SYSTEMIC MYCOSIS
Systemic Mycosis
Fungal infection of internal organs.
Primarily involve the respiratory system.
Infection occurs by inhalation of air- borne
conidia.
More than 95% are self limiting &
asymptomatic.
Rest are symptomatic & disseminate by
hematogenous route.
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Systemic Mycosis
Caused by dimorphic fungi which infect healthy &
immunocompetent individuals.
Other systemic infections found in
immunocompromised patients are called as
opportunistic mycotic infections.
Includes :
Histoplasma capsulatum
Blastomyces dermatitidis
Coccidioides immitis
Paracoccidioides brasiliensis
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HISTOPLASMOSIS
Intracellular infection of the RES caused by
Histoplasma capsulatum. Endemic in parts of USA
Also called Darling’s disease; 1st described by
Samuel Darling.
“histio” within histiocytes
“plasma” resembled plasmodium.
Present in soil, rotting areas and in feces of
chicken, bats & other birds. (high N2 content)
Involves all phagocytic cells of RES, cytoplasm
being studded with fungal cells.
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Clinical types
1. Pulmonary – resembles TB
2. Cutaneous & mucocutaneous
3. Disseminated histoplasmosis – commonly
seen in children below 2 yrs & adolescents
- individuals with HIV are at a greater risk.
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Blastomycosis
Caused by Blastomyces dermatitidis
Primarily involves respiratory system
May disseminate via blood to skin, bones &
genitourinary system.
Cutaneous – commonest form, hence the
name “dermatitidis”.
Also called as Gilchrist’s disease or Chicago
disease
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Coccidioidomycosis
Infection of the respiratory system caused by
Coccidioides immitis. Also known as Valley Fever or
Desert Rheumatism
Most virulent of all the fungal pathogens but no
person to person spread reported.
Fungus present in soil & in rodents.
Infection occurs by
- inhalation OR
- reactivation of latent infection in immunocompromised patients
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Paracoccidioidomycosis
Caused by Paracoccidioides brasiliensis.
Primarily involves lungs, later disseminates to
skin, mucosa, LNs & other internal organs.
- triad of pulmonary, oral mucosal & skin
lesions.
Confined to S.America (S.American
blastomycosis).
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Laboratory Diagnosis of Systemic Mycosis
Specimen – sputum, scrapings from skin or
mucosal lesions, biopsy, pus aspirates, CSF
(coccidioides)
Microscopy – wet mount - KOH or CFW
Fungal culture – two sets of SDA inoculated,
incubated at 25° & 37°C
Immunodiagnosis - Serology and skin tests
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Microscopic findings
Histoplasma – small, oval
2- 4µ yeast like cells
within polymorphs with
narrow neck budding
daughter cells
Blastomyces – double
contoured, thick walled,
giant yeast cells with
broad base budding
daughter cells
15.11.09 Dr Ekta, Microbiology
Microscopic findings
Coccidioides – doubly
refractile thick walled
globular spherules, 30-
60µ in diameter & filled
with endospores
Paracoccidiodes – round
refractile yeast cells, 2-
10 to 30µ, single or in
chains
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Fungal culture – LPCB mount
Histoplasma - White cottony
mycelia with large (8-20µ)
thick walled, spherical spores
with tubercles or finger like
projections – Tuberculate
Macroconidia.
Blastomyces : at 25°C - fine,
branched septate hypha with
conidia located on terminal or
lateral branches
At 37°C – budding yeast cells.
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Fungal culture
Coccidioides - branching
septate hypha & chains of
thick walled rectangular
arthroconidia
Paracoccidioides – spherical
mother cell surrounded by
multiple thin-necked
daughter cells “Mariner’s
Wheel”
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Immunodiagnosis
Histoplasmosis
1. Skin test – I.D. test with 0.1 ml histoplasmin
Ag – DTH response.
2. Serological tests – Immunodiffusion
- Latex agglutination
- CFT
* titer of 1:32 or higher or 4-fold increase in
titer of Abs is significant.
Coccidioidomycosis - ID test , induration >
5mm in 24- 48hrs is positive
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Treatment & Prophylaxis
Disseminated & other severe forms –Amphotericin B
I.V.
Mild to moderate illness - Oral azoles like
Itraconazole, Ketoconazole, Fluconazole, etc
Regular cleaning of farm buildings, chicken houses
for prevention of histoplasmosis
Paracoccidioides – long term therapy, AMB with
sulfonamides, reviewed periodically as relapses are
frequent.
15.11.09 Dr Ekta, Microbiology
CANDIDIASIS
Commonest fungal disease in humans
Affects mucosa, skin, nails & internal organs -
superficial and deep infections
Caused by yeast- like fungi of genus candida.
Candida albicans : commonest pathogenic
species.
Normal flora of skin, GIT & female genital
tract.
Commonest fungal infection in HIV +ve
individuals
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Epidemiology
Predisposing factors
1. Natural receptive states like infancy, old age,
pregnancy.
2. Changes in local bacterial flora 2º to antibiotics.
3. Endocrine diseases like DM
4. Severe chronic underlying debilitated conditions
5. Malignancy
6. Drugs – steroids, immunosuppressants &
chemotherapeutic agents.
7. Trauma, burns or injury.
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Pathogenesis & Pathology
Adhesion – entry into host as yeast cell
Local colonization & invasion into deeper
tissues
Hyphal form - phospholipase at tip -
invasion
large size - resistant to
phagocytosis
Biofilm formation around cells – facilitates
survival of organisms.
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Clinical Classification of Candidiasis
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Mucocutaneous Manifestations
Oral candidiasis or oral thrush – commonest
form: - Creamy white patches on tongue or
buccal mucosa
- 90% of AIDS pt.
Vaginitis
- Young & middle – aged females, during active
reproductive life.
- Acidic discharge, itching & burning sensation
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Cutaneous Manifestations
Intertriginous – skin folds
Paronychia – nail folds
Diaper dermatitis – in babies
- maceration & wet diapers
Systemic Candidiasis
Gastrointestinal candidiasis
- follow oral antibiotic therapy
- in leukemia & hematological
malignancy: ulcerations, peritonitis
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Clinical forms of Candidiasis in
HIV patients
Asymptomatic oral carriage
Oropharyngeal thrush
Angular cheilitis
Leukoplakia
Oesophagitis
Laryngitis
Vulvovaginitis, balanitis
Acute atrophic erythema
Hematogenous dissemination
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Laboratory Diagnosis
Clinical specimens are collected depending on
the site of involvement.
Direct Examination
Wet mount – KOH
- Yeast cells, 4-8
with budding &
pseudohyphae
Gram’s stain – gram
+ve budding yeast cells
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Fungal Culture
SDA & other bacteriological
media
Colonies appear in 2-3 days.
Creamy white, smooth &
pasty.
Identification of species
using
Tetrazolium reduction
medium (TRM)
CHROM agar
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C.tropicalis
C.krusei
C.albicans
CHROM Agar
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Germ tube test
Culture is treated with sheep or
normal human serum.
Incubated at 370C for 2 to 4 hrs.
Wet mount : shows long tube – like
projections extending from the
yeast cells, called GERM TUBE.
Positive for - C. albicans
- C. dubliniensis
- C. tropicalis
(sometimes)
Also known as Reynolds – braude
phenomenon.
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Chlamydospore formation
Cornmeal agar or Rice starch agar
Incubated at 250c
Large, highly refractive, thick – walled
chlamydospores after 2-3 days of
incubation.
Biochemical tests
Sugar fermentation
Sugar assimilation
15.11.09 Dr Ekta, Microbiology
Treatment & Prophylaxis
Correct the underlying condition
Oral & Mucocutaneous – 1% Gentian violet
Resistant mucosal lesions – Nystatin
Vaginal candidiasis – oral fluconazole (single dose),
suppositories & creams
Systemic lesions – AMB
Oral antifungals
15.11.09 Dr Ekta, Microbiology
