MEDICAL MYCOLOGY

BLOK INTEGUMEN (TA 2019-2020)

Program Studi Pendidikan Dokter
FKIK UIN Malang

dr. Avin Ainur

 Sifat mikrobiologi, struktur antigen, patogenesis,
temuan klinis, diagnosis laboratorium, prinsip
pengambilan sampel, prinsip terapi dan kontrol
epidemiologi agen infeksi jamur pada sistem
TUJUAN integumen:
PEMBELAJARAN
- Mikosis superfisial
- Mikosis kutaneus
- Mikosis subkutan
  Kingdom Fungi
FUNGAL
TAXONOMY,  Eukaryotes
STRUCTURE, AND  Rigid cell wall composed
REPLICATION of chitin and glucan
 A cell membrane
composed of ergosterol
Medically
Important Fungi
(Kingdom
Fungi)

(Modified from
Brandt ME,
Warnock DW)
Modes of
fungal growth

5
 Unicellular fungi, nonfilamentous, typically oval or
spherical cells. Reproduce by mitosis.
Yeasts are facultative anaerobes, which allows them
to grow in a variety of environments.

1. Yeast  When oxygen is available, they carry out aerobic

respiration.
 When oxygen is not available, they ferment
carbohydrates to produce ethanol and carbon
dioxide.
Yeast

Electron
Microscope
Structure :

yeast
Yeast
Yeast
Scheme :

Yeast
 ▪ Multicellular, filamentous fungi (Long filaments of cells
joined together)
▪ Identified by physical appearance, colony characteristics,
and reproductive spores.
▪ Hiphae:
 Septate hyphae: Cells are divided by cross-walls (septa).
2. Hyphae  Aseptate hyphae: Long, continuous cells that are not divided by
septa.
/ Molds ▪ Part of hiphae:
 Vegetative Hypha: Portion that obtains nutrients.
 Reproductive or Aerial Hypha: Portion connected with
reproduction.
▪ Mycelium: Large, visible, filamentous mass made up of
many hyphae.
Morphology :

hiphae/molds

13
Morphology :

Hyphae /
Molds
Mycelium:
Large, Visible
Mass of
Hyphae
Septate
hyphae

microscopis
Aseptate
hyphae
 Can exist as both multicellular fungi (molds) and
yeasts.
Many pathogenic species.
 Mold form produces aerial and vegetative
hyphae.
Dimorphic  Yeast form reproduces by budding.
Fungi Dimorphism in pathogenic fungi typically depends
on temperature:
 At 37oC: Yeast form.
 At 25oC: Mold form.
Dimorphism in nonpathogenic fungi may depend
on other factors: Carbon dioxide concentration
 ▪ Hiphae : form spores
 asexual reproduction – spores are formed through
budding or in conidia or sporangiospores
 sexual reproduction – spores are formed following
fusion of male & female strains & formation of
sexual structure
▪ Yeast : Asexual reproduction by mitosis
Reproduction  Fission yeasts: Divide evenly to produce two new
cells
 Budding yeasts: Divide unevenly by budding
Budding yeasts can form pseudohypha, a short chain
of undetached cells.

19
 A: Yeast cells reproducing by
nuclear fission and by
blastoconidia formation. The
elongation of budding yeast
cells to form pseudohyphae is
shown, as is the formation of
a germ tube.
B: Types of hyphae seen with
various molds.

 The most simple grouping => based on morphology

: yeasts or molds.
 A yeast can be defined morphologically as a cell that reproduces by
budding or by fission.
Asexual mold spores

22
Examples of asexual spore formation
and associated structures seen with a
Mucorales (A) and an Aspergillus spp.
(B).
Classification of Human
Mycoses and
Representative Etiologic
Agents
  grow readily on simple sources of nitrogen and
carbohydrate.
GROWTH AND
ISOLATION OF  The traditional mycological medium → Sabouraud’s
agar, contains glucose and modified peptone (pH
FUNGI 7.0), has been used because it does not readily
support the growth of bacteria.

Colonies of Candida albicans grown on

Sabouraud dextrose agar.
SUPERFICIAL
MYCOSES
  chronic mild superficial infection of the stratum corneum
caused by
1. Malassezia globosa,
Pityriasis 2. Malassezia restricta, and

Versicolor 3. other members of the Malassezia furfur complex.

 Invasion of the cornified skin and the host responses are both
minimal.
  Discrete, serpentine, hyper-,
or hypopigmented maculae
 occur on the skin, usually on
the chest, upper back, arms,
or abdomen.
Pityriasis  The lesions are chronic and
Versicolor occur as macular patches of
discolored skin that may
enlarge.
 scaling, inflammation, and
irritation are minimal.
Pityriasis versicolor. Multiple,
 a cosmetic problem. pale brown, hyperpigmented
patches on chest and shoulders.
Pityriasis
Versicolor
(D) Pityriasis versicolor: scattered
maculas on the abdomen (D1), which
become more evident after skin
stretching (Zireli’s sign – D2)

Link video : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5514591/figure/f8/

Zireli’s sign
Pityriasis
Versicolor
Pityriasis versicolor. Periodic acid–
Schiff–stained skin scraping Scanning electron micrograph of
showing yeastlike cells and short, Malassezia furfur demonstrating
infrequently branched hyphae that the liplike collarette around the
are often oriented end to end point of bud initiation on the parent
(×100). cell.
  disease of healthy persons
 occurs worldwide, but it is most prevalent in tropical and
subtropical regions.
Epidemiology  Young adults are most commonly affected.
 Human infection is thought to result from the direct or indirect
transfer of infected keratinous material from one person to
another.
Model showing the putative
interactions of Malassezia
yeasts with the skin

Velegraki A, Cafarchia C, Gaitanis G, Iatta R, Boekhout T (2015) Malassezia Infections in Humans and Animals: Pathophysiology, Detection, and
Treatment. PLOS Pathogens 11(1): e1004523. https://doi.org/10.1371/journal.ppat.1004523
https://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1004523
  direct visualization of the fungal elements on
microscopic examination of epidermal scales in 10%
potassium hydroxide (KOH)
 The organisms are usually numerous and may also be
visualized with hematoxylin and eosin (H&E) or
periodic acid–Schiff (PAS) stains
Laboratory  The lesions will also fluoresce with a yellowish color
Diagnosis upon exposure to a Wood lamp.

Left: Fungal hyphae in a (KOH)

preparation of skin scales as seen with
the 10x objective.
Right: Hyphae and arthroconidia as
seen with the 40x objective.
Laboratory
Diagnosis

Mycological examinations for pityriasis versicolor: (A) Direct mycological

examination of a sample collected through skin lesion scraping, clarified with
KOH 10%, illustrating yeasts grouped in a “grape bunch” format, and of short
and thick pseudo-hyphae. (B) Sabouraud agar culture, enriched with olive oil,
with beige yeast-like colony. (C) Yeasts grouped with short base single budding,
with “bowling pin” appearance, stained by the hematoxylin eosin method,
typical of Malassezia sp microgrowth
DOI: http://dx.doi.org/10.1590/abd1806-4841.20176018
 Patient exhibiting pityriasis versicolor lesions in the inguinal region (A),
under Wood lamp, reveals silver fluorescence (B)

DOI: http://dx.doi.org/10.1590/abd1806-4841.20176018
  a superficial chronic and asymptomatic infection of the stratum
corneum
 Hortaea (Exophiala) werneckii.
 more prevalent in warm coastal regions and among young
women.
 The lesions appear as a dark (brown to black) discoloration,
Tinea Nigra often on the palm.
 Microscopic examination of skin scrapings from the periphery
of the lesion will reveal branched, septate hyphae and budding
yeast cells with melanized cell walls.
 Tinea nigra will respond to treatment with keratolytic solutions,
salicylic acid, or azole antifungal drugs.
  dematiaceous, frequently branched, septate hyphae, 1.5 to 3.0 µm
wide.
 Arthroconidia and elongate budding cells are also present
 H. werneckii also grows in culture on standard mycologic media at
25° C, where it is a black mold producing annelloconidia (conidia
possessing annelids or rings), which often slide down the sides of
the conidiophore.

Morphology
  Tinea nigra appears as a solitary, irregular, pigmented (brown to
black) macule, usually on the palms or soles
 There is no scaling or invasion of hair follicles, and the infection is not
contagious.

Clinical
Syndromes
Tinea nigra. Darkly pigmented
macules with irregular edges
present on the palm.
  Tinea nigra is easily diagnosed by microscopic examination of
Laboratory skin scrapings placed in 10% to 20% KOH.
 The pigmented hyphae and yeast forms are confined to the
diagnosis outer layers of the stratum corneum and are easily detected on
H&E-stained
 Tinea nigra: brownish macula on
children’s palms

Tinea Nigra
Tinea nigra
Mycological examinations for tinea nigra: (A) Direct mycological
examination of a sample collected through skin lesion scraping, clarified with
KOH 10%, illustrating dematiaceous septatehyphae. (B) Culture Mycosel
medium (Difco, USA) with dematiaceous colony with a waxy appearance.
(C) Microgrowth revealing dematiaceous yeasts with binary fission, typical of
Hortaea werneckii

DOI: http://dx.doi.org/10.1590/abd1806-4841.20176018
 Morphology & Epidemiology
Clinical Syndromes
 White piedra is a superficial
infection of hair caused by
yeastlike fungi of the
genus Trichosporon: T. inkin, T.
asahii, or T. mucoides.
White Piedra  Microscopic examination reveals  This condition occurs in
hyphal elements, arthroconidia tropical and subtropical
(rectangular cells resulting from regions and is related to
the fragmentation of hyphal cells), poor hygiene.
and blastoconidia (budding yeast
cells).
 White piedra affects the hairs of
the groin and axillae.
 The infection does not damage the
hair shaft.
 Whitish nodule attached to the White piedra hair with nodule
hair shaft. due to growth of Trichosporon.
200×

White Piedra
White Piedra

Mycological examinations of white piedra: (A1) Optical microscopy (x40) offering a detailed
illustration of the light color nodule attached to the pillar shaft. (A2) Optical microscopy (x100)
illustrates the yeasts the make up the structure on the edge of the nodule. (B) Culture Mycosel
medium (Difco, USA) with yeast-like colony, with the cerebriform filamentous appearance. (C)
Microgrowth demonstrates yeasts with blasto-arthrospores, typical of Trichosporon sp

DOI: http://dx.doi.org/10.1590/abd1806-4841.20176018

Black Piedra  Another condition affecting
the hair, primarily the scalp,
is black piedra.
 Piedraia hortae.
Epidemiology & Clinical
Syndromes
 Latin America and Central
Africa.
 condition of poor hygiene.
 Black piedra presents as
small, dark nodules that
surround the hair shafts.
 It is asymptomatic and
generally involves the scalp.
 Black Piedra

Mycological examinations of black piedra: (A) Optical microscopy (x40)

offering a detailed illustration of the dark nodule attached to the pillar shaft.
(B) Culture Mycosel medium (Difco, USA) with dematiaceous colony. (C)
Optical microscopy (x100) identifying the ascus, round structures typical of
parasitism caused by Piedraia hortae
DOI: http://dx.doi.org/10.1590/abd1806-4841.20176018
 Black piedra hair with a hard,
black nodule, caused by growth of
the dematiaceous mold, Piedraia A
hortae. 200×

Black piedra: darkened nodule

attached to the hair shaft.

Black Piedra
CUTANEOUS MYCOSES
  The various forms of
dermatophytosis are
referred to as “tineas” or
 genera Trichophyton, ringworm
Epidermophyton, and  (1) tinea capitis of the scalp,
Microsporum. eyebrows, and eyelashes;
 (2) tinea barbae of the
 ability to invade the beard;
skin, hair, or nails.
dermatophytosis  (3) tinea corporis of the
 keratinophilic and smooth or glabrous skin;
keratinolytic and so  (4) tinea cruris of the groin;
are able to break down
the keratin surfaces of  (5) tinea pedis of the foot;
these structures.  (6) tinea unguium of the
nails (also known
as onychomycosis).
  identified by their colonial
appearance and microscopic
morphology after growth for
2 weeks at 25°C on
Sabouraud’s dextrose agar.
Morphology  Trichophyton species, which Trichophyton tonsurans is characterized by
may infect hair, skin, or the production of elongated microcondia
and nails, develop cylindric, attached to a supporting hypha.
smooth-walled
Identification macroconidia and
characteristic microconidia
 Coiled or spiral hyphae are
commonly found in primary
isolates.
 Microsporum
 Multicellular macroconidia
with echinulate walls.
 Microsporum canis forms a
Microsporum colony with a white cottony
surface, macroconidia
frequently have curved or
hooked tips.
 Microsporum gypseum Microsporum gypseum
produces a tan, powdery produces individual thin- and
colony and abundant rough-walled macroconidia.
thinwalled.
 Microsporum species infect
only hair and skin.
  Epidermophyton floccosum,
→ the only pathogen in this
genus
 produces only
macroconidia, smooth-
Epidermophyton walled, clavate, two- to four-
celled, and formed in small
clusters (Figure 45-10C). Epidermophyton floccosum has
club-shaped, thin- and smooth-
 The colonies are usually flat walled macroconidia that
and velvety with a tan to typically arise in small clusters.
olive-green tinge.
  begin in the skin after trauma and contact.
 host susceptibility may be enhanced by moisture, warmth,
specific skin chemistry, composition of sebum and perspiration,
youth, heavy exposure, and genetic predisposition.
 Anthropophilic species → transmitted by direct contact or
through fomites, such as contaminated towels, clothing.
Epidemiology
and Immunity  Trichophytin → crude antigen preparation → detect
immediate- or delayed-type hypersensitivity to dermatophytic
antigens.
 patients who develop chronic, noninflammatory dermatophyte
infections have poor cell mediated immune responses to
dermatophyte antigen.
Common and Uncommon Agents of Superficial and Cutaneous
Dermatomycoses and Dermatophytoses
 A. Specimens
 Specimens consist of scrapings from both the skin and the nails
plus hairs plucked from involved areas.
 The ectothrix spores of Microsporum-infected hairs fluoresce
under Wood’s light in a darkened room.
Diagnostic B. Microscopic Examination
Laboratory  Specimens are placed on a slide in a drop of 10–20% KOH

Tests  Branching hyphae or chains of arthroconidia (arthrospores)

 In hairs, Microsporum species form dense sheaths of spores
around the hair (ectothrix).
 Trichophyton tonsurans and T violaceum → producing
arthroconidia inside the hair shaft (endothrix).
 C. Culture
 The identification of dermatophyte species requires cultures.
Diagnostic  Sabouraud’s agar slants containing cycloheximide and
Laboratory chloramphenicol to suppress mold and bacterial growth

Tests  Incubated for 1–3 weeks at room temperature

 growth rate, surface texture, and any pigmentation, microscopic
morphology (macroconidia, and Microconidia)
Unstained microscopic KOH preparation of scrapings from a ringworm lesion.
The epidermal cells are lysed by KOH to reveal hyaline branching septate hyphae.
SUBCUTANEOUS MYCOSES
 Sporothrix schenckii
Following traumatic introduction into the skin, S schenckii causes
sporotrichosis, a chronic granulomatous infection.

SPOROTRICHOSIS
Morphology and Identification
 Sporothrix schenckii grows well on routine agar media, and at
room temperature the young colonies are blackish and shiny,
becoming wrinkled and fuzzy with age.
  The organism produces branching, septate hyphae
and distinctive small (3–5 μm) conidia, delicately
clustered at the ends of tapering conidiophores
 at 35°C on a rich medium it converts to growth as
small
Sporothrix
schenckii
 1. Antigenic Structure
Sporotrichin will elicit positive delayed skin tests in
infected humans or animals.

Sporothrix 2. Diagnostic Laboratory Tests

schenckii A. Specimens → Specimens include biopsy material or exudate
from granulomatous or ulcerative lesions.
B. Microscopic Examination → KOH or calcofluor white stain,
the yeasts are rarely found. fluorescent antibody staining. The
yeasts are 3–5 μm in diameter and spherical to elongated.
 2. Diagnostic Laboratory Tests
C. Culture
Sporothrix  Specimens are streaked on inhibitory mold agar or Sabouraud’s
agar containing antibacterial antibiotics and incubated at 25–
schenckii 30°C.
 The identification is confirmed by growth at 35°C and
conversion to the yeast form.
 Epidemiology and Control
 Sporothrix schenckii occurs worldwide in close
association with plants
 About 75% of cases occur in males, either because of
Sporothrix increased exposure or because of an X-linked
schenckii difference in susceptibility.
 The incidence is higher among agricultural workers,
and sporotrichosis is considered an occupational risk
for forest rangers, horticulturists.
  caused by traumatic inoculation of any of the recognized fungal
agents
 Dematiaceous fungi, having melanized cell walls: Phialophora
verrucosa, Fonsecaea pedrosoi, Fonsecaea compacta,
Rhinocladiella aquaspersa, and Cladophialophora carrionii.
 chronic and slow development of progressive granulomatous
lesions

CHROMOBLASTOMYCOSIS
  Morphology and
Identification
The colonies → compact, deep
brown to black, and develop a
velvety, often wrinkled surface.
The agents of
CHROMOBLASTOMYCOSIS chromoblastomycosis are
identified by their modes of
conidiation.
In tissue → spherical brown cells
(4–12 μm in diameter) termed
muriform or sclerotic bodies that
divide by transverse septation.
 Fonsecaea pedrosoi usually displays
Phialophora verrucosa produces short branching chains of
conidia from vase-shaped phialides blastoconidia, as well as other types
with collarettes. 1000×. of conidiogenesis. 1000×.

CHROMOBLASTOMYCOSIS
 Pathogenesis and Clinical Findings
 skin by trauma
 Chronics
 the primary lesion becomes verrucous
and wart-like with extension along the
CHROMOBLASTOMYCOSIS
draining lymphatics.
 Cauliflower-like nodules with crusting
abscesses
 Small ulcerations or “black dots” of
hemopurulent material are present on
the warty surface.
 elephantiasis
 Diagnostic Laboratory Tests
 Specimens of scrapings or
biopsies from lesions are
placed in 10% KOH and
CHROMOBLASTOMYCOSIS examined microscopically
for dark, spherical cells
 Detection of the sclerotic
bodies is diagnostic of
chromoblastomycosis.
 Tissue sections reveal
granulomas and extensive
hyperplasia of the dermal
tissue.
  chronic subcutaneous infection
induced by traumatic inoculation
with any of several saprophytic
species of fungi
 local swelling of the infected tissue
and interconnecting, often draining,
sinuses or fistulae that contain
granules, which are microcolonies of
the agent embedded in tissue
material.
MYCETOMA  An actinomycetoma is a mycetoma
caused by an actinomycetes; a
eumycetoma (maduromycosis,
Madura foot) is a mycetoma caused
by a fungus.
 Actinomycetomas may be more
invasive, spreading from the
subcutaneous tissue to the
underlying muscle.
 actinomycetoma

MYCETOMA
eumycetoma
  Pseudallescheria boydii (anamorph, Scedosporium
apiospermum), Madurella mycetomatis, Madurella grisea,
Exophiala jeanselmei, and Acremonium falciforme.
 Pseudallescheria boydii may also cause pseudallescheriasis,
which is a systemic infection of compromised patients.
 In tissue, the mycetoma granules may range up to 2 mm in size.
Morphology and  The color of the granule may provide information about the
Identification agent.
 For example,
- Pseudallescheria boydii and Acremonium falciforme are
white;
- Madurella grisea and Exophiala jeanselmei are black;
- Madurella mycetomatis produces a dark red to black
  after traumatic inoculation with soil contaminated with one of
the agents
 the pathology is characterized by suppuration and abscesses,
Pathogenesis and granulomata, and draining sinuses containing the granules.
Clinical Findings
 may spread to contiguous muscle and bone.
 Untreated lesions persist for years and extend deeper and
peripherally, causing deformation and loss of function.
  Granules can be dissected out from the pus or biopsy material
for examination and culture on appropriate media.

Diagnostic  The granule color, texture, and size and the presence of hyaline
or pigmented hyphae (or bacteria) are helpful in determining
Laboratory Tests the causative agent.
 Draining mycetomas are often superinfected with staphylococci
and streptococci.
OPPORTUNISTIC
MYCOSES
  Patients with compromised host defenses are susceptible to
ubiquitous fungi to which healthy people are exposed but
usually resistant.
 Candidiasis is the most prevalent systemic mycosis, and the
most common agents are :
- C albicans,
CANDIDIASIS - C parapsilosis,
- C glabrata,
- C tropicalis,
- C guilliermondii,
- C dubliniensis.
  In culture or tissue, Candida species grow as oval, budding yeast
cells (3–6 μm in size).

Morphology and  Pseudohyphae

Identification  On agar media or within 24 hours at 37°C or room temperature,
Candida species produce soft, cream-colored colonies with a
yeasty odor. Pseudohyphae are apparent as submerged growth
below the agar surface.

Candida albicans. Budding yeast
cells (blastoconidia), hyphae,
and pseudohyphae. 400×.
Candida
Germ tube. Unlike other species of Candida, Candida
albicans produces true hyphae as well as budding yeast
cells and pseudohyphae. After incubation in serum at
37°C for 60–90 minutes in the laboratory, clinical isolates
of Candida albicans are stimulated to form hyphae, and
this process is initiated by the production of germ tubes,
which are thinner and more uniform than pseudohyphae
(see Figure 45-22). 1000×.
  Superficial (cutaneous or mucosal)
candidiasis → an increase in the local census
of Candida and damage to the skin or
epithelium that permits local invasion by the
Candida yeasts and pseudohyphae
pathogenesis  Systemic candidiasis → Candida enters the
bloodstream and the phagocytic host defenses
are inadequate to contain the growth and
dissemination of the yeasts.
  The local histology of
cutaneous or
mucocutaneous lesions is
characterized by
inflammatory reactions
varying from pyogenic
abscesses to chronic
granulomas.
 The lesions contain
Clinical finding abundant budding yeast
cells and pseudohyphae.
 Large increases of Candida
in the intestinal tract often
follow the administration of
oral antibacterial antibiotics,
and the yeasts can enter the
circulation by crossing the
intestinal mucosa.
 A. Specimens
 Specimens include swabs and scrapings from superficial lesions,
blood, spinal fluid, tissue biopsies, urine, exudates, and material
from removed intravenous catheters.
Diagnostic B. Microscopic Examination
Laboratory Tests  Tissue biopsies, centrifuged spinal fluid, and other specimens
may be examined in Gram-stained smears or histopathologic
slides for pseudohyphae and budding cells
 Skin or nail scrapings are first placed in a drop of 10% KOH and
calcofluor white.
 Candidiasis.
Yeasts and pseudohyphae in
tissue, stained with periodic
acid-Schiff. 1000×.

Diagnostic
Laboratory
Tests
ANTIFUNGAL
CHEMOTHERAPY
 The polyenes (amphotericin B and nystatin)
which bind to ergosterol in the cell membrane

Flucytosine, a pyrimidine analog

The azoles and other inhibitors of ergosterol synthesis

Classes such as the allylamines

The echinocandins
which inhibit the synthesis of cell wall β-glucan

Griseofulvin
which interferes with microtubule assembly
TOPICAL ANTIFUNGAL
AGENTS
 Nystatin
polyene antibiotic, structurally related to
amphotericin B, treat local candidal infections of the
mouth and vagina.

Clotrimazole, Miconazole, and Other Azoles

Classes broad spectrum of activity

Tolnaftate and naftifine Other antifungal

Haloprogin and ciclopirox agent
URL=https://www.frontiersin.org/article/10.3389/fmicb.2017.00036
Determinants
for outcome of
invasive mycoses

David Andes et al. Antimicrob. Agents Chemother. 2009;

doi:10.1128/AAC.00705-08
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Elseviers. ISBN: 978-0-323-08692-9
2. Cynthia Nau Cornelissen; Bruce D. Fisher; Richard A.
Harvey, Ph.D. Lippincott’s Illustrated Reviews:
Microbiology Third Edition. Lippincott Williams &
Wilkins
3. Geo. F. Brooks; Karen C. Carroll; Janet S. Butel; Stephen
A. Morse; Timothy A. Mietzner. Jawetz, Melnick, &
Adelberg’s Medical Microbiology Twenty-Sixth Edition. A
Lange Medical Book