MYCOLOGY - Study of fungi

- Usefulness & disease produced – certain fungi

- Mycoses

GENERAL CHARACTERISTICS OF FUNGI

1. Eukaryotic
2. Chemoheterotrophic
3. Saprophytic
4. Commensals
5. Parasitic

BENEFICIAL USES OF FUNGI

1. Food consumption – Mushrooms
2. Food production – Yeast – make bread
3. Fermentation of Alcoholic drinks – beverages
4. Tobacco& Rubber Manufacturing
5. Decomposition of Waste products- Waste disposal
EFFECTS OF FUNGI
1. Spoilage of stored foods
2. Diseases in humans and Animals
3. Destruction of crops
4. Spontaneous combustion of stacked hay & peat
5. Attack all materials especially wood

CONDITIONS CONDUCIVE TO FUNGAL INFECTIONS

1. Disruption Body’s Barrier - Physical, Chemical,
Physiologic
2. Immunosuppression - loss of CD4 Tʜ1 responses
3. Indiscriminate use of Antibacterial agents
- Alters normal bacterial flora
FUNGAL STRUCTURAL COMPONENTS
A. CELL WALL
- Carbohydrates = 80-90%
- Chitin, Mannan, Glucans
- Activates Complement  INFLAMMATION
- Mediates attachment to Host cells
- Antigenic - elicits CMI & antibody responses
- Others: Contain MELANIN - DEMATIACEOUS FUNGI
- Imparts brown or black color
- Diagnostic & associated with virulence

B. CAPSULE OR SLIME LAYER

- Main Composition: POLYSACCHARIDES
- Adherence & clumping of fungal cells
- Influence growth of fungi
C. CELL MEMBRANE
- Bilayer Structure:1.Phospholipids
2. Sterols - Zymosterol & Ergosterol
Functions
1. Cytoplasmic protection
2. Regulate intake & secretion of solutes
3. Facilities cell wall & capsular synthesis

D. CYTOPLASMIC COMPONENTS
1. Endoplasmic reticulum
2. Nucleus & Nucleoli
3. Vacuoles - Active Secretory apparatus (Yeast)
- Secretes 2nd ary metabolites - AFLATOXIN
4. Mitochondria - same in plants and animals
5. Other Organelles
1. YEAST - TISSUE FORM
- Single or Unicellular cells
- Ova-spherical to ellipsoidal
- Survive at 37ᴼC
- Culture Media: Creamy mucoid colonies

MODE OF REPRODUCTION
a) Budding
1. Blastoconidia formation
2. Pseudohyphae - failure to detach
3. Chlamydospores

b) Binary fission
2. MOLDS – MYCELIAL or FILAMENTOUS FORM
- Multicellular
- Colonies - branching filamentous made up of
cylindrical structures  HYPHAE
- Survive at 24ᴼC or Room temperature
- MYCELIUM - mass of intertwined hyphae
1. COENOCYTIC/ NON-SEPTATED HYPHAE
- NO SEPTA OR DIVISIONS
- Continuous : E.g. Zygomycetes
2. SEPTATE HYPHAE
- WITH CROSS-WALLS OR DIVISIONS
- Communication through pores

1. VEGETATIVE or SUBSTRATE HYPHAE

- Part of the hyphae growing into the medium
- Absorb the nutrients

2. AERIAL HYPHAE
- Part of the mycelium which projects on the surface
- Carry reproductive structures of the molds

NOTE: Most pathogenic fungi: DIMORPHIC EXCEPT CRYPTOCOCCUS

SPORES
- Specialized structures
- Enhance survival of fungi
- Produced from both Sexual & Asexual reproduction

1. ASEXUAL SPORES
- Produced by means of Mitosis
- Commonly encountered in Clinical situations
- CLASSIFIED INTO:
a) Vegetative Spores
b) Aerial Spores
A. BLASTOCONIDIA & PSEUDOHYPHAE(CANDIDA) B. CHLAMYDOSPORES (CANDIDA)
C. ARTHROSPORES ( COCCIDIOIDES) D. SPORANGIA & SPORANGIOSPORES (MUCOR)
E. MICROCONIDIA (ASPERGILLUS) F. MICRO & MACROCONIDIA (MICROSPORUM)
CONIDIOSPORES OR CONIDIA
- Spores borne externally on sides or tips of hyphae
- Conidia - means DUST ( Float in the air )
- MAJOR ASEXUAL STRUCTURE
1. Microconidia - small conidia
2. Macroconidia - Large or multicellular conidia

CONIDIOPHORES - Specialized structures

SPORANGIUM
Sac-like structures where asexual spores are produced
 CHLAMYDOSPORES
3.ARTHROSPORES
1. - CHLAMYDOCONIDIA
- Arthroconidia
- -Formed
Large, thick-walled
by productionspherical conidia/
of cross-septa in resting
hyphaespores
developed
resulting by roundingthick-walled
in rectangular up & thickening
sporesof terminal
or intercalary hyphal
- Fragmentation segments
of hyphal cells - E.g. C. immitis
- E.g. Candida albicans
2. BLASTOSPORES - Blastoconidia
4. SPORANGIOSPORES
Conidial formation through budding from parent cell
- Mitotic spores formed within the sporangium
- E.g. Yeasts
developed on ends of hyphae called Sporangiophores
- Characteristic of Zygomycetes – Mucor & Rhizopus
5. PHIALOCONIDIA
- Special type of conidia
- Production of VASE-LIKE PHIALIDE
- E.g. .Phialophora verrucosa
2. TYPES OF SEXUAL SPORES

1. ASCOSPORES - Meiosis, 4-8 meiospores form within an ascus

- Fusion of nuclei of 2 cells ( morphologically similar or dissimilar
- Ascus- sac-like structure where spores are produced.

2. BASIDIOSPORES - Meiosis 4 meiospores form externally ( surface) on a base

pedestal or club-shaped structure - Basidium
Ratio: 4 Basidiospores / Basidium

3. ZYGOSPORES - Large, thick-walled spores

- Results from fusion of nuclei of 2 cells, morphologically
similar to each other

3. PARASEXUAL REPRODUCTION
- Results from Genetic exchange via Mitotic recombination
- Characteristic of Imperfect fungi
BASIDIOMYCOTA/BASIDIOMYCETES/CLUB- FUNGI
- Includes fungi that produced Mushrooms
- Sexual Reproduction: Basidiospores supported by base
pedestal called BASIDIUM
- Complex Septate Hyphae
- E.g. Mushrooms, Filobasiella neoformans
( Anamorph: Cryptococcus neoformans )

DEUTEROMYCETES
- Artificial grouping of IMPERFECT FUNGI
- Asexual Reproduction: Conidia
- NO SEXUAL REPRODUCTION
- E.g. C. immitis, P. brasiliensis, C. albicans
1. MYCOTOXICOSES
- Accidental or Recreational ingestion - 2nd ary Metabolites
& other toxic compounds
- E.g. Ergot Alkaloids, Aflatoxin

2. HYPERSENSITIVITY DISEASES
- Hypersensitivity Pneumonitis
- Rhinitis, Bronchial asthma, Alveolitis, Atophy
- Manifested in sensitized persons - post exposure to fungus
& its metabolites

3. COLONIZATION
- Infection – low pathogenic potential
- Predisposing Factors:
a. Broad spectrum antibiotics
b. Debilitation by use of Therapeutic Measures - Radiation, Steroids
c. Host Immune System Alteration
- Endocrine Disorders - E.g. Uncontrolled Diabetes mellitus
1. MICROSCOPIC EXAMINATION
Histologic Stains:
a. KOH or NAOH ( 10-15% ) b. Lactophenol Cotton Blue ( LPCB )
c. Mucicarmine d. Hematoxylin & Eosin (H &E)
e. Periodic Acid Schiff ( PAS ) f. India Ink or Nigrosin

2. CULTURE
- SDA- Sabouraud's Dextrose Agar
- PDA
- Cornmeal Tween 80
3. Sugar Utilization Test
4. Wood’s Lamp
5. Serology
6. Biochemical Test
7. Animal Inoculation
8. Ouchterlony or ELISA Test
1. SUPERFICIAL MYCOSES

2. CUTANEOUS MYCOSES

3. SUBCUTANEOUS MYCOSES

4. SYSTEMIC MYCOSES

5. OPPORTUNISTIC MYCOSES
Infection limited - DEAD LAYER OF SKIN & HAIR SHAFT
- Skin - involves the STRATUM CORNEUM
- Hair - involves the cuticle
Cellular Immune Response - not involve
Easy to Treat and are of cosmetic problem

A. SKIN
1. PITYRIASIS VERSICOLOR ( AN-AN )
- Chronic, mild infection of S. corneum
- Location: Areas rich in Sebaceous Glands (Upper Torso)
- LESION: HYPER/ HYPOPIGMENTED MACULAR LESION
CHALKY APPEARANCE - SCALES VERY EASILY
- ETIOLOGIC AGENT: MALASSEZIA FURFUR
CLINICAL DIAGNOSIS
a. MICROSCOPY: SKIN SCRAPPING
10-20% KOH , Stained with Calcoflour White
SPAGHETTI & MEAT BALLS APPEARANCE - Diagnostic

b. WOOD’S LAMP - reveals yellow fluorescence

c. CULTURE
1. SABOURAUD’S DEXTROSE AGAR (SDA)
Growth: 2-4 days at 35ᴼC
Yeast-like colonies , creamy consistency

MODE OF MANAGEMENT & TREATMENT

1. Selenium Sulfide - daily application
2. Topical or oral
2. TINEA NIGRA
Chronic & asymptomatic – Stratum corneum
Lesion: Demarcated gray-black macular areas
Etiologic Agent: Exophiala werneckii - Dimorphic fungi
- Dematiaceous
CLINICAL DIAGNOSIS
a. Skin Scrapings with Alkali stain
- Feature: Branched Septate hyphae &
Budding yeast cells melaninized cell walls
b. Culture:
- SDA: Black colonies: pigmented yeasts and hyphae

MODE OF MANAGEMENT AND TREATMENT

1. Keratolytic solutions
2. Salicylic acid
3. Azoles – Antifungal agents
B. HAIR
1. BLACK PIEDRA
- Black nodular infection of the hairs hafts, scalp beard,
moustache, pubic hair - ECTHOTHRIX HAIR INFECTION
- Nodules - contain Asci & ascospores
- Etiologic Agent: PIEDRA HORTAE

MICROSCOPIC CLINICAL FEATURES

1. Pigmented septate hyphae

2. Asci & Ascopores - fusiform and unicellular with

polar filaments

MODE OF TREATMENT:
A. Topical Salicylic acid
B. Azole Cream
2. WHITE PIEDRA
- Pasty cream-colored growth - along infected hair shaft
- Location: Hairs of axilla, beard, moustache, pubic &scalp
- Etiologic Agent: Trichosporon beigelli

CLINICAL DIAGNOSIS
A. MICROSCOPY:
- Septate hyphae that develop into  Arthroconidia
- Sleeve-like Colllarette around the hair shaft

B CULTURE:
- Pasty and white - developed deep radiating furrows
 becoming yellow & creamy
MODE OF TREATMENT
1. Selenium sulfide
2. Thiosulfate
3. Salicylic acid
4. Hyposulfide
5. Miconazole - inhibition of Ergosterol
- Affects the: SKIN, HAIRS AND NAILS
- RESTRICTED TO:
Keratinized layers of integuments & it’s appendages
- REFERRED TO AS:
1. Keratophilic / Keratinophilic Fungi
2. Dermatophytes - Tinea and Ringworm

THREE GENERA OF CUTANEOUS MYCOSES

1. TRICHOPHYTON

2. MICROSPORUM

3. EPIDERMOPHYTON
A.TRICHOPHYTON
SEXUAL FORM: ARTHRODERMA
- Infection: Skin, hairs, & Nails
- MORE MICROCONIDIA than macroconidia

ETIOLOGIC AGENTS:
1. T. mentagrophytes
- GRAPE-LIKE clusters of microconidia
on terminal branch
2. T. rubrum - TEAR-DROP SHAPED microconidia
3. T. tonsurans - CLAVATE microconidia
4. T. schoenleinii - FAVIC CHANDELIER
 T. Mentagrophytes – grape-like
SPIRAL OR CORKSCREW LIKE HYPHAE microconidia & thin-walled macroconidia

CIGAR-SHAPED macroconidia ( Black Arrow)

& GRAPE_LIKE clusters of Microconidia T. SCHOENLEINII –FAVIC CHANDELIER
 T. TONSURANS - NUMEROUS MICROCONIDIA,
T. RUBRUM - PYRIFORM MICROCONIDIA
BORNE SINGLY OR IN CLUSTERS
BORNE SINGLY ON HYPHAE - SINGLE MACROCONIDIUM
B. MICROSPORUM
- Sexual Form: NANNIZIA
- MORE MACROCONIDIA than Microconidia

ETIOLOGIC AGENTS
1. M. canis - Macroconidia with curved or
- HOOKED SPINY TIP
2. M. gypseum - Thinner walled Macroconidia
3. M. audouinii - Thick walled Chlamydospores

C. EPIDERMOPHYTON
- Invade skin and nails
Etiologic agent: E. floccosum
Feature: Fuseaux in Banana Bunch
M. CANIS - MACROCONIDIA WITH CURVED OR M. audouinii – Thick walled Chlamydospores
- HOOKED SPINY TIP

M. gypseum - Ellipsoidal, multiple

Thinner walled Macroconidia
CLINICAL FEATURES
A. ANATOMIC LOCATION

1. Tinea pedis - ATHLETE’S FOOT

- Trichophyton & Epidermophyton

2. Tinea corporis - Entire body - especially the trunk area

- Microsporum, Trichophyton &
Epidermophyton

3. Tinea cruris - Inguinal or Groin area

- JOCK ITCH
- Trichophyton & Epidermophyton
4. Tinea capitis - Scalp and hair
- Endothrix Infection - Spores and hyphae seen inside hair shaft
- WOOD’S LAMP - hairs do not fluoresces
- Cuticle is not affected
TRICHOPHYTON TONSURANS
- Ecthothrix Infection - Spore surrounding exterior the hair shaft
- WOOD’S LAMP - fluoresces green-yellow
ETIOLOGIC AGENTS
1. Microsporum gypseum 2. T. mentagrophytes 3. T. rubrum

5. Tinea barbae - Bearded areas of the face & Neck

- Trichophyton species
6. Tinea manuum - Hands
7. Tinea unguium - Nails
8. Favus - Hair Infection - T, schoenleinii
- Waxy mass of hyphal elements ( Scutuium)
around base of hair follicle at the scalp line
- Microscopy: Hair:
- Degenerative hyphal elements throughout
the hair shaft
- Hairs referred to as : Favic – Diagnostics
B. ECOLOGIC LOCATION
1. ANTHROPOPHILIC
- T. rubrum

2. GEOPHILIC
- M. gypseum

3. ZOOPHILIC
- M. canis - in cats and dogs
- M. nanum - in swine
- M. gallinae - in fowl
- M. equinum - in horses
- M. verrucosum - in cattle
2 BASIC TYPES OF DERMATOPHYTIC INFECTION

1. ACUTE INFLAMMATORY TYPE

- Associated with CMI ( Cell Mediated Immunity )
- Heals spontaneously, respond to treatment

2. CHRONIC / NON-INFLAMMATORY TYPE

- Failure to express CMI
- Relapsing
- Responds poorly to treatment
DERMATOPHYTID REACTION OR ID REACTION
- Lesions on the dominant hand of patients
infected with Dermatophytes
- No fungi can be recovered
- 2nd ary - Immunologic Sensitization to a primary
infection somewhere else
- Does not respond to treatment, will resolve
if primary infection is treated

MODE OF TREATMENT
1. Azole Derivatives
- INTERFERE WITH Cytochrome p450 Dependent
Enzyme Systems at
- Demethylation Step – Lanosterol to Egrosterol
Accidental SC traumatic inoculation of causative fungi
Causative agents - reside in soil and vegetation
Chronic, localized infections - skin and SC tissue
Granulomatous response - occurs at the site of infection
INFECTION CONFINED TO:
- Subcutaneous tissues
- rarely causes systemic disease
Disease Causative organisms Incidence

Sporotrichosis Sporothrix spp. Rare

Chromoblastomycosis Fonsecaea, Phialophora, Rare

Cladophialophora etc.

Phaeohyphomycosis Cladophialophora, Exophiala, Rare

Bipolaris, Exserohilum etc

Mycotic mycetoma Scedosporium, Madurella, Trematosphaeria, Rare

Sporotrichosis
Acremonium, Exophiala etc.

(Entomophthoromycosis) Chromoblastomycosis
Subcutaneous zygomycosis Basidiobolus ranarum Rare
Conidiobolus coronatus

Subcutaneous
zygomycosis
Mycetoma
Rhizopus, Mucor,
Rhizomucor,
Rare

(Mucormycosis)
Phaeohyphomycosis
Lichtheimia,
Saksenaea etc.

Lobomycosis Loboa loboi Rare

Rhinosporidiosis Rhinosporidium seeberi Rare

CHRONIC SUBCUTANEOUS MYCOTIC INFECTION
Characterized by development in tissue of DEMATIACEOUS
(brown-pigmented), planate-dividing, ROUNDED SCLEROTIC
BODIES
MELANINIZED CELL WALLS
LESION: Granulomatous with hyperplasia of epidermal tissue

ETIOLOGIC AGENTS
1. Fonsecaea pedrosoi 6. Others: Wangiella dermatitides
2. Fonsecaea compacta Taniolella bopii
3. Cladosporium carionii
4. Phialophora verrucosa
5. Rhinocladiella aquaspersa
FONSECAEA PEDROSOI
The most common in tropical regions with high humidity
and rainfall rates

CLADOSPORIUM CARRIONII
Frequent in tropical countries with semi-arid regions and
little precipitation such as:
- Cuba
- Venezuela
- Australia
- South Africa
Inoculated by trauma usually at legs or feet
LESIONS: Over months  years
Becomes WART-LIKE AND VERRUCOID OF SKIN
CAULIFLOWER-LIKE NODULES are formed
Crusting abscesses (black dots) of purulent
material appear on surface
Rare: ELEPHANTIASIS - lymphatic obstruction

LOCATION: usually of the LOWER EXTREMITIES

LIMITED TO THE SUBCUTANEOUS TISSUE
No involvement of bone, tendon, or muscle
LESIONS OF CHROMOBLASTOMYCOSIS
Small SCALY PAPULES OR NODULES painless, itchy 
SATELLITE LESIONS - arises and as the disease develops 
RASH-LIKE AREAS- enlarge 
RAISED IRREGULAR PLAQUES - often scaly or verrucose

IN LONG STANDING INFECTIONS

Tumorous- like lesions - cauliflower-like in appearance
OTHER PROMINENT FEATURES INCLUDE:
1. Epithelial hyperplasia
2. Fibrosis and microabscess formation in the epidermis
3. Mimic protothecosis, leishmaniasis, verrucose tuberculosis,
4. Leprosy
5. Syphilis

Note: tissue hyperplasia forming a white verrucoid cutaneous lesion. In Australia,

Chromoblastomycosis due to C. CARRIONII occurs mostly on the hands and arms of
timber and cattle workers in humid tropical forests
 Mycological and histopathological investigations
- Essential to confirm the diagnosis

1. Specimen
DIRECT of scrapings
MICROSCOPY ORorHISTOPATHOLOGY
biopsies placed in 10% KOH and
examined
Does microscopically
not offer for dark spherical
a specific identification cells
of the causative agent

2. Detection of sclerotic body (spherical brown cells) in tissue

NOTE:
sections
Direct microscopy of tissue is necessary to differentiate
between Chromoblastomycosis and Phaeohyphomycosis
3.where
Culture
theon SDA morphology
tissue with chloramphenicol
of the causative organism
is mycelial
4. Dematiaceous identified by characteristic conidial structure
1. DIRECT MICROSCOPY
A. Skin scrapings - using 10% KOH and Parker ink
or Calcoflour white mounts

B. Tissue sections stained using - H&E, PAS digest, and

Grocott's Methanamine silver (GMS)

PHIALOPHORA VERRUCOSA
HISTOLOGICAL EXAMINATION:
Presence of brown pigmented, planate-dividing, rounded
SCLEROTIC BODIES -muriform cells with perpendicular
septations or so-called “COPPER PENNIES” - characteristic
feature
2. CULTURE
SABOURAUD'S DEXTROSE AGAR - primary isolation
Dematiaceous fungi
(+) POSITIVE CULTURE in order to significant needs
to be supported by:
A. Clinical history
B. Direct Microscopic evidence
MICROSCOPY
Ascending to erect, olivaceous-green, apically branched,
ELONGATE CONIDIOPHORES with branched ACROPETAL
CHAINS of conidia
CONIDIA - pale olivaceous, smooth-walled or slightly
‘verrucose, LEMONIFORM TO FUSIFORM

BULBOUS PHIALIDES
With large collarettes and minute, hyaline conidia
formed on nutritionally poor media
EPIDEMIOLOGY
C. carrionii - recognized agent of Chromoblastomycosis
Isolated from soil , Eucalyptus fence posts

GEOGRAPHIC LOCATIONS
Most prominently in tropical and sub-tropical regions
Australia, Brazil, China, Mexico, N. Venezuela, Madagascar
- which are rife with plants inhabited by the fungus

INCIDENCE
Most cases target MALES over the age of 30
- Predominant work in the agricultural industry
- Directly work with plants commonly colonized by fungi
MINOR CASES OF CHROMOBLASTOMYCOSIS can be resolved by:
1. SURGICAL EXCISION
2. CHEMOTHERAPY WITH :
a. Flucytosine b. Itraconazole
3. COLD THERAPY (CRYOSURGERY)
- Applying cool liquid nitrogen onto lesions effective if
combined with antifungal therapy & chemotherapy
4. SERIOUS CASES
6-12 months prolonged period of treatment
- Itraconazole and terbinafine
CURE RATES: 15-80% of cases
C. carrionii- cure rates higher than infections caused by
Fonsecaea pedrosoi
CHRONIC INFECTION: Txt. is ineffective - resulting in high
RELAPSE RATES
Chronic infection: SKIN, FASCIA, BONES OF HANDS OR FEET
Cutaneous fungal granulomas have a confusing array
of names
- Eumycotic mycetomas
- Maduromycosis - MADURA FOOT
- Chromoblastomycosis

MODE OF TRANSMISSION:
Traumatic inoculation - contaminated twigs, thorns, or leaves
ETIOLOGIC AGENTS: MYCELIAL(SOIL) FUNGI - ASCOMYCOTA
1. Drechslera 2. Allescheria 3. Cladosporium
4. Madurella grisea, mycetomatis 5. Fonsecaea
6. Pseudallescheria boydii 7. Exophiala jeanselmei
8. Acromonium falciforme 9. Fusarium & Aspergillus

SUPPURATIVE & GRANULOMATOUS SC MYCOSIS

- DESTRUCTIVE OF CONTIGUOUS BONE, TENDON, & SKELETAL
MUSCLE
- Presence of DRAINING SINUS TRACTS
- Grossly visible pigmented grains or granules - extruded
- GRAINS - microcolonies of fungi
1. EUMYCOTIC MYCETOMA
Pseudallescheria boydii - most common agent

2. ACTINOMYCOTIC MYCETOMA
Nocardia brasiliensis - most common

Fungi - characteristically produces pigmented brown to black

- known as DEMATIACEOUS (MELANIZED) FUNGI
Melanin pigment - deposited in the cell walls
SMALL HARD PAINLESS NODULE 
Over time soften on the surface 
ULCERATE - viscous discharge, purulent containing 
GRANULES OR GRAINS - HALLMARK OF MYCETOMA
Slowly SPREADS to adjacent tissue 
Bone - often causing considerable deformity
Sinuses continue to discharge serosanguinous fluid

RANGE OF INFECTIONS FROM :

Superficial  Subcutaneous  Deep (visceral) infection
Characterized by: Presence of Dematiaceous hyphal and/
or yeast-like cells in tissue
1. Microscopic examination of crushed granule
2. Culture on fungal media

MICROSCOPY
A. Serosanguinous fluid with granules
- 10% KOH and Parker ink or Calcoflour white mounts

B. Tissue sections stained - H&E, PAS digest,

Grocott's Methanamine silver

C. Cytologic diagnosis is limited to:

- Identifying granulomatous or pyogranulomatous
inflammation with one or more fungal forms
- HYPHAE - SPHERULES
A.K.A.: ROSE GARDENER’S DISEASE
ETIOLOGIC AGENT: Sporothrix schenckii - DIMORPHIC FUNGUS
Kingdom: Fungi
Division: WITH:
ASSOCIATED Ascomycota
Plants, grasses, trees, sphagnum moss
Class: Sordariomycetes
and rose bushes
Order: Ophiostomatales
GROWTH PATTERN: Family: Ophiostomataceae
1. At ambient temperature
Genus: Sporothrix
- Grows as a MOLD with branching septated hyphae
Species: S. schenckii
and conidia
2. In tissues or in vitro at 35-37° C
- It appears as a BUDDING YEAST
TRANSMISSION: SKIN TRAUMA
LOCATION: Generally located on EXTREMITIES
- Children: often present with facial lesion
- 75% lesions
1. LYMPHOCUTANEOUS & GRANULOMATOUS NODULE
 progress to form necrotic lesions
 Cord-like draining lymphatics with multiple
subcutaneous nodules and abscesses

NOTE: Rarely disseminates - occur in immunocompromised

1. FIXED CUTANEOUS SPOROTRICHOSIS
Most common form
SITE: Hand/arm after handling contaminated plant matter
LESION: Start - painless palpable nodules & ulcerate
- contain single nodule, less progressive
- seen in endemic areas

2. LYMPHOCUTANEOUS SPOROTRICHOSIS
Develop at site of implantation 
Secondary lesions appear along lymphangitic channels
follow same indolent course as the primary lesion
No systemic symptoms are present
3. PULMONARY SPOROTRICHOSIS
INHALATION OF CONIDIA
Nonspecific include:
Fever, productive cough, shortness of breath,
Upper lobe lesion, chest pain, and weight loss
Hemoptysis - can be massive and fatal

3. DISSEMINATED SPOROTRICHOSIS
Infection spreads to other parts of the body
- Bones, joints, or the central nervous system
Usually affects people - weakened immune systems,
E.g. HIV infection
SPECIMEN: Biopsy material or exudate from ulcerative lesion

A. MICROSCOPIC EXAMINATION
1. KOH (Potassium Hydroxide)
YEASTS are rarely found
2. Calcoflour white stain

3. Gomori Methanamine silver

YEASTS 3-5 µm spherical
or elongated
4. PAS (Periodic acid Schiff stain)
 Small NARROW BASE BUDDING YEAST CELLS (2-5um). Note
they are often present in very low numbers and may be
difficult to find. PAS and GMS stains are essential.
5. H & E Stain- ASTEROID BODY / CIGAR-BODIES or
SPLENDORE - HOEPPLI PHENOMENON
- Central basophilic yeast cell is surrounded
by eosinophilic material
- Not specific for Sporothrix can be seen
also in:
- Zygomycetes (Mucorales)
- Aspergillosis
- Blastomycosis
- Candida
- usually seen in endemic areas
6. CULTURE
Most reliable method
Sabouraud's agar with chloramphenicol
- incubated at 25-30° C

YOUNG COLONIES
- Blackish, shiny, wrinkled and fuzzy with age
- Branching septated hyphae with small conidia

IDENTIFICATION: Confirmed by growth at 35°C

and conversion to yeast form
USUALLY SELF LIMITED
1. Saturated Solution of Potassium Iodide (SSKI) in milk
- for cutaneous sporotrichosis
NOTE: SSKI and azole - not used during pregnancy

2. Oral Itraconazole - Treatment of choice

Localized sporotrichosis - taken for 3 to 6 months

3. Amphotericin B IV
Preferred treatment – for severely ill patients
Total of at least 1 year of antifungal treatment
Pulmonary sporotrichosis - may need surgery to cut away
infected tissue
Deep infections due to Dematiaceous fungi in SC tissues

CAUSATIVE AGENTS: MYCELIAL FORMS

- GRAIN (MYCOTIC MYCETOMA) or SCLEROTIC BODY

1. Exophiala jeanselmei 2. Phialophora richardsiae

3. Bipolaris spicifera 4. Wangiella dermatitidis
5. Exserohilum 6. Cladophialophora
7. Verruconis 8. Aureobasidium
9. Curvularia 10. Alternaria
CLINICAL FORMS RANGE FROM:
1. Localized superficial infections - Stratum corneum TINEA NIGRA
2. Subcutaneous cysts - PHAEOMYCOTIC CYST
3. Invasion of the brain
:
A. SUBCUTANEOUS PHAEOHYPHOMYCOSIS
Worldwide distribution: Affects ADULTS
Traumatic implantation of fungal elements
MOST COMMON ETIOLOGIC AGENTS:
1. Exophiala jeanselmei
2. Wangiella dermatitidis
Verrucous lesions - in immunosuppressed patient
B. PARANASAL SINUS PHAEOHYPHOMYCOSIS
Sinusitis caused by:
1. Bipolaris 2. Exserohilum 3. Curvularia 4. Alternaria
In patients with a history of allergic rhinitis or
immunosuppression

C. CEREBRAL PHAEOHYPHOMYCOSIS
Rare infection - in immunosuppressed patients
INHALATION OF CONIDIA
Cladophialophora bantiana infection
- reported without any obvious predisposing factors
- fungus is NEUROTROPIC
- Dissemination to sites other is rare
CLINICAL MATERIAL
Skin scrapings, tissue biopsy - visceral organs, sputum and
bronchial washings, CSF, pleural fluid, blood and indwelling
catheter tips

1. DIRECT MICROSCOPY
Specimens -
A. Using 10% KOH & Parker ink or Calcoflour white mounts
B. Tissue sections stained with H&E, PAS digest, and
Grocott's Methanamine silver (GMS)
MORPHOLOGIC DESCRIPTION
Presence in tissue of brown pigmented fungi
Branching septated hyphae, planate-dividing, rounded
sclerotic bodies - PRESUMPTIVE

NOTE: Remember direct microscopy or histopathology does

not offer a specific identification of the causative agent
Infection with members of Zygomycetes
Fast growing, largely saprophytic - cosmopolitan distribution

MEDICALLY IMPORTANT ORDERS AND GENERA

1. MUCORALES AND MORTIERELLALES

MUCORMYCOSIS = Subcutaneous & Systemic Zygomycosis
a. Rhizopus b. Lichtheimia c. Rhizomucor
d. Mucor e. Cunninghamella f. Saksenaea,
g. Apophysomyces h. Cokeromyces i. Mortierella

2. ENTOMOPHTHORALES
ENTOMOPHTHOROMYCOSIS - causing SC Zygomycosis
a. Conidiobolus b. Basidiobolus
Zygomycosis - in debilitated patients
- most acute & fulminate fungal infection known

AREA OF INVOLVEMENT:
1. Rhino-facial-cranial area
2. Lungs
3. Gastrointestinal tract
4. Skin
5. Other organs - less commonly
ASSOCIATED RISK FACTORS
1. Acidotic diabetes 2. Starvation 3. Severe burns
4. IV drug abuse 5. Leukemia 6. Lymphoma
7. immunosuppressive therapy 8. Renal transplant
9. Therapy with desferrioxamine
10. Use of cytotoxins & corticosteroids
11. Major trauma

PREDILECTION
Infecting fungi invades vessels of the arterial system 
EMBOLIZATION & NECROSIS of surrounding tissue

NOTE: A rapid diagnosis is extremely important if

management and therapy are to be successful
1. RHINOCEREBRAL ZYGOMYCOSIS
Infections - begin in the PARANASAL SINUSES
Inhalation of SPORANGIOSPORES
AREA: orbit, palate, face, nose or brain

2. PULMONARY ZYGOMYCOSIS
Infections - inhalation of SPORANGIOSPORES
- Pulmonary infraction and necrosis with
cavitation
3. GASTROINTESTINAL ZYGOMYCOSIS
Rare associated with severe malnutrition in children
Primary infections - ingestion of fungal elements
- Presents with necrotic ulcers

4. CUTANEOUS ZYGOMYCOSIS
E.g. Extensive burns, trauma
Lesions varied morphology
- plaques, pustules, ulcerations, deep abscesses
and ragged ZYGOMYCOSIS
5. DISSEMINATED necrotic patches
Originate from any of the above, especially in severely
debilitated patients with hematological malignancies,
burns, diabetes or uremia

6. CENTRAL NERVOUS SYSTEM ALONE:

IV drug abuse
Traumatic implantation leading to brain abscess
A. Scrapings, sputum and exudates
- 10% KOH & Parker ink or Calcoflour mounts
B. Tissue sections stained - H&E and GMS

1. DIRECT MICROSCOPY
If (+) from a sterile site, considered significant
DESCRIPTION:
COENOCYTIC OR ASEPTATE THIN-WALLED HYPHAE
WITH IRREGULAR BRANCH
Asexual spores : Conidia
SPORANGIOSPORES IN SPORANGIA
Sporangiophores - simple or branched

Sexual sores: producing a thick-walled sexual

resting spore = ZYGOSPORE
Chronic, localized, sub-epidermal infection
CAUSATIVE AGENTS: LACAZIA LOBOI

CHARACTERIZED BY PRESENCE OF:

Keloidal, verrucoid, nodular lesions or
by vegetating crusty plaques and tumors

LESIONS: masses of SPHEROIDAL, YEAST-LIKE CELLS

NO SYSTEMIC SPREAD
The disease has been found in:
1. HUMANS AND DOLPHINS

GEOGRPAHIC LOCATION: Restricted to Amazon Valley, Brazil

LESIONS:
Small, hard nodules resembling keloids
Slowly dermal spread : Develop over a period of many years
Older lesions - verrucoid and ulcerate
Spread to other areas of the skin
- further trauma or autoinoculation
Areas of involvement quite extensive
LOCATIONS: Arms, legs, face or ears

CASES: 90% = MEN, mostly in farmers and other high

Clinical material: Tissue sample obtained by curettage
or surgical biopsy
1. DIRECT MICROSCOPY
Presence of chains of darkly pigmented, spheroidal,
yeast-like organisms is typical for LOBOMYCOSIS
ETIOLOGIC AGENT: RHINOSPORIDIUM SEEBERI
DISEASE: RHINOSPORIDIOSIS - chronic subcutaneous mycosis

LESIONS: Formation of polypoid masses at nasal mucosa,

conjunctiva, genitalia, and rectum
RESERVOIR: Fish and aquatic insects

MICROSCOPIC DESCRIPTION:
Forms SPHERULES in infected tissue ,filled with endospores

NOTE: Microorganism cannot be cultured in vitro on artificial

media. Based on these findings, some investigators
classified it as an ASCOMYCETOUS FUNGUS
Others preferred the term "FUNGUS-LIKE"
Do not normally cause disease in healthy people
Cause disease in people with weakened immune defense
Organisms involved - very low inherent virulence

WEAKENED
SPECIES IMMUNE
CAUSING FUNCTION: INFECTIONS:
OPPORTUNISTIC
1.-Candida
Inherited immunodeficiency diseases
2.- Cryptococcus
Cancer chemotherapy
3.-Aspergillus
Corticosteroids
4.- Mucor
Immunosuppressants
& Rhizopus
5.- Pneumocystis
Radiation therapy
6.- Penicillium
Infections - E.g. HIV diabetes, Advanced age, malnutrition
Opportunistic mycoses are infections due to fungi with low inherent
virulence which means that these pathogens constitute an almost limitless
number of fungi. These organisms are common in all environments

Disease Causative organisms Incidence

Candidiasis Candida, Debaryomyces, Kluyveromyces, Meyerozyma, Pichia, etc. Common

Cryptococcosis Cryptococcus spp. especially C. neoformans/C. gattii Rare/Common

Aspergillosis Aspergillus fumigatus complex, A. flavus, complex, Rare

A. terreus complex etc.

Scedosporiosis Scedosporium and Lomentospora. Rare

(Pseudallescheriasis)

Zygomycosis Rhizopus, Mucor, Rhizomucor, Rare

(Mucormycosis) Lichtheimia etc.

Hyalohyphomycosis Penicillium, Paecilomyces, Rare

Beauveria, Fusarium,
Scopulariopsis etc.

Phaeohyphomycosis Cladophialophora, Exophiala, Bipolaris, Exserohilum etc. Rare

 - Oval yeast with a single bud
- Tissues - forms pseudohyphae
- PSEUDOHYPHAE - elongated yeasts, not true hyphae
- Most important species
- MEMBER OF INDIGENOUS MICROBIAL FLORA OF HUMANS
GIT - gastrointestinal tract
URT- upper respiratory tract
BUCCAL CAVITY
VAGINA

DISEASE: Localized  Disseminated disease

 Can be a normal inhabitant of mucocutaneous surfaces
& does not necessarily signal the presence of disease

A. DISEASES IN NORMAL HOSTS

1. Oral thrush 2. Candida intertrigo - skin folds
3. Vulvovaginitis 4. Diaper rash
5. Perleche (angular cheilitis)- seen in malnutrition

B.
5. IMMUNOCOMPROMISED - AIDS
Septicemia - due to indwelling or neutropenic patients
catheters
1. Esophagitis E.g. subclavian catheter
2.
6. Thrush spreadscandidiasis
Disseminated down GI tract
3. Endocarditis
7. Chronic mucocutaneous candidiasis
4. IV- drug
Localusers
infection due to T-cell deficiency
- Systemic infection is due to neutropenia
Occurs in different forms at different temperatures:
1. IN VITRO - Mostly YEAST at 20 - 25° C

2. IN VIVO - Yeast, hyphae and pseudohyphae at 37° C

- GERM TUBE FORMATION at 37°C - DIAGNOSTIC

TRUE HYPHAE sprout from yeast seen on light microscopy

1. Nystatin & Nystatin - for superficial infection
2. Fluconazole
3. Oropharyngeal & Esophageal Thrush DOC: Fluconazole
4. Mucocutaneous Candidiasis - Ketoconazole
5. Disseminated candidiasis - Amphotericin B or fluconazole
with or without Flucytosine
6. Oral Thrush - Oral Clotrimazole troches
- Nystatin Swish and swallow
7. Fluconazole - Prevention in high risk patients
- BM transplantation
- Neonates
8.Vulvovaginitis - Clotrimazole
Fungal infection by fungi in the order Mucorales

MEMBERS OF THE GENERA

1. Mucor 2. Rhizopus
3. Lichtheimia (formerly Absidia) 4. Cunninghamella

DISEASE: Characterized by hyphae growing in & around BV

Life- threatening in diabetic or severely
immunocompromised

ETIOLOGIC AGENT: Rhizopus oryzae - most common

REDUCTASE - Ketone enzyme, allows them to thrive in high
glucose, acidic conditions
Serum from individuals in diabetic ketoacidosis
stimulates growth

ANGIOINVASIVE - infarction of infected tissues hallmark of

invasive disease
1. RHINO-ORBITAL-CEREBRAL MUCORMYCOSIS
- most common

2. PULMONARY MUCORMYCOSIS
BOTH: Acquired by the inhalation of spores.
INFECTION IN SUSCEPTIBLE INDIVIDUALS
Begins in the nasal turbinates or the alveoli

3. GASTROINTESTINAL MUCORMYCOSIS

4. CUTANEOUS MUCORMYCOSIS
ASSOCIATED RISK FACTORS FOR INVASIVE MUCORMYCOSIS
Predisposes to infection & influences the clinical presentation
1. Diabetes mellitus, particularly with ketoacidosis
2. Treatment with glucocorticoids
3. Hematologic malignancies
4. Hematopoietic cell transplantation
5. Solid organ transplantation

RHINO-ORBITAL-CEREBRAL MUCORMYCOSIS
Frequency of symptoms and signs
1. Fever - 44 percent
2. Nasal ulceration or necrosis - 38 percent
3. Periorbital or facial swelling - 34 percent
4. Decreased vision - 30 percent
5. Ophthalmoplegia - 29 percent
1. SERUM ASSAY TESTS
a. 1,3-beta-D-glucan assay
b. Aspergillus Galactomannan assay
BOTH: Used in patients suspected of having invasive fungal
infection

2. POLYMERASE CHAIN REACTION (PCR)

-Based techniques on histologic specimens – Investigation

3. MATRIX-ASSISTED LASER DESORPTION IONIZATION-TIME

OF FLIGHT (MALDI-TOF) MASS SPECTROMETRY
- Can be used to identify causative species - culture specimens

4. CULTURE
APPROACH : TREATMENT COMBINATION

1. ANTIFUNGAL THERAPY
a. IV amphotericin B - DRUG OF CHOICE FOR INITIAL THERAPY
b. Posaconazole or Isavuconazole
Step-down therapy for patients who responded to
amphotericin B
Salvage therapy - not respond to or cannot tolerate
amphotericin B

2. SURGICAL DEBRIDEMENT OF INVOLVED TISSUES

Aggressive surgical debridement of involved tissues
Leads to disfigurement
MOT: Inhalation of CONIDIOSPORES, NOT DIMORPHIC
Distribution: Soil, food, compost, Agricultural building,
Air vents, Offices
MANIFESTATION: Mild Allergies  Serious Disseminated Dse.
Can infect - All body tissues

PATHOGENIC SPECIES
1. A. fumigatus and A. flavus
- produces AFLATOXIN - A toxin and a carcinogen

2. A. fumigatus and A. clavatus

Species causing allergic disease
A. fumigatus - exists only as molds, not dimorphic
SEPTATE HYPHAE and forms V- SHAPED BRANCHES
1. ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS
Asthma-like allergic reaction in airways proximal
Bronchiectasis mucus plugs form
Type I and type IV Hypersensitivity
TREATMENT
- Systemic corticosteroids
- Oral Itraconazole

2. ASPERGILLOMA
Seen in TB patients (or other granulomatous disease)
"FUNGUS BALL" forms in pre-existing lung cavities
TREATMENT : Surgery
3. INVASIVE ASPERGILLOSIS
- Infection of the lungs & paranasal sinuses
- immunocompromised
- Pleuritic pain, hemoptysis
- Infiltrate seen on radiograph and CT
- May disseminate - brain, kidneys, liver, heart, and bones

- TREATMENT:
Strongest antifungals including
A. Voriconazole
B. Amphotericin B
C. Caspofungin
TOXINS
- Aspergillus produces AFLATOXIN - causes liver damage
and liver cancer
- AFLATOXIN B1
Causes : G:C -> T:A mutation in codon 249 of p53
increased risk of hepatocellular carcinoma
1. MICROSCOPY
Monomorphic SEPTATED HYPHAE BRANCH AT ACUTE
ANGLES (V- SHAPE) fruiting bodies are rare
Catalase-positive

2. CULTURE
 CONIDIA

VESICLE

HYPHAE

METULE

PHIALIDE

CONIDIOPHORE
PENICILLIUM MARNEFFEI
Dimorphic & Pathogenic Invasive Fungus
Pulmonary Disease: INHALATION OF CONIDIA
3rd Most Common Disease - AIDS in S.E. Asia - Emerge
Early Indicator: Particular Geographic Area
- Thailand, China
Behind PTB & Cryptococcosis
Serious Disseminated Infection
Skin Lesions : Papular in AIDS
Molluscum contagiosum-like lesions
Hematogenous Dissemination

Infection - Mononuclear phagocytic System

- Mimics: Clinical Manifestations
1.Tuberculosis
2. Leishmaniasis
3. Histoplasmosis
4. Cryptococcosis

Isolated – Bamboo Rats & Occasionally – Soil

INHALATION OF CONIDIA
PROBABLY AIDS DEFINING INFECTION
Primary Site of Infection  RES = RETICULOENDOTHELIAL SYSTEM

1. Fever, chills, malaise

2. Cough
3. CXR - Pulmonary Infiltrates
4. Lymphadenopathy
5. Hepatomegaly and splenomegaly
6. Blood - Leukopenia & Thrombocytopenia
 Blood, Tissues, skin lesions, Lymph node, Bone marrow
Broncho-alveolar lavage (BAL)
Use of Special Stains

1. MICROSCOPY
- ELLIPTICAL FISSION YEAST
- Inside Phagocytes (Buffy Coat BM, lesions, LN)
- INTERNAL CROSS-WALLS or TRANSVERSE SEPTA
NO BUDDING CELLS
- DIAGNOSTIC
DIMORPHIC FUNGI
1. MOLD FORM - 25ᴼ C - Sporulates

2. ELLIPTICAL YEAST CELLS

- 37ᴼ C - Fission
- Intracellular inside macrophages and resembles
Histoplasmosis
- Corda’s Phenomenon - Distal Conidia larger than
proximal to the vesicle
- Colonies - Blue-green in color & powdery surface
2. Culture - Sabouraud's dextrose Agar
- BLUE-GREEN TO YELLOWISH COLONIES
- Produces : Soluble Red or Rose colored Pigment
at 25ᴼC = Diagnostic
3. Fluorescent Antibody Staining - For Diagnosis
4. Immunoblotting methods
5. PCR - Polymerase Chain reaction
6. Nucleic Acid Based Testing - Confirm identification

1.Amphotericin B with or without Flucytosine

- Treatment of choice
- Amphotericin x 2 weeks ; followed by Itraconazole x 10 wks.
2. Prevention of Relapse in AIDS
- Lifelong treatment - Itraconazole
ERA OF AIDS
- Most important Opportunistic fungal pathogen
- Disease almost Diagnostic for AIDS
- Primary Indicator of AIDS

Discovered - 1909
- Found in Healthy humans
- Thought: Developmental Stage of Trypanosomes
- 1988 - Reclassified  YEAST
- Molecular & Genetic Evidence
- 1999 - Name change to PNEUMOCYSTIS JIROVECI
- Worldwide
- Harmless Commensal of URT
- DIFFERS FROM OTHER FUNGI
- Lacks Ergosterol
- Obligate Parasite

1. Mild respiratory infection during childhood

2. Interstitial pneumonitis(PCP) - Pneumocystis Pneumonia
- Hallmark
Plasma Cell Infiltrates - Most common presentation
CXR: Ground glass Appearance Interstitial infiltrates
Primarily AIDS
Hospitalized infants - premature & malnourished
Elderly
Cancer & Organ Transplant Recipients
- Under immunosuppressive drugs

1. Corticosteroid therapy
2. Transplant recipients
3. Antineoplastic therapy
4. Transplant recipients

Spleen, Lymph nodes, Bone marrow

Liver, S.I. GUT, eyes, ears, bone, thyroid
1. SEXUAL PHASE

2. ASEXUAL PHASE
Human Infection:
a. Free trophic forms
b. Uninucleated Sporocyst or Thick Walled Cyst
- 8 ovoid- fusiform intracystic bodies  Ruptures 
Trophozoites  Asexual reproduction (Fission) or
 Sexual Reproduction - Encystation
P. jirovecii  Inhalation of Spores  Lining of Alveoli
In AIDS patients
- Alveolar infiltrates Plasma Cells 
Epithelial Slough off  Foamy exudates 
Interstitial Plasma Cell Pneumonias
Plasma cells - Absent in AIDS related Pneumocystis
pneumonia
Blockade of oxygen exchange interface  Cyanosis
DEATH  Respiratory Failure
1.Bronchoalveolar Lavage - (BAL) = 90-100% Sensitive
2. Sputum, Trans-bronchial aspirate,
3. Brush biopsy, Open lung biopsy

A. Microscopic Examination - CYSTS OR TROPHOZOITES

Stains: Giemsa, Toluidine blue, Methanamine silver
Calcoflour white

B. Culture - Not possible - Non-Cultivable

D. Serologic Test
Used for epidemiological Study - Establish prevalence
of Infection
1. Direct Fluorescent Method - Monoclonal Antibody
- Rapid and Emerging method

E. CX- Ray -Supports Diagnosis

NOTE: If retroviral treatment is delayed - Major cause of Death
in AIDS patients
MORTALITY : 100 % - IF UNTREATED
1. Acute Cases - Trimethoprim- Sulfamethoxazole
2. Isothionate -very effective
3. Aerosolized pentamidine - particularly for AIDS patients
4.Trimethoprim-Dapsone
5. Clindamycin- Primaquine
6. Atovaquone
7. Trimetrexate
Basidiomycete Family - MONOMORPHIC ORGANISMS
(Not Dimorphic)
Filobasidiella neoformans - Sexual form

OTHER NAMES:
Busse- Buschke Disease
Turolosis
European Blastomycosis

MOST COMMON CAUSE  FUNGAL MENINGITIS

Worldwide Distribution - Ubiquitous saprophytes

C. neoformans - Soil contaminated with avian excreta
C. gattii - Tropical & Subtropical Regions - Eucalyptus Trees
Both: Pathogenic  Immunocompetent Individuals
1. C. neoformans variant neoformans
- Worldwide- Immunocompromised hosts
- CRYPTOCOCCOSIS - 50% of cases
- Capsular Serotypes : A, D, AD
- Variants : Serotype A - C. grubii
Serotype D - neoformans
- More mortality

2. Cryptococcus gattii
- Immunocompetent individuals
- Outbreaks in California - AIDS patients
- Serotypes: B and C
- Associated with CNS GRANULOMA FORMATION 
Severe Neurologic complication
1. YEASTFORM
- ONLY ENCAPSULATED YEAST
- True Yeast - Spherical-Ovoid
- SMALL CONSTRICTED BUDS - NARROW BASED
- Single or rarely multiple buds
- No hyphae nor pseudohyphae

INDIA INK SMEARS

- Variable in size, spherical - elliptical

NIGROSIN STAIN
- Huge clear halo - Extracellular Polysaccharide Capsule
- Distinctive Marker

MAYER MUCICARMINE STAIN -RED

1. A and D - C. neoformans variant neoformans
- Causes of most of the Infections
2. B and C - C. neoformans variant gatti
- CRYPTOCOCCOMA
- Discrete nodules
- More Common - C. gattii
- Solid fungal mass - Cerebral Hemisphere
Cerebellum
Rarely - Spinal cord
- MISTAKEN FOR CEREBRAL TUMOR

DISTRIBUTION: Wild & domesticated birds

Pigeons carry C. neoformans
Birds do not get infected
Entry: Respiratory  INHALATION OF YEAST OR BASIDIOSPORES
Pulmonary Infection
 Subclinical
 Flu-like Symptoms
Men >>> Infections than women
Self limiting - Immunocompetent
MIMICS TUBERCULOSIS

INFECTION IS BY ENHANCE BY:

1. Capsule - provides phagocytic-resistant
2. Laccase
3. Melanin production - inhibits phagocytosis
- Fontana- Masson Stain
4. CNS PREDILECTION
Inhalation: Aerosolized Spores or Dried Yeast forms
Pigeon and chicken droppings
Proliferates - High nitrogen content - Droppings
Highest rate - AIDS patients

DEFECTIVE CELLULAR IMMUNITY

- CD4+ Lymphocytes = < 100/mm (<2oomm²)
- RISK OF DISSEMINATED & CNS CRYPTOCOCCOSIS

- C. var. neoformans & var. grubii - Worldwide

- Soil contaminated with avian excreta

- C. gattii - Tropical & subtropical climates

- Associated : Bark of Eucalyptus Tree
Aggravated by: Abnormalities of T lymphocyte function
CLINICAL MANIFESTATIONS OF MENINGEAL SIGNS
1. Head ache, nausea and vomiting
2. Low grade fever
3.Visual abnormalities - blurring f vision
4. Lethargy
5. Coma - fatal

AIDS PATIENTS: 3- 20%  Develop Cryptococcosis

Manifestations: Chronic meningitis
Meningoencephalitis
DISSEMINATED FORM
Involvement : Skin, Mucosa
Organs - Adrenals
Prostate glands
Bones, eyes
1. PULMONARY CRYPTOCOCCOSIS
- Asymptomatic  Fulminant
- Pneumonia: Bilateral, lung nodules Diffuse
Cavitation - rare
- Impaired Immunity  Yeast escape  Circulation

2. CRYPTOCOCCAL MENINGITIS
- Highly Neurotropic: Brain & meninges
- TUMOR-LIKE MASSES
- Headache, meningismus, paralysis
Eye disturbances
Paralysis, seizures, coma
- Most common form of cryptococcal infection
3. DISSEMINATION
- Few cases: Skin, Bones, Viscera, prostate
Ocular Infection - Chorioretinitis, vitritis,
Ocular nerve invasion

4. CUTANEOUS CRYPTOCOCCOSIS
- Rare case
- Transcutaneous Inoculation
- 10-15% - Mimic Molluscum contagiosum
- AIDS - 2nd most common manifestation
- Location of lesions: Head & Neck

Mortality: 30%
1. INDIA INK STAIN
- Specimens: CSF, tissue biopsy, bronchial washings
- CSF = ENCAPSULATED BUDDING YEAST CELLS
NO PSEUDOHYPHAE FORMATION

2. CULTURE
- Blood and CSF
- GROWTH: Flat shiny mucoid colonies color
Creamy to tan & pink colonies
- CSF findings mimic like Tuberculosis
2. UREASE TEST (+)
3. Carbohydrate Assimilation Testing
4. Growth on Niger Seed Agar
C. neoformans - colonies - brown to black
5. Phenoloxidase Activity - C. neoformans = (+)
6. SEROLOGIC TESTS
- Cryptococcal Antigen detection in CSF
- Rapid, sensitive & specific
a. Latex Agglutination - Best Serologic Test
b. Enzyme Immunoassay Kits

7. DNA Probes & FAT

1. CRYPTOCOCCAL MENINGITIS & DISSEMINATED FORMS
a. Induction Therapy - Amphotericin + Flucytosine x 2 weeks
- Repeat CSF Examination
b. Consolidation Therapy - Oral fluconazole or Itraconazole
x 8 weeks
Repeat CSF Analysis

2. AIDS PATIENTS
Lifelong Maintenance - Fluconazole or Itraconazole
AIDS patients -Not totally cured
Relapses - Frequent with fatal outcome
Rapid resistance with Fluconazole
Avoid contact with Birds
3. IMMUNODEFICIENCY OTHER THAN AIDS
- Amphotericin B & Flu cytosine

4. IMMUNE COMPETENT
- Fluconazole & Itraconazole
- Treatment reduces the morbidity & cure in
non- immunosuppressed is expected
• Fungi affecting internal organs
• Mode of Entry: Lungs (main), GUT, skin, paranasal sinuses
• Spore inhalation – Lungs to different parts of the body
• Spread via the bloodstream to multiple organs
 Multi-organ failure & eventual death of patient
• NOT CONTAGIOUS
 ETIOLOGIC DISEASE SAPROPHYTIC PARASITIC PHASE TREATMENT
AGENT PHASE (YEAST FORM)
(MOLD FORM)

Histoplasma Darling’s Septate mycelial Small single budded AMPOTHERICIN B

capsulatum Disease microconidia; intracellular yeast
Histoplasmo- Tuberculate
sis macroconidia
Colonies; white &
buff
Blastomyces North Septate mycelium; Budding yeast with broad AMPOTHERCIN B
dermatitides American Pyriform conidia, based bud with double
Blastomycosis globose or double contoured wall
Colonies: white &
buff
Coccidioides Coccidioido- Thick-walled Round wall spherules;;
immitis mycosis Arthroconidia with endospores
San Joaquin Barrel shape
Valley fever

Paracoccidioi- Similar to lollipop Mariner’s wheel

des brasiliensis form Multiple blastoconidia
Paracoccidioid
Like Blastomyces budding from the sides of
omycosis
blastospores
South
Mikey Mouse cap
American
Blastomycosis
 P. BRASILIENSES
B. DERMATITIDIS PYRIFORM CONIDIA LOLLIPOP FORM MORLD

H. CAPSULATUM
C. IMMITIS ARTHROSPORES TUBERCULATE MACROCONIDIA
C. IMMITIS SPHERULES H. CAPSULATUM
WITH ENDOSPORES INTRACELLULAR YEAST CELLS

P. BRASILIENSES B. DERMATITIDIS
MARINER’S WHEEL BROAD BASED BUDS
TREATMENT OF HISTOPLASMOSIS
1. Itraconazole - Oral - Lung Lesions
2. Amphotericin B – Disseminated Infection Days – wks.
3. Fluconazole - Meningitis
4. Ketoconazole - Mild Infection
5. Maintenance Therapy - AIDS patients
TREATMENT OF COCCIDIOIDOMYCOSIS
1. Amphotericin B - Drug of Choice
2. Fluconazole - DOC: Meningitis
3. Wearing of Protective mask
- Endemic areas - Prevent exposure to spores

TREATMENT FOR PARACOCCIDIOIDOMYCOSIS

1. Amphotericin B or Ketoconazole
2. Sulfa drugs
3. DOC - Itraconazole - orally x several months
1. Jawetz Microbiology
2. Murray Medical Microbiology
3. Center for Disease Control (CDC)
4. Microbiology - Baveja
5. Koneman Microbiology
6.Foundations in Microbiology - Talaro
7. Microbiology - Bauman, Baron, Prescott