MICROBIOLOGY LECTURE M2 – Superficial Mycoses some perifollicular patches are evident on the upper abdomen.

(A)
Lecture and Notes by Dr. Ng
USTMED ’07 Sec C – AsM

SUPERFICIAL MYCOSES
Hyperpigmented Tinea
Versicolor
INFECTIONS DUE TO Malassezia Species
Perifollicular round patches
of hyperpigmented lesions
3 Species of Medical Importance are tightly grouped on the
• Malassezia furfur upper back. (B)
• Malassezia pachydermatis
• Malassezia sympodialis

MALASSEZIA FURFUR
- causes Pityriasis versicolor – a chronic, usually Hyperpigmented Tinea
asymptomatic fungal infection of the stratum corneum Versicolor
The fine, branny scaling is
- synonyms for Pityriasis versicolor - tinea versicolor, tinea not readily evident until
flava, dermatomycosis furfuracea, “liver spots” lesions are gently scraped
- member of the normal skin flora with the end of a glass
microscope slide. (C)
HISTORY

• 1846 - detected by Eichstedt & named the disease

pityriasis versicolor
Inflammatory Tinea
• 1853 - Robin named the fungus Microsporon furfur Versicolor
• 1874 - Malassez described the yeast-like cells from
lesions of the scalp
• 1889 - Baillon created genus Malassezia
• 1939 - Benham described the lipophilic nature of the
fungus

EPIDEMIOLOGY

• worldwide distribution but more prevalent in the tropics Folliculitis

& subtropics - uncommon variant
• some countries - 50% of people are infected - lesions resemble acne - papules & pustules
- history of antibiotic or steroid intake
• occurs in both sexes, all ages, all races
- may resolve spontaneously or evolve into abscesses
• major factor - excessive sweating
• other factors - poor hygiene, malnutrition, poor health, Sepsis
pregnancy, systemic steroids, Cushing’s syndrome - catheter-acquired
- neonates & adults on prolonged IV lipid
hyperalimentation
CLINICAL MANIFESTATIONS
- peripheral blood is usually negative
• Pityriasis versicolor - usual source - patient’s skin or medical personnel other
• Folliculitis conditions
• Sepsis
Other Conditions
• other conditions
o Peritonitis - peritonitis
o Nipple discharge
- nipple discharge
o Dacryoliths - dacryoliths
o Sinusitis - sinusitis
Pityriasis versicolor DIAGNOSIS
- usually: asymtomatic, hyperpigmented macules or
patches • Direct Examination
- common sites - chest, upper back, shoulder, upper arms, o KOH mount - short, angular, occasionally
abdomen branching, septate hyphae & clusters of
- may extend to - thighs, neck, forearms budding yeast
- rare in - scalp, palms, feet o Wood’s light - most lesions fluoresce yellow
- hair shafts & nails - not infected
- color varies according to : Skin scrapings stained with
(1) pigmentation periodic-acid schiff’s stain
(2) exposure to sunlight showing typical yeast-like and
(3) severity hyphal fragments of Malassezia
furfur, the etiology agent of
CLINICAL PRESENTATION OF PITYRIASIS VERSICOLOR Pityriasis Versicolor

KOH wet mount of Tinea

Versicolor
Abundant short hyphae and round
spores, so-called Spaghetti and
meatballs are apparent. (A)

Hyperpigmented Tinea
Versicolor
Round, hyperpigmented,
barely palpable plaques and
Adding a small amount of Parker’s blue-black ink to the KOH stains - in man - associated with psoriasis or mycosis fungoides,
Pityrosporon organisms blue and facilitates their identification from the
skin scrapings.
febrile systemic syndrome (neonates)...
- isolated from urine, CSF, blood, vaginal, eye & ear
• Culture
discharge, tracheal aspirate
o often not necessary, tedious & meticulous
o Sabouraud’s agar with antibiotics at 37C
- also reported in patients receiving IV lipid
hyperalimentation (esp. neonates)
o overlay with olive oil or whole-fat milk
- grows on agar at 37C without the addition of oil
o colonies appear dry, smooth or lightly
wrinkled, glistening or dull, white to creamy
MALASSEZIA SYMPODIALIS
- isolated from the scalp of an AIDS patient with tinea
capitis (1990)

PIEDRA (Black & White)

DEFINITIONS

• a chronic, fungal infection of the hair shaft, forming

firm, irregular nodules or encrustations composed of
fungal elements
• 2 varieties - black & white, produced by 2 different
Gram stain and calcofluor white preparation of Malassezia furfur species
• synonyms - tinea nodosa, trichomycosis nodularis,
trichomycosis nodosa, Beigel’s disease, Chignon disease

ETIOLOGY

• Black Piedra - Piedraia hortai

• White Piedra - Trichosporon beigelii

Hair infected wth Piedraia

hortae. The hard black
nodule contains asci and
ascospores, the sexual
phase of the fungus.

Clinical presentation of
DIFFERENTIAL DIAGNOSIS
white piedra

• steroid-induced acne
• acne vulgaris
• vitiligo
• pigmentary disorders eg. Chloasma
• inflammatory conditions eg. tinea circinata, seborrheic
dermatitis, pityriasis rosea, erythrasma, syphilis, pinta BLACK PIEDRA
Piedraia hortai on hair
IMMUNOLOGY

• rare in children under 10 years, associated with increase

sebaceous gland activity
• sweating - predisposing factor
• genetics - may play a role HISTORY
• antibodies - detectable in chronic cases
• indirect IF - organism in skin scales & culture • 1865 - Beigel first observed white piedra
• 1901 - Malgoi-Hoes described black piedra
PATHOLOGY
• 1911 - Horta differentiated black from white piedra
• limited to the stratum corneum • 1928 - Fonseca & Leao named the etiology of black
• moderate hyperkeratosis may be seen piedra, Piedraia hortai
• increase in melanosome size but not in number • 1936 - Langeron summarized findings on both varieties
• other changes - mild acanthosis & perivascular EPIDEMIOLOGY – BLACK PIEDRA
lymphocytic infiltrate
• tropics & subtropics
TREATMENT
• males = females
• selenium sulfide • common among regular swimmers
• Na thiosulfate
EPIDEMIOLOGY – WHITE PIEDRA
• salicylic acid
• benzoyl peroxide • more common in the temperate zone
• the azole family eg. Ketoconazole
• affects both sexes of all age group
• NB. recurrence rate - very high despite treatment
• lower incidence than black variety

CLINICAL MANIFESTATION – BLACK PIEDRA

MALASSEZIA PACHYDERMATIS
- first isolated in 1925 from Indian rhinoceros
- often associated with otitis externa of dogs
• usually on scalp hair only
 • infected hair - rough, sandy or granular
• nodules - hard, fusiform, firmly attached to hair shaft
• thick part - layers of fungal cells cemented
• thin part - single layer of cells & hyphae
• does not penetrate cortex of hair
• hair follicles not involved

CLINICAL MANIFESTATION – WHITE PIEDRA

• usually on facial & genital hair

• nodules are softer, mucilaginous, white to light brown in
color
• nodules are not as adherent
• hair follicles not affected
DIFFERENTIAL DIAGNOSIS
• pediculosis (pubic hair)
• trichomycosis axillaries
o Gram stain - cocci & short bacilli
o UV light - (+) fluorescence
o due to Corynebacterium tenuis
• nits & lice
• tinea capitis
LABORATORY DIAGNOSIS
• Direct Examination]
o KOH mount – Black Piedra
 nodules are composed of tightly
packed, regularly arranged, thick-
walled cells
 dichotomously branching,
dematiaceous hyphae
 central part - fungal cells cemented
 periphery - aligned hyphal strands
 asci are found within the locules
containing up to 8 ascospores
o KOH mount – White Piedra
 nodules are softer, less adherent,
not as discrete
 often - transparent, greenish,
rregular sheath
 cells are not as organized
 one sees only blastospores
arthrospores
• Culture
o Culture - Piedraia hortai
 compact, dark-brown to black,
conical colonies with short aerial
hyphae
 grows slowly on Sabouraud’s agar (2-
4wk) at 25-30C
 some colonies : reddish-brown,
diffusable pigment on agar
 examination - dematiaceous,
septate, branching hyphae with asci
& ascospores
o Culture - Trichosporon beigelii
 grows moderately on Sabouraud’s
agar (1-2 weeks) at 25-30C
 colonies appear smooth, highly-
wrinkled or radially folded,
yeastlike, cream-colored
 examination - hyaline, septate
hyphae with many arthrospores
TREATMENT – BLACK & WHITE
• shaving affected area or cutting infected hair
• topical medication in lotion
TINEA NIGRA
DEFINITION
• a chronic, superficial, usually asymtomatic, fungal
Infection usually of the palms
• synonyms - keratomycosis nigricans palmaris,
cladosporiosis epidermica, pityriasis nigra, microsporis
nigra
• primary medical importance - often misdiagnosed as
melanoma
ETIOLOGY
• Cladosporium werneckii or Exophiala werneckii
HISTORY
• 1891 - first observed in Brazil by Cerqueira
• 1916 - Cerqueira-Pinto reported his own observation &
his father’s
• 1921 - Ramos e Silva reported first case in Rio de
Janeiro; Horta isolated a fungus from the same patient:
Cladosporium werneckii
• 1970 - von Arx transferred the genus to Exophiala
EPIDEMIOLOGY
&
• considered a tropical disease but extends to the
temperate zone (esp. WH)
• occurs in any age group but more common under 20
• male:female (1:3)
• no known predisposing factor although many patients
are hyperhydrotic
• transmission not known to occur
CLINICAL MANIFESTATION
• usually asymptomatic
• lesion - usually, a dark patch on the palm of one
hand with well-defined, irregular margin about 1-5 cm
in diameter
• other locations - sole of foot, interdigits, wrists,
forearm, trunk, neck
• no induration, no erythema, and has the characteristic
“stained appearance”
• ocassionally - pruritus & scaling
TINEA NIGRA: Dark pigmentation
in the center of palm

TINEA NIGRA: Dark pigmentation

in the center of palm
 ETIOLOGIC AGENTS

TINEA NIGRA: Dark • Histoplasma capsulatum

pigmentation in the • Fusarium solani
center of palm
EPIDEMIOLOGY

• More often in males and individual below the age of 50

years.

CLINICAL MANIFESTATIONS

• Raised cornea ulcers with occassional satellite lesions,

plaques or hypopyon

DIAGNOSIS

• Direct examination (demonstration of hyphae)

o corneal scrapings
o Surgical specimens
DIFFERENTIAL DIAGNOSIS
• Culture
• melanoma o Fusarium species grow rapidly in:
• junctional nevus  Sabourauds medium
 Enriched medium
• contact dermatitis
• pigmentation of Addison’s disease Fusarium spp. Colony on potato
• post-inflammatory melanosis dextrose agar. The colonies
• syphilis appear to be cottonlike, usually
white, turning pink-violet or brown
• pinta
at the center with age
• staining from chemicals

PATHOLOGY
Fusarium spp. Stained with
• confined to the lactophenol cotton blue. Typical
Fusarium spp: Microconidia with a
upper layers of the fusiform or oval shape extending
stratum corneum from delicate lateral phialides. Macroconidia are fusiform, usually curved,
• mild hyperkeratosis giving the appearance of a sickle and have three to five septae.
may be seen
• pigmentation is due
to the fungus

TINEA NIGRA: Hematoxylin-eosin-stained section of palmar skin

Show abundant dark-colored fungal elements.

LABORATORY DIAGNOSIS

• Direct Examination
o KOH mount - long, sinuous, strongly -fin-
dematiaceous branching, septate hyphae &
elongated budding cells auds

audsmartinez@gmail.com
ustmedc3@yahoogroups.com

Yeastlike cells of Exophiala werneckii, the causative agent of tinia nigra

• Culture
o Sabouraud’s agar with antibiotics at 25-30C
o colonies appear shiny, moist, yeastlike, dirty
white to brown, covered with masses of
conidia & budding cells
o will turn black in 2-3 weeks

TREATMENT

• sulfur
• salicylic acid
• Na thiosulfate
• the azoles eg. Ketoconazole
• NB. recurrence rate – low

MYCOTIC KERATITIS (KERATOMYCOSIS)

- FUNGAL INFECTIONS OF THE CORNEA

o cause: History of trauma leading to the
inoculum of eyes with a fungus