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By

H.RAMLAN SADELI,dr.MS,SpMK

CLINICAL MYCOLOGY

Introduction to Mycology :
1. History, and development of mycology
2. Structure, morphology, classification and taxonomy of fungi
3. Growth and cultivation of fungi
4. Diagnostic and examination of fungal disease

Introduction to Mycology
In modern mycology, the fungi are placed within a separate Kingdom :
1. Monera
2. Protista
3. Fungi
4. Plantae
5. Animalia

Phyllum Eumycota, the four classes of fungi in which the human pathogens are
placed :
Fungi (Kingdom)
Eumycota (Phylum)
Classes : Zygomycetes
Ascomycetes - yeast
Basidiomycetes - mushrooms
Deuteromycetes - asexual (anamorph)
state only

Classes :
1. Zygomycetes :
is characterized by the production of large, non-septate (coenocytic) hyphae
and sporangia
are found everywhere, they produce diseases most often in diabetics
2. Ascomycetes :
are identified by their sexual (teleomorphic) state
since this state is not often seen in the laboratory, the fungi found as human
pathogens usually are not identified in this class
telemorph state is characterized by production of ascus (or sac) within which
sexual spore are produced (ascospores)

Classes :
3. Basidiomycetes :
are identified by their sexual (teleomorphic) state
the teleomorphic structure is the basidium and sexual spores, basidiospores,
are produced on the outside of the basidium
4. Deuteromycetes (fungi imperfecti) :
no sexual state is seen
are identified by the type of conidia and other asexual structures formed in
culture on standard media

Structures :
1. Yeast :
may bud from another mature cell
or from the septal area of certain hyphal fungi
2. Hyphae :
is the thread-like structure that form the cell body of most fungi
may be large ang without cross-walls (septae) :
non-septate or coenocytic; is found in the Zygomycetes
may be thinner and produced cross-walls (septae) :
septate hyphae; are formed by all other fungi

Structures :
3. Conidia : may be small (microconidia) or large (macroconidia)
blastoconidia : form as buds
arthroconidia : form directly from hyphal fragmentation
chlamydospore : form directly from the hyphae by a rounding up and
thickening of the wall
4. Sporangiospores :
asexual cells developed within a sporangium
produced by the Zygomycetes
5. Vesicle : is the swollen tip of a conidiophore or sporangiophore
6. Phialide : flask-shaped structure which produces phialoconidia

BASIC LABORATORY PROCEDURES

Successful isolation of a fungus causing deseases is dependent upon each of


the following factors :
proper collection of specimen
proper handling and correct processing of the specimen (including the

inoculation of the specimen into the appropriate culture medium and


incubation at a suitable temparature
the expertise of the technologist for identifying the fungus

Collection of specimens :
1. Skin scrapings :
clean the lesion of dirt or any topical medicines
scrape the outer edge of the lesion with a scalple
collect the scrapings in a clean container
2. Hair : remove hair from the infected site with clean forceps
collect in a clean container
3. Biopsied tissue :
placed in a sterile containers;
add steril water or saline to keep the tissue moist
do not freeze the tissue
4. Exudate or pus :
should be aspirated from an unopened abscess
placed in a steril tube and taken directly to the laboratory
never let the specimen dry

Collection of specimens :
5. Sputum :
collect sputum early in the morning as soon as the patient awakens
before collecting the sputum, the patient should brush his teeth or remove his
dentures, then thoroughly rinse his mouth
ask the patient to take a deep cough and raise sputum from the lung
collect the sputum in a wide-mouthed, sterile container that can be tightly
closed to prevent leakage
send the specimen directly to the laboratory

Collection of specimens :
6. Blood : should be collected aseptically
placed in the culture medium at the patients bedside
7. Spinal fluid :
collect aseptically and place into a sterile tube
do not refrigerate spinal fluid
8. Urine : collect in asterile container
take directly to the laboratory

Processing of specimens :
Specimens should be processed as soon as possible :
to ensure that the infecting fungus does not die
to control contaminating organism
If the specimen cannot be promtly processed, it should be refrigerated (except
spinal fluid).
1. Sputum and bronchial washings :
examine specimen grossly for purulent or caseous material or particles
prepare smears and wet mounts and inoculate this material onto appropriate
culture media

Processing of specimens :
2. Spinal fluid, urine and pleural fluid :
concentrate the specimen by centrifugation
make a wet preparation of the sediment and inoculate the appropriate media
with the remaining sediment
3. Tissue taken by surgical procedure :
remove any caseous or purulent material and place onto the appropriate
media & prepare wet preparation & smears
cut the tissue into small pieces with sterile scissors and grind the tissue with
a sterile mortar and pestle
transfer the homogenized tissue to appropriate media

Processing of specimens :
Direct microscopic examination :
is an essential step in diagnosing a fungal disease
often provide a rapid, tentative diagnosis (without having to wait for the
culture to grow)
culture must always be made to correctly identify the fungus
most mycological specimens are examined in the fluid state (wet mount),
include a KOH (or NaOH) preparation, India ink. lactophenol-cotton blue

Processing of specimens :
Culture media for isolation and identification :
The proper selection of isolation media is critical to obtaining a laboratory
diagnosis of a fungal disease. If the wrong medium is used, the fungus causing
disease may not grow.
Culture media routinely used may be divided into two main
primary isolation media (non-selective or selective ---> may contain
antibiotics to inhibit rapidly growing fungi)
differential media; are used to identify selected genera or or species (by
stimulation of characteristic growth/sporulation; or by the production of
physiological reaction on these media)

Processing of specimens :
Culture media for isolation and identification :
the isolation medium selection depends upon :
the type of specimen (heavily contaminated, or sterile)
the suspected etiological agent
A non selective medium like Sabouraud dextrose agar (SDA) should be routinely
used because it will support the growth of almost all the medically important
fungi.
However, without the addition of selective agent (such as chloramphenicol and
cycloheximide) this medium is practically useless.

Processing of specimens :
Temparature of incubation :
is important in the primary isolation of fungi
may be room temparature (25 - 27C) but prefarably 30C
can act as a selective factor (incubation at 45C will inhibit most fungi and
bacteria, but not Aspergillus fumigatus)

Processing of specimes :
Primary isolation media :
non-selective : Sabouraud dextrose agar
Brain heart infusion agar
Blood agar base
selective : Sabouraud dextrose agar
Brain heart infusion agar
Blood base agar
)* penicillin, streptomycin or chloramphenicol
Differential media : Neger seed agar
Yeast assimilation media
Sporulation media : cornmeal agar
yeast extract agar
potato dextrose agar
Czapek agar

with antibiotics )*
or antibiotics and
cycloheximide

MYCOSES
Superficial mycoses
Cutaneous mycoses
Subcutaneous mycoses
Systemic mycoses : pathogenic
opportunistic

SUPERFICIAL MYCOSES

Disease

Agent

Pityriasis versicolor

Malassezia furfur

Pityriasis nigra

Exophiala hortae

Black piedra

Piedraia hortae

White piedra

Trichosporon beigelii

PITYRIASIS VERSICOLOR = Tinea versicolor


caused by Malassezia furfur (Pityrosporum obiculare) is part of normal flora of
the skin & scalp ---> the infections may be endogenous
the organism is lipophilic, requiring lipid for growth
Pityriasis versicolor is a chronic, mild, asymptomatic infection of the stratum
corneum; lesion are sharply delineated, noninflamatory & cover with
furfuraceous scales

PITYRIASIS VERSICOLOR
the term versicolor is particularly appropriate, since color of the lesion varies
according to the normal skin pigmentation, exposure to sunlight & severity of
infection
lesion occur more often on the upper body, face, neck, arm
the reason for a change from normal flora status to a pathogenic agent are not
clear

PITYRIASIS VERSICOLOR
Laboratory diagnosis :
under uv ligth (Woods lamp) ---> Fluoresence : yellow
wet mount of skin scales : lesion contain short typical elements & spherical
cells (yeast) & this observation is virtually pathognomonic (spaghetti & meat
ball appearance)
culture identification is not diagnostic (may be positive from non-infective
person); but the organism can be cultured onto SDA (Sabouraud dextrose agar)
covered with olive oil
Treatment : selenium sulfide, sodium thiosulfate, miconazole; but recurrent is
frequent.

SUPERFICIAL MYCOSES

PITYRIASIS NIGRA = Tinea nigra = Tinea nigra palmaris

is caused by Exophiala werneckii; a dematiaceous fungus

is a superficial, chronic & asymptomatic infection of the stratum corneum; is


frequently found in the palm of the hand, characterized by brownish color
which is often darker at the edge of the macule

because infection may resemble melanoma or other types of skin cancer; a


diagnosis of a fungal etiology is important

skin scraping examined for fungal element, reveal pigmented hyphae

Treatment : keratolytic agent such as salicylic acid or sulfur have been used;
topical miconazol

SUPERFICIAL MYCOSIS
BLACK PIEDRA

caused by Piedraia hortae; mostly in tropical climate

infection of hair shaft (of the scalp), characterized by black, hard nodules on
the hair shaft; very difficult to remove the nodules

in some area of the world, the infection may be encouraged for cosmetic
purpose

diagnosed by direct examination of the hair & nodules; reveals hyphal strands
are often aligt along the periphery of the mature nodules; and the center of the
mass resembles organized tissue with area in which asci are produced

Treatment : by cutting the hair

SUPERFICIAL MYCOSIS
WHITE PIEDRA

caused by Trichosporon beigelii; mostly in temperate climate

infection of hair shaft (moustache; axilla; pubis); characterized by soft, lightcolored nodules of the hair sharf, easily to remove

direct examination of the hair sharf reveal the mass of intertwined hyphae of
the nodules; often fragmented into arthroconidia

Treatment : by cutting the hair

CUTANEUS MYCOSES

may be dermatophytosis, caused by dermatophytes (Trichophyton,


Microsporum, Epidermophyton); or candidiasis, caused by Candida sp.

Dermatophytosis :
may involve the skin, hair, nails (parts of the body which contain keratin)
may be acquired from animal (zoophilic), soil (geophilic), in which lesion are
quite inflammatory & may heal spontaneously
may be acquired from human (anthropophilic); usually less inflamation but
may be chronic
dermatophytosis are classified by the area of the body involved

DERMATOPHYTES

Antrophophilic

Zoophilic

E.floccosum
M.canis
M.audouinii
M.nanum
T.rubrum
T.verrucosum
T.schonleini
T.equinum
T.tonsurans
M.gallinae
T.violaceum
T.mentagrophytes
T.frrugineum
var mentagrophytes
T.concentricum
T.mentagrophytes var interdigitale

Geophilic
M.gypseum
M.fulvum
T.ajelloi
T.terrestre

DERMATOPHYTOSIS

Tinea capitis (ringworm of the scalp) :


is an infection of the skin and hair of the head
Clinical features :
graypathes ringworm/epidemic tinea capitis
blackdot ringworm
kerion / zoophilic (geophilic) tinea capitis

TINEA CAPITIS

Grapatches ringworm :

occurs in children & is anthrophilic


is caused by M.audouinii (Europe) & M.ferrugineum (Asia)
is usually non-inflammatory; produced gray pathes of hair; the hair shaft
breakage above the scalp
is contagious through head bands, hats and so on; can be epidemic in schools;
may heal spontaneously at puberty (prapubertal tinea capitis)
is treated with oral griseofulvin; topical fungistatic agent such as boric acid

TINEA CAPITIS
Blackdot ringworm :
caused by T.tonsurans; occurs in adults & is a chronic infection
characterized by hair breakage, leaving follicles with dark conidia (the hair
shaft breakage right on the surface of the scalp);
may be results in alopecia; usually treated with griseofulvin or ketoconazol
Kerion :
occurs primarily in children; usually transmitted by pets; accordingly by farm
animals
is most commonly caused by M.canis or T.mentagrophytes; more
inflammatory & occurs with kerion
may results in inflammation, keloid, kerion, & alopecia
my heal spontaneously; but usually treated with antifungal

DERMATOPHYTOSIS
TINEA FAVOSA (FAVUS)

is caused by T.schonleini; occurs in both childrens & adults


is a severe form, with scutula formation & permanent hairloss cause by
scarring & it has a mousy odor
is treated with griseofulfin & by removal of debris

TINEA BARBAE :
is an acute or chronic folliculitis of the beard, neck or face
is most commonly cause by zoophilic dematophytes (T.verrucosum;
T.mentagrophytes)
results in pustular; or dry, scally lesion; my be superinfected with bacteria;
treated with griseofulvin

DERMATOPHYTOSIS
TINEA CORPORIS :
is fungal infection of the glabrous skin; most commonly caused by T.rubrum,
T.mentagrophytes & M.canis
is characterized by annular lesion with active border & may be vesicular or
pustular
is treated with topical antifungal (tolnaftate, myconazol) or griseofulvin
(systemic)
TINEA IMBRICATA
is caused by T.concentricum; occurs on Pacific Ocean Islands & numerous
countries of Asia
is characterized by concentric ring on the skin; may cover large area of the
body; the scally often overlap
is treated by griseofulvin

DERMATOPHYTOSIS
TINEA CRURIS = Jock itch
is an accute or chronic fungal infection of the groin
is caused by E.floccosum, T.rubrum, T.mentagrophytes,
has some predisposing factors such as : hyperhidrosis, obesity, diabetes,
pregnancy, fluor albus, neurodermatitis
is treated with tolnaftate, miconazol, ketoconazol
TINE APEDIS = Athlete foot
is an acute or chronic fungal infections of the feet; most commonly caused by
T.rubrum, T.mentagrophytes, E.floccosum
may be superinfected with bacteria, which may require antibiotic treatment
before tinea pedis is treated

DERMATOPHYTOSIS

TINEA PEDIS
Clinical features : Chronic intertriginous tine pedis :
results in white mascerated tissue bet ween the toes (the most common form)
is treated with tolnaftate or imidazole & by keeping the feet dry (by using
alumunium chroride) & aerated; if infections persist, griseofulvin or
ketoconazole is used.
Clinical features : chronic dry scally tinea pedis :
results in hyperkeratotic scales on the heel, sole, or side of the feet; also
known as mocasin foot
is treated with hyperkeratotic agent such as whitfield ointment & griseofulvin

DERMATOPHYTOSIS

TINEA PEDIS
Clinical features : vesicular tinea pedis
is characterized by vesicles & vesiculopustules
permanganate or Burrows solution is used to open vesicle;
dermatophytid reactions my occur;
griseofulvin is the treatment of choice
TINEA MANUM :
is chronic, unilateral fungal infection of the hand, caused by T.rubrum,
T.mentagrophytes, E.floccosum
is characterized by diffuse hyperkeratotic; exfoliative, vesicular;
treatment = tinea pedis

DERMATOPHYTOSIS

TINEA UNGUIUM :

is fungal infections of the nails caused by Dermatophytes (if the infections


cause by non-dermatophytes, its called Onychomycosis)
almost always all dermatophytes cause tinea unguium & the most resistant to
treatment
the nails becomes opaque & brittle; usually lose luster; then discolored,
thickened, distorted, seperated from its bed, thinned & broken
treatment : systemic griseofulvin, long-term (a year or more)
topical : K-permanganate 1:4000; phenol; salicylic acid 10%; iodium 1%;
operative : ablatio

course of disease

Tinea unguium
(Dermatophytes)

Onychomycosis
(Candida sp.)

distal proximal

proximal distal

debris

non

pain

non

non

thickness

DERMATOPHYTOSIS

Laboratory diagnosis :

a diagnosis of fungal etiology based on morphology of individual lesion &


their body locations is not always sufficient (except for tine imbricata)
infections of skin or nails; a scraping is digested in KOH and examined for the
presence of hyphal element
the infections of the hair shatf show arthroconidia outside the shaft (ectothrix)
or inside the hair shaft (endothrix)
some species that infect hair fluorescence under Woods lamp

DERMATOPHYTOSIS

Laboartory diagnosis :
species identification requires culture
culture identification is based primarily on the appearance of the asexual
reproductive conidia or the specific hyphae
while all of these species grow as molds, they have distinctive features
the reverse of colonies of some species may be pigmented (red, yellow) and
the tops may be fluffy, velvety; white or pigmented
this characteristics combine with the microscopic morphology generally
permit an identification

SUBCUTANEUS MYCOSES

Diseases
Agent
Mycetoma pedis
Eumycetoma Pseudoallescheria boydii; Madurella sp;
Acremonium sp; Fusarium sp;
Actinomycetoma
Actinomyces israeli; Nocardia sp;
sp; Acinomadura sp;

Chromoblastomycosis
Fonseca pedrosoi; Fonseca compecta;
Cladosporium carionii; Phialophora
verrucosa
Sporotrichosis Sporothrix schenckii

Rhinosporidiosis

Lobomycosis

Rhinosporidium seeberi

Loboa loboi

Streptomyces

SUBCUTANEUS MYCOSES

General characteristic :

are found worldwide; some of the infection are endemic


several species of fungi can cause the same clinical syndrome
the causative agent are common soil saprophytes
the organism invade the tissue by traumatic implantation
the course of infection is usually slow & may continue over period of years
(chronic infections)

SUBCUTANEUS MYCOSES

MYCETOMA PEDIS = Madura foot = Maduromycosis

Characterized by : swollen lesion, usually on foot or hand


suppurating abcesses & multiple sinus tracts
exudate contain sulfur granules

Mycetoma with fungal etiologies = eumycetoma = eumycotic mycetoma

mycetoma with bacterial etiologies = actnomycetoma


actinomycotic mycetoma

MYCETOMA PEDIS : Etiologies


Eumycetoma :

Actinomycetoma :

Pseudoallescheria boydii
Madurella sp;
Acremonium sp;
Fusarium sp;
.

Actinomyces israeli
Nocardia sp;
Streptomyces sp;
Actinomadura sp;
.

MYCETOMA PEDIS
Laboratory diagnosis :
direct microscopic examination : granules obtain from the draining tissues are
examined for ther gross physical characteristic
microscopic examination (wet mount with KOH) reveal that bacterial filament
less than 1 um; & fungi filamen (hyphae) greater than 1 um
Treatment :
eumycetoma : amphotericin B; azole compound; & nystatin topical;
actinomycetoma : sulfonamide
surgical excition or even amputation may indicated

SUBCUTANEUS MYCOSES
CHROMOBLASTOMYCOSIS :

caused by dematiaceus fungi, such as : F.pendrosoi; F.compacta; C.carionii;


P.verrucosa
the organism occur in soil worldwide; the common fungi found in rotting
wood & decaying vegetables
the disease is encountered most frequently in 30-50 years old; more frequent
in men than women
after the organism introduced into the tissue (by traumatic implantation), there
are some latent period (may be many years)
the lesion begin as small, scally papules at the site of inoculation & gradually
develops into : multiple nodules (cauliflower; bloom kol) or verrucous,
ulcerative &crusted lesion

CHROMOBLASTOMYCOSIS :
Laboratory diagnosis :
direct microscopic examination : wet mount --> examination of tissue from
lesion reveals characteristics pigmented (brown) sclerotic bodies a round, thickwalled form that have cross divisions
culture : is required to identified the etiologic agent specifically
the colonial morphology growth rate & microscopic morphology of conidial
productions (sporulations) are characteristic of the species
Treatment : surgical exicition; antifungal drugs

SUBCUTANEUS MYCOSES
SPOROTRICHOSIS
caused by Sporothrix schenckii, a dimorphic fungus, is found worldwide as
inhibitant in soil & decaying vegetation
is characterized by a lesion that begin as a movable nodule & subsequently
became necrotic
if it is untreated, new lesion appear along the lymphatic draining area (this
pattern is pathocnomonic for this form of sporotrichosing)
the infections is particularly associated with gardener --> rose gardener
syndrome

SPOROTRICHOSIS
in endemic area, a non-lymphatic or fixed form may be seen
single lesion, do not spead, often found on the face, neck or finger (occurs in
hypersensitive / allergic person)
another form of non-cutaneus, systemic infections is pulmonary infections; is
seldom diagnosed & often found in chronic alcoholic; infections is initiated
following inhalation of fungal conidia

SPOROTRICHOSIS
Laboartory diagnosis :
the appearance of the lymphatic form is very characteristic; however diagnosis
requeres isolation & culture identification diagnosis requires isolation & culture
identification
direct microscopic examination : material removed from such lesion can be
directly examined for cigar-shaped yeast cells
stain such as calcoflour white & fluorescence antibodies may be useful
however, the number of orgnaism is often too few for releable observation and
material should be submitted for fungal culture

SPOROTRICHOSIS

Laboratory diagnosis :
the organism is thermally dimorphic; in soil or at room temperature is grows
as mold with distinctive conidia that are produced in a pattern often described
as a daisy head

at 37C the organism grows as a budding yeast (yeast colony)


serologic method are not important indiagnosis

Treatment :
KI (pottasium iodida), oral; topical
amphotericin B

SUBCUTANEUS MYCOSES
RHINOSPORIDIOSIS

is caused by Rhinosporidium seeberi; the organism may have a natural aquatic


or perhaps soil habitat; & has not been cultured

is a chronic, granulomatous infections (may persist for years) in which polyps


form in the nasal or conjnuctival; occur primarily in India & Sri Langka

in tissue, the organism a large (6-300 um), spherical sporangia (sperula) that,
when mature, is filled with endospres; on lysis, these endospore then repeat
the development sequence

Treatment : surgical excition

SUBCUTANEUS MYCOSES

LOBOMYCOSIS = Loboss disease = Keloid blastomycosis

caused by Loboa loboi; which has not been culture


the cases have been reported from America & mostly South America
is chronic infection, localized in the skin & may be spread by autoinoculation;
the lesion is a keloid; verrucous & ulcerated may develop over an extended
period of time
the course of infection is slow; may persist for 20-30 years; the organism
appears in tissue as yeast cells in chain

Treatment : surgical excition

SYSTEMIC MYCOSIS : Pathogenic

Diseasea

Agent

Blastomycosis

Blastomycoss drmatitidis

Histoplasmosis

Histoplasma capsulatum

Coccidioidomycosis

Coccidioides immitis

Paracoccidioidomycosis

Paracoccidoides brasiliansis

BLASTOMYCOSIS
= Notrh American Blastomycosis
= Gilchists disease
Etiologic agent : Blastomyces dermatitidis, a dimorphic fungus that grows as
mold at room temperature and as a yeast at 35 - 370C
Epidemiology :

B. dermatitidis is saprophytic in nature & grows in the mold fom in soil

or decaying wood associated with soil, has been isolated several times, but
repeated isolation from the same sites were not succesful

most of the cases have been found in Noth America, but also prevalent in
Africa & has been reported in India, occurs most often in adult males

the lack of a specific skin test antigen has prevented the determination of the
prevalence of asymptomatic Blastomycosis in large population

BLASTOMYCOSIS
Cxlinical features :

the primary site of Blastomycisis is the lung, with mild infiltrat & few clinical
symptoms
in severe disease, pulmonary infiltrate may be more extensive & the patients
will have fever, cough & weight lose, nodular pulmonary lesion may occur
some cases may progres to chronic disease with pulmonary fibrosis & the
cavitation
the fungus may disseminate to any organ of the body, mostly skin & bone
skin lesion are frequently a manifestationof disseminated disease, with
dry & scaly, extensive granulomatous with vescle or pustule

BLASTOMYCOSISIS

Laboratory diagnosis :
Direct microscopic examination :

wet mount : B. dermatitidis appear asa large, thick-walled single-budding


yeast ( 8 - 18 m ), the bud has a wide base

histiphatology : the yeast form is usually easily fount in infected tissue, are
best detected with PAS or GMS stain

BLASTOMYCISIS
Laboratory diagnosis :
Culture :
is the dimorphic fungus, that grws in the mycelial form (mold) at room
temperature & as a yeast at 370C
the mold form grows slowly, became visible in 7 - 10 days, the colony is
usually white & cottony
the yeast-like colony grows on blood agar at 370C after 3 - 4 days
Microscopic morpology :
the mold produces small, smooth walled cinidia & attached to the
conidiophores that arise directly from the hyphae
yaest are large, thick-walled, single-budding & the bud has a wide base (neck)
the diagnostic structure of B. dermatitidis

BLASTOMYCOSIS

Serology :

ID test is the most reliable, CFT not detect antibodies in all cases, will
cross-react with antibodies to H. capsulatum

Treatment : Amphoterisin B, Ketoconazole

HISTOPLASMOSIS
= reticuloendothelionsis
= Darlings disease
Etiologic agent : Histoplasma capsulatum, a dimorphic fungus, having a mold form at
room temperature & yeast form at 370C
Epidemiology :
H. capsulatum grows in soil, especially in soil that esriched with bat or bird manure

often be isolated from old building/caves, where birds/chickens or bats have roosted

H. capsulatum grows in soil in the mycelial form & large number of conidia are
produce

the disease is acquired by inhaling conidia & reported from most area of the world

HISTOPLASMOSIS

Clinical features :
is primarily a pulmonary disease; when conidia are inhaled, infections is established in
the lungs; the disease may be mild, with few or no symptom (95%)

may be severe with lung infiltrates, from mild to extensive

primary pulmonary histoplasmosis progresses to chronic pulmonary disease in about

5 % of those with disease; is characterized by fibrosis & cavitation, symptoms


includes : cough, fever, chills & weight lose (resembles to toberculosis, sarcoidosis, &
other systemic fungal disease)

the most severe form of histoplasmosis is disseminated disease; the fungus invade any
organs of body

HISTOPLASMOSIS

Laboratory diagnosis :
Direct microskopic examination : wet mount :

H. capsulatum may be seen in sputum, bronchial washed, or in any body fluids


as a small yeast, 4 - 6 m

histopathology : the yeast form can be found in tissue removed from the
infected sites, ussually in the macrophage & in granulomas

GMS (gomori methenamine silver) stain should be used


( the yeat dark-brown - black )

HISTOPLASMOSIS
Culture :

colony morphology : H. capsulatum grows slowly in the mold form when incubated at
room temperature, appear in 7 - 10 days but conidia is not form until later; on SDA
( sabouraud dextrose agar ) the colony Is ussually white & cottony

microscopic morphology :
two types of conidia are prodeced by H. capsulatum small, pyriform smoth-walled
conidia (microconidia, 4 - 6m ) and large, round, thick-waled tuberculated conidia
( macroconidia, 8 - 18m )
the diagnostic conidia

to prove the identification of H. capsulatum, convert the mold form - yeast form; be
done by transferring the mold colony to blood agar & incubate at 37 0C in 3 - 5 days the
yeast colony will be white
brown

HISTOPLASMOSIS

Serology :
antibodies to the fungus are produced within 10 - 21 days after a person is infected by
H. capsulatum

agglutination test, measures IgM antibodies, is a quantitative test

CFT, measures both IgM & IgG, is quantitative test; ID test is a quantitative test

Treatment :
Amphotericin B, Ketoconazole

COCCIDIOIDOMYCOSIS
= valley fever
Etiologic agent : Coccidioides immitis, a biphasic fungal pathogen
Epidemiology :
C. immitis grows in semi-acrid, solid, is known to exist in North, Central,
& South American, especially California; its inhaled into the alveoli, where it
produces disease, either benign ( resembles flu ), or acute, depending on many
factors ( race; incculum )
Clinical features :
most is a benign disease, prodeces only mild symptoms; among certain races
( Filipinos, Black ), immunosupressed or the used of corticosteroids,
disseminated may occur

there is no site of predilection for this organism; any body tissue may become
infected

COCCIDIOIDOMYCOSIS

Laboratory diagnosis :
Direct microscopic examination :

wet mount : specimens in KOH mounts, C. immitis may be seen as sporangia


( spherula ) filled with endospora

histophatology : the sporangia stain well with HE & PAS stain

COCCIDIOIDOMYCOSIS
Culture : Never work with culture on the laboratory bench OUTSIDE of a
biohazard hood !

C. immitis is a biphasic fungal phatogen, grows at room temperature repidly


producing a dirty gray-white colony; at maturity, the hyphae develops
arthroconidia wich enlarged & barrel-shaped; alternate cells empty
the hyphae break easilly into separate artrhoconidia
float in the air
spread by the wind

Serology : used as diagnostic & prognostic tools; include CFT, latex aglutination,
ID test
Treatment : Amphotericin B, Ketoconazole

PARACOCCIDIOIDOMYCOSIS
= South American blastomycosis
Etiologic agent : Paracoccidioidomycosis brasiliaensis, a domorphic fungus that
grows as mold at room temperature & as a yeast at 370C / in infected tissues
Epidemiology :
the saprophytic habitat of P. brasiliensis is not known; endemic mostly in
South America

most cases of paracodioidomycosis are seen in adult males; is rare in children


& adult women; appears to reflect a host-parasite relasionship by sex
hormones

PARACOCCIDIOIDOMYCOSIS
Clinical features :
the primarily site of infection is the lung; disease may be benign, primary
pulmonary form or may disseminate to produce acute & chronic, progresive
disease, includes lymph nodes & skin

the primary benign form may ultimately results with some residual interstitial
fibrosis

acute & chronic, progresive paracoccidioidomycosis, disseminated from of the


disease, most prequently recognized on the basic of lesion on oropharynx &
gingivae

progresive chronic pulmonary disease may involve all lobes of the lung;
produce extensive fibrosis

PARACOCCIDIOIDOMYCOSIS

Laboratory diagnosis :
Direct microscipic examination :
wet mount : appears a large, yeast-like cells ( 30 - 360 m ), budding with one or
more buds ( multiple buds ) with narrow necks

histophatology : in infected tissue appears as large cells, multiple buds, connected


to the parent cell by narrow necks, it has been called a pilot wheel or
mickey mouse

PARACOCCIDIOIDOMYCOSIS

Laboratory diagnosis :
Culture :
colony morphology : P. brasiliensis is a dimorphic fungus, grows slowly in the
mycelial form at room temperature; readily convert to the yeast phase when
grown at 370C on enriched media

microscopic morphology : the mycelial form is thin, septate hyphae, conidia,


chlamydospora & arthroconidia may be formed;
yeast phase cultures will demonstrate both mycelial element & yeast; the yeast
are characterized by large ( 30 um or more ); multiple-thin-walled buds, with
narrow necks

PARACOCCIDIOIDOMYCOSIS

Laboratory diagnosis :
Serology : CFT & ID test have been shown to be reliable; however cross reactions
may occur
Tretment : Ketoconazole, Amphotericin B, Sulfadiazine

SYSTEMIC MYCOSES

SYSTEMIC MYCOSIS : Opportunistic


Disease

Agents

Candidiasis

Cabdida albicans; Candida sp.

Cryptococcosis

Cryptococcus neoformans

Aspergillosis

Aspergillus fumigatus; Aspergillus sp.

Zygomycosis

Mucor, Rhizopus, Absidia

SYSTEMIC MYCOSES

Pathogenic

Opportunistic

Agent

dimorphic fungus

non-dimorphic fungus

Port dentre

lung (per inhalation )

lung & others

Disease

usually chronic

usually acute

Patients

could be healthy patients

usually ill patient

SYSTEMIC MYCOSES

CANDIDIASIS = Candidosis
acute / chronic fungal infections, involving, the mouth, vagina, skin nails,
bronchi / lung, alimentary tract, urinary tract, blood steam and less commonly,
the heart or menungen

are caused by Candida albicansor other species

are predisposed by : extremes of age, wasting, & nutritional disease, excessive


moisture, pregnancy, diabetes, long-term antibiotics, & steroid use, indwelling
catheter, immunosupressed & AIDS

are generally treated with imidazoles, polyenes or both

CANDIDIASIS

Candida albicans :

is part of the normal flora of the skin, mucous membranes & GI tract along
with other Candida sp.

normal colonization must be distinguised from infection

form elongated budding forms called pseudohyphae, which are often seen in
clinical material along with true hyphae, blastoconidia & yaest cells

CANDIDIASIS

Clinical features :oral thrush :

is a yeast infectoins of the oral mucocutaneus membranes

manifest as white curd-like patches in the oral cavity

occurs in premature infants; older infants beingtreated with antibiotics,


immunosuppressed patients, long-term antibiotics & AIDS patients

CANDIDIASIS

Clinical features : Vulvovaginitis :

is a yeast infection of the vagina; manifest with a thick yellow-white discharge, a


burning sensation, curd-like patches on the vaginal mucosa & inflamation of
perineum

is predisposed by diabetes, antibiotic therapy, oral contraceptive use & pregnancy

may be trasmitted to sexual partner as balanitis

CANDIDIASIS
Clinical features : Cutaneus candidiasis :

involves the nails ( onychomycosis; paronychis ), skin folds


( intertriginosa ) or groin ( such as diaper rash )
may be eczematoid or vesicular / pustular; is predisposed by moist condition

Clinical feature : alimetary tract disease :

is usually an extension of oral thrush & may include esophagitis & ultimately
the entire gastrintestinal tract

is found in patients with AIDS or other immunosuppressive disorder,


particularly those patients on long-term antibiotics therapy

CANDIDIASIS

Clinical feature : chronic mucocutaneus candidiasi :

is a chronic, often disfiguring, infections of the epithelial surfaces of the body

is diagnosed microscipically & by the lack of cell mediated immunity

Clinical feature : Bronchopulmonary infections :

occurs in patient with chronic lung disease; its usually manifested by


persistent cough

CANDIDIASIS
Clinical feature : Candidemia / blood borne infections :

occurs most commonly in patients with indwelling catheter; these infections


are manifested by fever, macronodular skin lesion & endopthalmitis

Clinical feature : Endocarditis :

occurs in patient who have manipulated or damaged valves, or in IV drug


abusers

Clinical feature : Cerebrospinal infections :

may occur in compromised patients

CANDIDIASIS
Laboratory diagnosis :

direct microscopic examination : wet mount of the skin / nail scraping or


exudate, demonstration of the presence of pseudohyphae / hyphae, & yeast in
the tissue

culture : of the specimens on to SDA at room temperature, Candida will


grows as yaest-like colony

C. albicans be identified by :
* germ tube test -- yeast germination in serum at 370C
* culture on corn-meal-agar -- reveals chlamydospres
* culture on Eosin-methylen-blue-agar : reveals spider colony
* fermentation test of : glucose, lactose, maltose, sacharose

serologic : high levels of Candida precipitins or antigens

SYSTEMIC MYCOSES : Opportunistic

CRIPTOCOCCOSIS
include subacute or chronic fungal infections involving the lungs, meninges, or less
commonly the skin, bones & other tissues

most commonly occur as cryptococcal meningtis; often occuring in AIDS patients

is caused by Cryptococcus neoformans; yeast that posseses an antigenic


polysaccharidae capsule

is associated with pigeon feces; considered to be an opportunist in the present of


underlying disease in patients with Hodgkins disease, leukomias; or leucocyte
enzyme deficiency disease

CRYPTOCOCCOSIS

= Busse-Buschkes disease
= European Blastomycosis

Clinical feature :

pulmonary infections : are ussually asymptomatic; & self resolving; most


common in pigeon breeder

meningitis ( most often ) or meningoencephalitis occurs in AIDS patients most


commonly with headache, ussually with fever, followed by typical sign of
meningitis

CRYPTOCOCCOSIS

Laboratory diagnosis :

microscopic examination : wet mount, demonstration of encapsulated yeast in


CSF sediment in india-ink

detection of the capsular material in the CSF ( the cryptococcal antigen ) by


latex agglutination test

culture : in SDA ( Sabouraud dextrase agar ) revealyeast colony

Treatment : Amphotericin B, 5- fluorocytosisn or fluconazol

SYSTEMIC MYCOSES : Opportunistic

ASPERGILLOSIS

caaused by Aspergillus fumigatus, an opportunistic organism

is a ubiquitous filmentous fungus whose airborne spores are contantly in the air

is recognized both in tissue & in culture by its characteristic septate hyphae with
dichotomous branching, produced conidial heads with numerous conidia

ASPERGILLOSIS

Clinical feature : Aspergilloma = fungus ball :

is a roughly spherical growth of Aspergillus in pre existing lung cavities &


does not invade the lung tissue

occurs clinically as reccurent hemoptysis & diagnosed by radiologig method

Treatment : surgical ( lobectomy )

ASPERGILLOSIS

Clinical features : invasive aspergillosis :

occurs most commonly during severe neotropenic in leukemia & transplantm


patients; most commonly occurs as fever of unknown origin in patient with
neutropenia fewer than 500/mm3 & pneumonia

it may begin as sinisitis or lungs; it disseminate to any part of the body, most
frequently brain

is diagnosed by microscopy & culture of lung biopsy material

is trested with amphotericin B or intraconzole & has a high fatality rate

ASPERGILLOSIS

Clinical features : Allergic bronchopulmonary aspergillosis

is an allergic disease, in which the organism colonies the mucous plugs form
in the lung, but does not invade lung tissue

is diagnosed by finding of high titer of IgE antibodies

SYSTEMIC MYCOSES : Opportunistic


ZYGOMYCOSIS = Mucormycosis + Phycomycosis

caused by the genera Rhizopus, Mucor & Absidia; non-septate fungi; phylum
Zygomycota; grow repidly & predilection for invading blood vessels & the
brain

Clinical features : thoracic infectoins

occur in leukemia & lymphoma patients

abdominal-pelvic infections occurs in malnourish patients

cutaneus infections occurs in patients with leukemia

ZYGOMYCOSIS
Clinical features : Rhinocerebral infections

is the common form; occurs in patients with acidotic diabetes

presents with facial swelling & blood tinged exudate in the turbinate bones &
eyes; lethargy & fixated pupil

is a fatal infections & spreads rapidly

must be diagnosed rapidly; ussually by a KOH mount of necrotic tissue or


exudate from the eye, nose, or ear

Treatment : control of diabetes; surgical debridement; amnphotericin B