Variant of tineacorporis - Also known as.. - T. concentricum - common in West pacific, Southeast Asia, and Amazonia - scaly patches in concentric pattern - has genetic predisposition

Worldwide

Specimen of Choice: All ages are susceptible Scrapings from raised Direct contact with advancing infected animals or human edge Indirect contact with fomites Microscopic examination in 10-20% KOH Culture

Treatment of Choice: Systemic griseofulvin Few spots: - Sulfur and salicyclic acid ointment - 1% tonalfate solution

Tineacruris leg

Infection of the groin, perineum, or perianal area E. floccosum T. mentagrophytes T. rubrum

Scaly, erythematous margin gradually spreads down the thighs and may extend backwards to involve the perineum and buttocks Bilateral and symmetrical and affects the inner aspects of the thigh Scrotum is not infected, unlike in Candida infection

Worldwide Often affects young male adults Source infections: Patient s feet - Transferred to the

Direct microscopic examination Culture

Griseofulvin

groins from the fingers or towels Moisture, occlusion, and skin trauma predisposes one to recurrent disease Contributing factors: Wet bathing suits, athletic supporters, tight fitting slacks, and pantyhose Worldwide Common in person who use communal changing facilities, showers, and swimming pools *most frequently occurring dermatophyte infection

Tineapedis pes Tineamanuu m hand

Tineaunguiu m nail

Athlete s foot Dermatophytic infections of hands and feet T. rubrum y Produces chronic type of tineapedis T. mentagrophytes y Produces inflammatory type of tine pedis E. flocossum Onchomycosis of dermatophyte etiology Infection of one or more nails of hands and feet

Fine scales to vesiculopustular eruption y Hyperkeratotic type shows diffuse hyperkeratosis with white scaling on soles and heels where the skin is often fissured y Vesicular variety is painful, with multiple blisters and pustules. y Erosion with peripheral scales occurs due to maceration and friction. y Intertriginous type is usually located at 3rd and 4thinterdigital spaces of feet y MOcasin type?- seen in soles and lateral aspect of skin; not just ordinary drying of the skin y HAND LESIONS are usually unilateral y PALM- Mild scaling with erythema y DORSUM-inflammatory change with well -defined edge

Direct microscopic examination Culture

Local treatment during acute phase - Daily foot baths with potassium permanganate Chronic and Hyperkeratotic lesions - Respond to benzoic and salicylic acid ointment Griseofulvin SysteminGriseofulvi n after ID of the agent Resistant to treatment and difficult to treat

Chronic, difficult to treat; mostly toe nails Nails becomes disfigured, thickened and lusterless, and debris accumulates under the free edge. Onycholysis- drying of nail Nail plate rises and separates from the nail bed due to debris

Worldwide Invariably associated with athlete s foot

Specimen of choice: Debris under the nail plate and scrape nail bed Direct

Trichophyton E. floccosum

accumulation in the nail bed and the nail may be destroyed Yellowish-white discoloration of the nail plate is characteristics

microscopic examination of the nail Culture

TRICHOPHYTON SPP Species T. rubrum*

Cultural Morphoogy Variable Most common: White floccose colonies with dark red to brown pigment on the reverse Variable Surface: buff and powdery or white and downy Reverse: red or brown pigment Slow growing, small and button-like, white and have a hard texture Reverse: non-pigmented to yellow

T. mentagrophytes*

Macroconidia Variable in number Long, narrow, thin-walled with parallel sides 2-8 celled May form directly on ends of thick hyphae, singly or in groups Not always present Cigar-shaped, thin-walled, narrowly attached to the hyphae and contain 1-6 cells Absent

Microconidia Oval and borne along the sides of the hyphae

OTHERS

T. verrucosum

Numerous Borne in clusters along the side of the hyphae Coiled spiral hyphae may also be seen. absent

T. tonsurans*

Variable Powdery colonies suede-like and folded as C/S ages Surface: white, gray, buff, or yellow Reverse: brown

Rare and irregular

Numerous along the hyphaeor are short conidiospores that are perpendicular to parent hyphae Tear drop or club shaped but may elongate or enlarge to form balloons form Tear shaped along hyphae

Has CHLAMYDOSPORES which are often in chains - Numerous when incubated at 37oC than 26oC CHLAMYDOSPORE are common

T. soudanense

Slow growing Orange to deep red, glabrous with prominent stellate fringe Reverse: similar color as surface

ABSENT

Reflexive branching of hyphae which often break to form ARTHROCONIDIA

T. violaceum

Slow growing, waxy, wrinkled, heaped , glabrous and deep purplish red

RARE OR ABSENT

RARE OR ABSENT

T. schoenleinii*

Slow- growing, glabrous, heaped or folded and whitish or gray Often submerged in the agar Reverse: colorless or yellowish orange to tan

ABSENT

ABSENT

T. concetricum*

Slow- growing, soft, glabrous and gray or buff in color

RARE OR ABSENT

RARE OR ABSENT

Hyphae - Tangled, branched, irregular with intercalary CHLAMYDOSPORES Hyphae: - Irregular and knobby - Subsurface hyphae: - antler-like hyphae [favic chandeliers] - Tips: - Round and swollen resembling nailheads appearance Hyphal swellings and Chlamydospores

MICROSPORUM spp Species Culture Morphology M. canis* Rapidly growing Flat surface with abundant aerial hyphae Reverse: deep yellow which turns brownish yellow with age M. gypseum* Flat and spreading with powdery to granular surface, irregularly fringed border. Surface: Buff tan cinnamon brown Reverse: yellow, tan, brownish or purplish red Sterile white hyphal border or cottony white center often develops.

MACROCONIDIA Numerous, long , thick-walled, spindle-shaped but tapering to knob-like ends Rough at the knob, and usually having more than 6 cells. Numerous, spindle shaped, symmetric with rounded ends and having no more than 6 cells

MICROCONIDIA few, club-shaped, smooth- walled, and formed along the hyphae Club-shaped and usually seen along the hyphae

OTHERS

M. auduoinii

Flat, thin, spreading growth Reverse: light salmon with reddish brown center Surface: Smooth, waxy,heaped, and yellow to rusty orange Reverse: cream to brownish

Distorted if present

Elongated microconidia along the hyphae

M. ferrugineum

Rare and resemble those of M. canis

Pectinate (comblike) hyphae commonly seen and chlamydosporesthat are often pointed on the end are common. Hyphae may be straight with prominent crosswalls (bamboo-like) or irregularly branched, clubbed, and fragmented

EPIDERMOPHYTON spp Species Colonies morphology Macroconidia E. floccosum* Olive green or khaki colored with Smooth, club-shaped with rounded powdery surface but become folded ends, contain 2-6 cells, found singly or in with floccose patches to brownish characteristic at times with yellow border clusters CHLAMYDOSPORES with age *very important, this are the organisms mentioned during our lecture

Microconidia ABSENT

Others

Treatment: - Benzoic acid compound - Whitfield s ointment - Tolnaftate - Know the source of infection for prognosis and prevention o Causative agent was M. gypseum- soil is probably contaminated o Causative agent was M. canis- pet is the source of infection - Known source of infection must be avoided End of transcription Know the basics and read DrPadla s questions well, she s good in making simple yet confusing questions. Good luck batchmates!!! This is unedited and most of the info is from Dr. Padla s book of mycology. Sorry kung walang pic..wala n kasiakong time maghanap at mag-DL.. so kanyakanyangkayod n langpo kung naisnyong picture..