Mikosis Adelaide

Mycoses
Clinical Groupings for Fungal Infections

The following clinical groupings may be recognized
Superficial Mycoses
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These are superficial cosmetic fungal infections of the skin or hair shaft. No living tissue is
invaded and there is no cellular response from the host. These infections are often so
innocuous that patients are often unaware of their condition.
Cutaneous Mycoses
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These are superficial fungal infections of the skin, hair or nails. No living tissue is invaded,
however a variety of pathological changes occur in the host because of the presence of the
infectious agent and its metabolic products.
Subcutaneous Mycoses
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These are chronic, localized infections of the skin and subcutaneous tissue following the
traumatic implantation of the aetiologic agent. The causative fungi are all soil saprophytes
whose ability to adapt to the tissue environment and elicit disease is extremely variable.
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Dimorphic Systemic Mycoses
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These are fungal infections caused by fungal pathogens which can overcome the defences of
the normal human host by changing their morphological form. They are geographically
restricted and the primary site of infection is usually pulmonary, following the inhalation of
conidia.
Opportunistic Systemic Mycoses
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These are fungal infections which occur almost exclusively in debilitated patients whose
normal defence mechanisms are impaired. The organisms involved are cosmopolitan fungi
which have a very low inherent virulence.
Superficial Mycoses
These are superficial cosmetic fungal infections of the skin or hair shaft. No living tissue is
invaded and there is no cellular response from the host. Essentially no pathological changes
are elicited. These infections are often so innocuous that patients are often unaware of their
condition.
Disease Causative organisms Incidence
Pityriasis versicolor Malassezia spp. Common
Seborrhoeic dermatitis (a lipophilic yeast)
including Dandruff and
Follicular pityriasis
Tinea nigra Hortaea werneckii Rare
White piedra Trichosporon spp. Common
Black piedra Piedraia hortae Rare
Malassezia Infection
Malassezia species are basidiomycetous yeasts and form part of the normal skin flora of
humans and animals. The genus now includes 14 species of which 13 are lipid dependent.
These include M. caprae (goat, horse), M. cuniculi (rabbit), M. dermatis (human), M.
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equina (horse, cow), M. furfur (human, cow, elephant, pig, monkey, ostrich, pelican), M.
globosa (human, cheetah, cow), M. japonica (human), M. nana (cat, cow, dog), M.
obtusa (human), M. pachydermatis (dog, cat, carnivores, birds), M. restricta (human), M.
slooffiae (human, pig, goat, sheep), M. sympodialis (human, horse, pig sheep) and M.
yamatoensis (human) (Cabanes et al. 2011).
M. sympodialis, M. globosa, M. slooffiae and M. restricta are the most frequently found species
responsible for colonisation of humans (Arendrup et al. 2014).
Malassezia species may cause various skin manifestations including pityriasis versicolor,
seborrhoeic dermatitis, dandruff, atopic eczema and folliculitis. M. pachydermatis is known to
cause external otitis in dogs. Fungaemia due to lipid-dependent Malassezia species usually
occurs in patients with central line catheters receiving lipid replacement therapy, especially in
infants (Tragiannides et al. 2010, Gaitanis et al. 2012, Arendrup et al. 2014).
Note:
With the exception of M. pachydermatis, the primary isolation and culture
of Malassezia species is challenging because in vitro growth must be stimulated by natural oils
or other fatty substances. The most common method used is to overlay Sabouraud’s dextrose
agar (SDA) containing cycloheximide (actidione) with olive oil or alternatively to use a more
specialised media like modified Leeming and Notham agar (Kaneko et al. 2007), or modified
Dixon’s agar (see specialised culture media).
Clinical Manifestations
Pityriasis versicolor:
This is a chronic, superficial fungal disease of the skin characterised by well-demarcated
white, pink, fawn, or brownish lesions, often coalescing, and covered with thin furfuraceous
scales. The colour varies according to the normal pigmentation of the patient, exposure of the
area to sunlight, and the severity of the disease. Lesions occur on the trunk, shoulders and
arms, rarely on the neck and face, and fluoresce a pale greenish colour under Wood's ultra-
violet light. Young adults are affected most often, but the disease may occur in childhood and
old age.
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Pityriasis folliculitis:
This is characterised by follicular papules and pustules localised to the back, chest and upper
arms, sometimes the neck, and more seldom the face. These are itchy and often appear after
sun exposure. Scrapings or biopsy specimens show numerous yeasts occluding the mouths of
the infected follicules. Most cases respond well to topical imidazole treatment, however
patients with extensive lesions often require oral treatment with ketoconazole or itraconazole.
Once again, prophylactic treatment once or twice a week is mandatory to prevent relapse.
Seborrhoeic dermatitis and dandruff:

Current evidence suggests Malassezia, combined with multifactorial host factors is also the
direct cause of seborrhoeic dermatitis, with dandruff being the mildest manifestation. Host
factors include genetic predisposition, an emotional component (possible endocrine or
neurologically mediated factors), changes in quantity and composition of sebum (increase in
wax esters and a shift from triglycerides to shorter fatty acid chains), increase in alkalinity of
skin (due to eccrine sweating) and external local factors such as occlusion. Patients with
neurological diseases such as Parkinson's disease and those with AIDS are commonly
affected. Clinical manifestations are characterised by erythema and scaling in areas with a
rich supply of sebaceous glands ie the scalp, face, eyebrows, ears and upper trunk. Lesions
are red and covered with greasy scales and itching is common in the scalp. The clinical
features are typical and skin scrapings for a laboratory diagnosis are unnecessary. Once
again, the use of a topical imidazole is recommended, especially ketoconazole which has
proved to be the most effective agent. Relapse is common and retreatment when necessary is
the simplest approach for long term management.
Fungaemia:
Malassezia has also been reported as causing catheter acquired fungaemia in neonate and
adult patients undergoing lipid replacement therapy. Such patients may also develop small
embolic lesions in the lungs or other organs. Diagnosis requires special culture media and
blood drawn back through the catheter is the preferred specimen. Culture of the catheter tip is
also recommended.
Laboratory Diagnosis:
1. Clinical Material:
Skin scrapings from patients with superficial lesions, blood and indwelling catheter tips from
patients with suspected fungaemia.
2. Direct Microscopy:
Skin scrapings taken from patients with Pityriasis versicolor stain rapidly when mounted in
10% KOH, glycerol and Parker ink solution and show characteristic clusters of thick-walled
round, budding yeast-like cells and short angular hyphal forms up to 8um in diameter (ave.
4um diam.). These microscopic features are diagnostic for Malassezia furfur and culture
preparations are usually not necessary.
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3. Culture:
Culture is only necessary in cases of suspected fumgaemia. M. furfur is a lipophilic yeast,
therefore in vitro growth must be stimulated by natural oils or other fatty substances. The
most common method used is to overlay Sabouraud's dextrose agar containing cycloheximide
(actidione) with olive oil or alternatively to use a more specialized media like Dixon's agar
which contains glycerol mono-oleate (a suitable substrate for growth).
4. Serology:
There are currently no commercially available serological procedures for the diagnosis
of Malassezia infections.
5. Identification:
Microscopic evidence of inipolar, broad base budding yeast cells and special lipid
requirements for growth in culture are usually diagnostic.
Management:
The most appropriate antifungal treatment for pityriasis versicolor is to use a topical imidazole
in a solution or lathering preparation. Ketoconazole shampoo has proven to be very effective.
Alternative treatments include zinc pyrithione shampoo or selenium sulfide lotion applied daily
for 10-14 days or the use of propylene glycol 50% in water twice daily for 14 days. In severe
cases with extensive lesions, or in cases with lesions resistant to topical treatment or in cases
of frequent relapse oral therapy with itraconazole [200 mg/day for 5-7 days] is usually
effective. Mycologically, yeast cells may still be seen in skin scrapings for up to 30 days
following treatment, thus patients should be monitored on clinical grounds. Patients also need
to be warned that it may take many months for their skin pigmentation to return to normal,
even after the infection has been successfully treated. Relapse is a regular occurrence and
prophylactic treatment with a topical agent once or twice a week is often necessary to avoid
recurrence.
Tinea nigra
A superficial fungal infection of skin characterised by brown to black macules which usually
occur on the palmar aspects of hands and occasionally the plantar and other surfaces of the
skin. World-wide distribution, but more common in tropical regions of Central and South
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America, Africa, South-East Asia and Australia. The aetiological agent is Hortaea werneckii a
common saprophytic fungus believed to occur in soil, compost, humus and on wood in humid
tropical and sub-tropical regions.
Clinical Manifestations:
Skin lesions are characterised by brown to black macules which usually occur on the palmar
aspects of hands and occasionally the plantar and other surfaces of the skin. Lesions are non-
inflammatory and non-scaling. Familial spread of infection has also been reported.
Note:
There is no inflammatory reaction.
Skin scrapings.
Skin scrapings should be examined using 10% KOH and Parker ink or calcofluor white
mounts.
3. Culture:
Clinical specimens should be inoculated onto primary isolation media, like Sabouraud's
dextrose agar.
4. Serology:
Not required for diagnosis.
5. Identification:
Characteristic clinical, microscopic and culture features.
Causative agents:
Hortaea werneckii
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Management:
Usually, topical treatment with Whitfield's ointment (benzoic acid compound) or an
imidazole agent twice a day for 3-4 weeks is effective.
White piedra
White piedra is a superficial cosmetic fungal infection of the hair shaft caused
by Trichosporon. Infected hairs develop soft greyish-white nodules along the shaft.
Essentially no pathological changes are elicited. White piedra is found worldwide, but is most
common in tropical or subtropical regions.
Trichosporon species are a minor component of normal skin flora, and are widely distributed
in nature. They are regularly associated with the soft nodules of white piedra, and have been
involved in a variety of opportunistic infections in the immunosuppressed patient.
Disseminated infections are most frequently (75%) caused by T. asahii (Arendrup et al.
2014) and have been associated with leukaemia, organ transplantation, multiple myeloma,
aplastic anaemia, lymphoma, solid tumours and AIDS. Disseminated infections are often
fulminate and widespread, with lesions occurring in the liver, spleen, lungs and
gastrointestinal tract. Infections in non-immunosuppressed patients include endophthalmitis
after surgical extraction of cataracts, endocarditis usually following insertion of prosthetic
cardiac valves, peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD),
and intravenous drug abuse.
Infections are usually localised to the axilla or scalp but may also be seen on facial hairs and
sometimes pubic hair. White piedra is common in young adults. The presence of irregular,
soft, white or light brown nodules, 1.0-1.5 mm in length, firmly adhering to the hairs is
characteristic of white piedra.
Epilated hairs with white soft nodules present on the shaft.
Hairs should be examined using 10% KOH and Parker ink or calcofluor white mounts. Look
for irregular, soft, white or light brown nodules, 1.0-1.5 mm in length, firmly adhering to the
hairs.
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3. Culture:
Hair fragments should be implanted onto primary isolation media, like Sabouraud's dextrose
agar. Colonies of Trichosporon spp. are white or yellowish to deep cream colored, smooth,
wrinkled, velvety, dull colonies with a mycelial fringe.
4. Serology:
5. Identification:
Causative agents:
Trichosporon spp. Six species are of clinical significance: T. asahii, T. asteroides, T.
cutaneum, T. inkin, T. mucoides and T. ovoides. Other species reported from human and
animal infections include T. dermatis, T. domesticum, T. faecale, T. jirovecii, T. loubieri and
T. mycotoxinovorans (Rodriguez-Tudela et al. 2005, Chagas-Neto et al. 2008, Colombo et al.
2011).
Management:
Shaving the hairs is the simplest method of treatment. Topical application of an imidazole
agent may be used to prevent reinfection.
Black Piedra
Black piedra is a superficial fungal infection of the hair shaft caused by Piedra hortae, an
ascomycetous fungus forming hard black nodules on the shafts of the scalp, beard, moustache
and pubic hair. It is common in Central and South America and South-East Asia.
Infections are usually localised to the scalp but may also be seen on hairs of the beard,
moustache and pubic hair. Black piedra mostly affects young adults and epidemics in families
have been reported following the sharing of combs and hairbrushes. Infected hairs generally
have a number of hard black nodules on the shaft. Black piedra may be confused with
trichorrhexis nodosa and trichonodosis but mycological examination will always confirm the
diagnosis.
Epilated hairs with hard black nodules present on the shaft.
Hairs should be examined using 10% KOH and Parker ink or calcofluor white. Look for
darkly pigmented nodules that may partially or completely surround the hair shaft. Nodules
are made up of a mass of pigmented with a stroma-like centre containing asci.
3. Culture:
Hair fragments should be implanted onto primary isolation media, like Sabouraud's dextrose
agar. Colonies of Piedra hortae are dark, brown-black and take about 2-3 weeks to appear.
4. Serology:
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5. Identification:
Causative agents:
Piedra hortae
Management:
The usual treatment is to shave or cut the hairs short, but this is often not considered
acceptable, particularly by women. In-vitro susceptibility tests have shown that Piedra
hortae is sensitive to terbinafine and it has been successfully used, at a dose of 250 mg a day
for 6 weeks, to treat a 23 year old Swedish Caucasian man following a 4 month visit to India
(Gip, 1994).
The Cutaneous Mycoses

These are superficial fungal infections of the skin, hair or nails. No living tissue is invaded,
however a variety of pathological changes occur in the host because of the presence of the
infectious agent and its metabolic products.
Dermatophytosis Dermatophytes (Arthroderma, Lophophyton, Common
Ringworm of the Microsporum, Nannizzia, Trichophyton,
scalp, Epidermophyton)
glabrous skin and
nails.
Candidiasis of skin, Candida, Debaryomyces, Kluyveromyces, Common
mucous membranes Meyerozyma,
and nails. Pichia, etc.
Dermatomycosis Non-dermatophyte moulds Rare
Neoscytalidium, Scopulariopsis
Mycoses Descriptions
 Dermatophytosis - Ringworm or Tinea

Dermatophytosis (tinea or ringworm) of the scalp, glabrous skin, and nails is caused by a
closely related group of fungi known as dermatophytes which have the ability to utilise
keratin as a nutrient source, i.e. they have a unique enzymatic capacity [keratinase].
The disease process in dermatophytosis is unique for two reasons: Firstly, no living tissue is
invaded the keratinised stratum corneum is simply colonised. However, the presence of the
fungus and its metabolic products usually induces an allergic and inflammatory eczematous
response in the host.
The type and severity of the host response is often related to the species and strain of
dermatophyte causing the infection. Secondly, the dermatophytes are the only fungi that have
evolved a dependency on human or animal infection for the survival and dissemination of
their species.
The common anthropophilic species are primarily parasitic on man (Table 1). They are
unable to colonise other animals and they have no other environmental sources. On the other
hand, geophilic species normally inhabit the soil where they are believed to decompose
keratinaceous debris.
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Some species may cause infections in animals and man following contact with soil. Zoophilic
species are primarily parasitic on animals and infections may be transmitted to humans
following contact with the animal host (Table 1).
Zoophilic infections usually elicit a strong host response and on the skin where contact with
the infective animal has occurred ie arms, legs, body or face.
Table 1. Ecology of Common Human Dermatophyte Species.
Species Natural Habitat Incidence
Epidermophyton floccosum Humans Common
Trichophyton rubrum Humans Very Common
Trichophyton interdigitale Humans Very Common
Trichophyton tonsurans Humans Common
Trichophyton violaceum Humans Less Common
Trichophyton concentricum Humans Rare*
Trichophyton schoenleinii Humans Rare*
Trichophyton soudanense Humans Rare*
Microsporum audouinii Humans Less Common*
Microsporum ferrugineum Humans Less Common*
Trichophyton mentagrophytes Mice, rodents Common
Trichophyton equinum Horses Rare
Trichophyton eriotrephon Hedgehogs Rare*
Trichophyton verrucosum Cattle Rare*
Microsporum canis Cats Common
Nannizzia gypsea Soil Common
Nannizzia nana Soil/Pigs Rare*
Nannizzia fulva Soil Rare
Nannizzia persicolor Voles and bats Rare*
Lophophyton cookei Soil Rare*
Lophophyton gallinae Chicken and other fowl Rare*
* Geographically restricted.
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Tinea pedis:
Infections by anthropophilic dermatophytes are usually caused by the shedding of skin scales
containing viable infectious hyphal elements [arthroconidia] of the fungus. Desquamated skin
scales may remain infectious in the environment for months or years. Therefore transmission
may take place by indirect contact long after the infective debris has been shed.
Substrates like carpet and matting that hold skin scales make excellent vectors. Thus,
transmission of dermatophytes like Trichophyton rubrum, T.
interdigitale and Epidermophyton floccosum is usually via the feet. In this site infections are
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often chronic and may remain subclinical for many years only to become apparent when spread
to another site, usually the groin or skin.
It is important to recognise that the toe web spaces are the major reservoir on the human body
for these fungi and therefore it is not practical to treat infections at other sites without
concomitant treatment of the toe web spaces. This is essential if a "cure" is to be achieved. It
should also be recognised that individuals with chronic or subclinical toe web infections are
carriers and represent a public health risk to the general population, in that they are constantly
shedding infectious skin scales.
Tinea cruris:
Tinea cruris refers to dermatophytosis of the proximal medial thighs, preum and buttocks. It
occurs more commonly in males and is usually due to spread of the fungus from the feet.
Thus the usual causative agents are T. rubrum, T. interdigitale and E. floccosum.
Tinea unguium (dermatophyte onychomycosis):

Trichophyton rubrum and T. interdigitale are the dominant dermatophyte species involved. In
countries like Australia, UK and USA the incidence of dermatophyte onychomycosis has been
estimated to be about 3% of the population, increasing up to 5% in the elderly, with some
subgroups such as miners, servicemen and sportsmen etc having an incidence of up to 20% due
to the use of communal showers and changing rooms.
It is important to stress that only 50% of dystrophic nails have a fungal aetiology, therefore it
is essential to establish a correct laboratory diagnosis by either microscopy and/or culture,
before treating a patient with a systemic antifungal agent.
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Dermatophyte onychomycosis may be classified into two main types; (1) superficial white
onychomycosis in which invasion is restricted to patches or pits on the surface of the nail; and
(2) invasive, subungual dermatophytosis in which the lateral, distal or proximal edges of the
nail are first involved, followed by establishment of the infection beneath the nail plate. Distal
subungual onychomycosis is the most common form of dermatophyte onychomycosis. The
fungus invades the distal nail bed causing hyperkeratosis of the nail bed with eventual
onycholysis, and thickening of the nail plate.
As the name suggests, lateral subungual onychomycosis begins at the lateral edge of the nail
and often spreads to involve the entire nail bed and nail plate. In proximal subungual
onychomycosis, the fungus invades under the cuticle and infects the proximal rather than the
distal nail bed causing yellowish-white spots which slowly invade the lunula and then the nail
plate.
Tinea corporis:
Tinea corporis refers to dermatophytosis of the glabrous skin and may be caused by
anthrophophilic species such as T. rubrum usually by spread from another body site or by
geophilic and zoophilic species such as M. gypseum and M. canis following contact with
either contaminated soil or an animal host.
Tinea capitis:
Tinea capitis refers to dermatophytosis of the scalp. Three types of in vivo hair invasion are
recognised:
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o Ectothrix invasion is characterised by the development of arthroconidia on the
outside of the hair shaft. The cuticle of the hair is destroyed and infected hairs usually
fluoresce a bright greenish yellow colour under Wood's ultraviolet light. Common agents
include Microsporum canis, Nannizzia.gypsea, Trichophyton equinum and T. verrucosum.
o Endothrix hair invasion is characterised by the development of arthroconidia
within the hair shaft only. The cuticle of the hair remains intact and infected hairs do not
fluoresce under Wood's ultraviolet light. All endothrix producing agents are anthropophilic
eg Trichophyton tonsurans and T. violaceum.
o Favus usually caused by Trichophyton schoenleinii, produces favus-like crusts
or scutula and corresponding hair loss.
Clinical Material:
Skin Scrapings, nail scrapings and epilated hairs. For a laboratory diagnosis, clinicians should
be aware of the need to generate an adequate amount of suitable clinical material. Unfortunately
many specimens submitted are either of an inadequate amount or are not appropriate to make
a definitive diagnosis. The laboratory needs enough specimen to perform both microscopy and
culture. Routine turn around times for direct microscopy should be less than 24 hours, however
culture may take several weeks.
In patients with suspected dermatophytosis of skin [tinea or ringworm] any ointments or other
local applications present should first be removed with an alcowipe. Using a blunt scalpel,
tweezers, or a bone curette, firmly scrape the lesion, particularly at the advancing border. In
cases of vesicular tinea pedis, the tops of any fresh vesicles should be removed as the fungus
is often plentiful in the roof of the vesicle.
In patients with suspected dermatophytosis of nails [onychomycosis] the nail should be pared
and scraped using a blunt scalpel until the crumbling white degenerating portion is reached.
Any white keratin debris beneath the free edge of the nail should also be collected.
Skin and nail specimens may be scraped directly onto special black cards which make it easier
to see how much material has been collected and provide ideal conditions for transportation to
the laboratory.
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It must be stressed that up to 30% of suspicious material collected from nail specimens may be
negative by either direct microscopy or culture. A positive microscopy result showing fungal
hyphae and/or arthroconidia is generally sufficient for the diagnosis of dermatophytosis, but
gives no indication as to the species of fungus involved. Culture is often more reliable and
permits the species of fungus involved to be accurately identified. Repeat collections should
always be considered in cases of suspected dermatophytosis with negative laboratory reports.
Direct Microscopy:
Skin Scrapings, nail scrapings and epilated hairs should be examined using 10% KOH and
Parker ink or calcofluor white mounts.
Culture:
Specimens should be inoculated onto primary isolation media, like Sabouraud's dextrose agar
containing cycloheximide (actidione) and incubated at 26-28C for 4 weeks. The growth of any
dermatophyte is significant.
Serology:
Identification:
See descriptions of individual species for details.
Management:
Treatment of dermatophytosis is often dependant on the clinical setting. For instance
uncomplicated single cutaneous lesions can be adequately treated with a topical antifungal
agent, however topical treatment of scalp and nail infections is often ineffective and systemic
therapy is usually needed to cure these conditions. Chronic or widespread dermatophyte
infections, acute inflammatory tinea and "Moccasin" or dry type T. rubrum infection involving
the sole and dorsum of the foot usually also require systemic therapy. Ideally, mycological
confirmation of the clinical diagnosis should be gained before systemic antifungal treatment is
commenced.
 Candidiasis - Thrush
Candidiasis is a primary or secondary mycotic infection caused by members of the
genus Candida and other related genera. The clinical manifestations may be acute, subacute or
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chronic to episodic. Involvement may be localized to the mouth, throat, skin, scalp, vagina,
fingers, nails, bronchi, lungs, or the gastrointestinal tract, or become systemic as in septicemia,
endocarditis and meningitis. In healthy individuals, Candida infections are usually due to
impaired epithelial barrier functions and occur in all age groups, but are most common in the
newborn and the elderly. They usually remain superficial and respond readily to treatment.
Systemic candidiasis is usually seen in patients with cell-mediated immune deficiency, and
those receiving aggressive cancer treatment, immunosuppression, or transplantation therapy.
Clinical manifestations:
1. Oropharyngeal candidiasis: including thrush, glossitis, stomatitis and
angular cheilitis.
Acute oral candidiasis is rarely seen in healthy adults but may occur in up to 5% of newborn
infants and 10% of the elderly. However, it is often associated with severe immunological
impairment due to diabetes mellitus, leukemia, lymphoma, malignancy, neutropenia and HIV
infection where it presents as a predictor of clinical progression to AIDS. The use of broad-
spectrum antibiotics, corticosteroids, cytotoxic drugs, and radiation therapy are also
predisposing factors. Clinically, white plaques that resemble milk curd form on the buccal
mucosa and less commonly on the tongue, gums, the palate or the pharynx. Symptoms may be
absent or include burning or dryness of the mouth, loss of taste, and pain on swallowing.
2. Cutaneous candidiasis: including intertrigo, diaper candidiasis, paronychia and

onychomycosis.
Intertriginous candidiasis is most commonly seen in the axillae, groin, inter- and sub-
mammary folds, intergluteal folds, interdigital spaces, and umbilicus. Moisture, heat, friction
and maceration of the skin are the principle predisposing factors in the normal patient,
however obesity, diabetes mellitus, warm water immersion or occlusion of the skin and the
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use of broad-spectrum antibiotics are additional factors. Lesions consist of a moist, macular
erythematous rash with typical satellite lesions present on the surrounding healthy skin.
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Diaper candidiasis is common in infants under unhygienic conditions of chronic moisture and
local skin maceration associated with ammonitic irritation due to irregularly changed unclean
diapers. Once again characteristic erythematous lesions with erosions and satellite pustules
are produced, with prominent involvement of the skin folds and creases.
Paronychia of the finger nails may develop in persons whose hands are subject to continuous
wetting, especially with sugar solutions or contact with flour, that macerates the nail folds
and cuticle. Lesions are characterized by the development of a painful, erythematous swelling
about the affected nails. In chronic cases the infection may progress to cause onychomycosis
with total detachment of the cuticle from the nail plate.
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Chronic Candida onychomycosis often causes complete destruction of nail tissue and is seen
in patients with chronic mucocutaneous candidiasis or other underlying factors that affect
either the hormonal or immunologic status of the host. These include diabetes mellitus,
hypoparathyroidism, Addison's disease, dysfunction of the thyroid, malnutrition,
malabsorption and various malignancies. The use of steroids, antibiotics and antimitotics may
also be contributing factors.
3. Vulvovaginal candidiasis and balanitis:
Vulvovaginal candidiasis is a common condition in women, often associated with the use of
broad-spectrum antibiotics, the third trimester of pregnancy, low vaginal pH and diabetes
mellitus. Sexual activity and oral contraception may also be contributing factors and
infections may extend to include the perineum, the vulva and the entire inguinal area. Chronic
refractory vaginal candidiasis, associated with oral candidiasis, may also be a presentation of
HIV infection or AIDS. Symptoms include intense vulval pruritus, burning, erythema and
dyspareunia associated with a creamy white, curd-like discharge.
In cases of balanitis, diabetes mellitus should be excluded and the sexual partner should be
investigated for vulvovaginitis. The symptoms include erythema, pruritus and
vesiculopustules on the glan penis or prepuce. Infections are more commonly seen in
uncircumcised men and poor hygiene may also be a contributing factor.
4. Chronic mucocutaneous candidiasis:
Chronic mucocutaneous candidiasis is a form of persistent candidiasis, usually caused by C.
albicans, of the skin, nails and mucous membranes that occurs in patients with various
metabolic disturbances to cell-mediated immunity. These include defects in leukocyte
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function or endocrine disorders such as hypoparathyroidism, Addison's disease,
hypothyroidism, diabetes, dysfunction of the thyroid and polyglandular autoimmune disease.
The patients are usually children. Candida granuloma is a severe localized form which may
occur with or without endocinopathy characterized by marked hyperkeratic granulomatous
lesions.
5. Neonatal and congenital candidiasis:
Low birthweight and age, prolonged intravascular catheterization and the use of antibiotic
drugs are the principle predisposing conditions for systemic candidiasis in neonates. Blood
cultures are often positive and there is also a high incidence of meningitis. Renal
complications due to fungus ball formation in the ureters or renal pelvis may also occur.
Congenital candidiasis acquired in utero is usually confined to the skin in the form of a
generalized erythematous vesicular rash, however intrauterine candidiasis may also result in
abortion.
6. Oesophageal candidiasis:
Oesophageal candidiasis is frequently associated with AIDS and severe immunosuppression
following treatment for leukemia or solid tumors. Concomitant oral candidiasis is often
present. Oesophagitis may also lead to septicemia and disseminated candidiasis. Symptoms
include burning pain in the substernal area, dysphagia, nausea and vomiting. The clinical
diagnosis relies on radiological and endoscopic findings, which usually shows white mucosal
plaques with erythema resembling those seen in oral candidiasis. Herpes simplex or
cytomegalovirus (CMV) infection may also be present and the clinical diagnosis may need to
be confirmed by histopathology and culture.
7. Gastrointestinal candidiasis:
Patients with acute leukemia or other hematological malignancies may have numerous
ulcerations of the stomach and less commonly the duodenum and intestine. Perforation can
lead to peritonitis and hematogenous spread to the liver, spleen and other organs.
Colonization and invasion of the stomach or intestinal mucosa is often accompanied by the
excretion of large numbers of yeasts which may be detected in stools.
8. Pulmonary candidiasis:
Pulmonary candidiasis can be acquired by either hematogenous dissemination causing a
diffuse pneumonia or by bronchial extension in patients with oropharyngeal candidiasis.
Aspiration of yeasts from the oral cavity has also been reported in infants. Pulmonary
candidiasis is difficult to diagnose due to non-specific radiological and culture findings and
most patients, especially those with granulocytopenia, present at autopsy. The presence of
yeasts in alveolar lavage or sputum specimens is not specific and blood cultures may also be
negative. Unfortunately, only histopathology can provide a definitive diagnosis and this is not
always possible in patients with coagulation problems.
9. Peritonitis:
Candida peritonitis can result from colonization of indwelling catheters used for peritoneal
dialysis (CAPD) or gastrointestinal perforation due to ulcers, diverticular colitis, surgery or
intra-abdominal neoplasm. Symptoms include fever, abdominal pain, tenderness and a cloudy
peritoneal dialysate containing greater than 100 leukocytes/mm3. Candida peritonitis usually
remains localized to the abdominal cavity unless patients are severely immunosuppressed.
10. Urinary tract candidiasis:
Transient asymptomatic candiduria may occur during antibiotic or corticosteroid treatment
which promotes the growth of Candida, throughout the gastrointestinal and genital tracts, and
most lower urinary tract infections result from local spread of yeasts from these sites. This
condition is most common in women. Candida cystitis or bladder colonization may be caused
by prolonged catheterization with concomitant antibiotic treatment, diabetes and glycosuria,
anatomical uropathy, previous bladder endoscopy or surgery, diabetic neurogenic bladder,
17
chronic outlet obstruction from prostatic hypertrophy, or pelvic irradiation for cervical
cancer.
Renal candidiasis (pyelonephritis) is usually the result of either an ascending infection or
more frequently, hematogenous dissemination from another organ focus. Symptoms include
fever, rigors, lumbar pain and abdominal pain. The development of a fungus ball in the renal
pelvis, although rare may complicate the infection. Predisposing factors for this include
constriction of the urinary tract, localized papillary necrosis, urethral or bladder catheters and
diabetes. Even though, up to 80% of patients with disseminated candidiasis also have renal
infection and associated candiduria, urine cultures alone are not a reliable method for
diagnosis of disseminated infection.
The practical problem in a patient with candiduria is to distinguish between colonization
and/or contamination and infection. Therefore, it is important to determine whether renal
function is present or whether infection is confined to the bladder. Mycological findings are
usually inconclusive which makes the clinical parameters important. The following criteria
are suggestive of renal infection; the isolation of yeasts in urine specimens obtained by
suprapubic aspiration, positive blood cultures and a positive immunodiffusion precipitin test
result or serological conversion in a patient with iatrogenic predisposing factors and/or an
underlying illness.
It should be noted that many clinicians do not recommend suprapubic aspirates as they are
invasive and require additional expertise, especially in immunocompromised patients.
Laboratories are also advised on the need to report the isolation of any yeasts from urine
specimens obtained from high risk immunosuppressed patients.
11. Meningitis:
Candida meningitis is a rare entity, predominantly seen in low birthweight neonates with
septicemia and in patients with hematological malignancies, complicated neurosurgery or
intracerebral prosthetic devices such as ventriculoperitoneal shunts. Symptoms include a
feverish meningeal irritation. Diagnosis in the neonate requires a high index of suspicion by
the clinician to the possibility of meningitis as a sequel to septicemia. The detection
of Candida cells in smears and its isolation from CSF is often difficult.
12. Hepatic and hepatosplenic candidiasis:
Hepatosplenic candidiasis occurs in patients with severe neutropenia, usually acute leukemia.
Symptoms include fever, hepatosplenomegaly and increased blood concentrations of alkaline
phosphatases. Histopathology shows diffuse hepatic and/or splenic necrotic lesions or
abscesses containing small numbers of pseudohyphae. However, blood and biopsy cultures
are usually culture negative. A definitive diagnosis is often difficult due to the inability to
adequately biopsy these patients.
13. Endocarditis, myocarditis and pericarditis:
Endocarditis is the most common form of cardiac candidiasis. Pre-existing valvular disease
with concomitant intravenous catheterization and antibiotic treatment, intravenous drug
abuse, heart surgery and valve prosthesis are the most common predisposing factors. Clinical
symptoms include fever, murmur, congestive heart failure, anemia and splenomegaly. Blood
cultures are often positive and echocardiology and serology for the detection of Candida
antibodies (immunodiffusion precipitin tests) are other useful diagnostic procedures.
Myocardial abscesses, arterial emboli and purulent pericarditis are additional rare
complications of Candida septicemia or surgery.
14. Candidemia (Candida septicemia) and disseminated candidiasis:
Candidemia has been defined as the presence of yeasts in the blood with or without visceral
involvement. Hematogenous dissemination may then occur to one or more other organ
systems with the formation of numerous microabscesses. Candida species have been reported
to cause up to 15% of cases of septicemia seen in hospital patients.
18
Predisposing factors include intravenous catheters, use of antibacterial drugs, urinary
catheters, surgical procedures, corticosteroid therapy, neutropenia, severe burns, parental
nutrition, and chemotherapy induced impairment of oropharyngeal or gastrointestinal
mucosa. A characteristic presentation is antibiotic resistant fevers in the neutropenic patient
with tachycardia and dyspnea. Hypotension is also common and skin lesions may also occur.
When yeasts are isolated from blood or from tissue biopsies a diagnosis is straightforward,
however this is not often the case. Blood cultures often remain negative even in patients
dying from proven disseminated candidiasis, especially in the granulocytopenic patient. If at
all possible, suspected foci should be aspirated, including articular, peritoneal, CSF, or even
vitreal specimens; and liver and/or lung biopsies should also be performed. However
histopathology is more often not a viable option because biopsies are contraindicated due to
the patients underlying illness. Finally, the detection of yeasts from more accessible no-sterile
sites, like urine, is too common to be of diagnostic value. In this situation, of clinically
suspected unproven disseminated candidiasis, only cutaneous and/or ocular lesions can
rapidly confirm the diagnosis. Specific, reliable serological tests are still not generally
available. Empiric antifungal treatment is usually initiated in these cases.
o
15. Ocular candidiasis:
Candida endophthalmitis is often associated with candidemia, indwelling catheters or drug
abuse, however it is rare in patients with severe neutropenia. Lesions are often localized near
the macula and patients complain of cloudy vision. Exogenous Candida endophthalmitis is
rare, but cases have been reported following ocular trauma or surgery. Similarly, conjunctival
and corneal infections have also been recorded following trauma.
16. Osteoarticular candidiasis:
Arthritis may be a late sequel of candidemia in neonates or neutropenic patients. Prosthetic or
rheumatoid joints are also prone to infection by Candida either by hematogenous spread or
direct inoculation during surgery or intra-articular corticosteroid injection. The knee is the
main site involved with pain on weight bearing or on full extension. The diagnosis depends
on the isolation of yeasts from joint fluid obtained by needle aspiration or from synovial
biopsies.
17. Other forms of candidiasis:
As candidiasis is an iatrogenic, nosocomial infection which is usually endogenous in origin
many other clinical manifestations may occur, especially in the debilitated patient. For
example, the reported cutaneous, ocular and arthritic manifestations reported in heroin
addicts; fever, rash and myalgia associated with leukemia patients;
Candida cholecystitis; Candida prostatitis; pancreatic abscesses; epiglottitis and
osteomyelitis, to name a few.
Summary of clinical groups and/or predisposing factors for invasive candidiasis.
Neutropenia (especially >7 days).
Hematological malignancy.
Solid tumor malignancy.
Postsurgical intensive care patients.
Prolonged intravenous catheterization.
19
Broad-spectrum or multiple antibiotic therapy.
Diabetes mellitis.
Parental nutrition.
Severe burns.
Neonates.
Corticosteroid therapy.
Intravenous drug abuse.
Laboratory diagnosis:
Skin and nail scrapings; urine, sputum and bronchial washings; cerebrospinal fluid, pleural
fluid and blood; tissue biopsies from various visceral organs and indwelling catheter tips.
o
(a) Skin and nails should be examined using 10% KOH and Parker ink or calcofluor white
mounts; (b) Exudates and body fluids should be centrifuged and the sediment examined using
either 10% KOH and Parker ink or calcofluor white mounts and/or gram stained smears; (c)
Tissue sections should be stained using PAS digest, Grocott's methenamine silver (GMS) or
Gram stain. Note Candida may be missed in H&E stained sections. Examine specimens for
the presence of small, round to oval, thin-walled, clusters of budding yeast cells
(blastoconidia) and branching pseudohyphae. Candida pseudohyphae may be difficult to
distinguish from Aspergillus hyphae when blastoconidia are not observed as often happens in
liver biopsies.
Interpretation:
As a rule, a positive direct microscopy from a sterile site, especially a tissue biopsy, should
be considered significant, even if the laboratory is unable to culture the yeast. Further, the
demonstration of pseudohyphae in scrapings or smears from cutaneous, oral, esophageal and
vaginal lesions should be considered significant, provided the clinical manifestations support
the diagnosis. However, the finding of just budding yeast cells in such material is of little
diagnostic importance. Note, pseudohyphae will not be observed in smears when C.
glabrata is involved and the diagnosis will require additional supporting evidence. Direct
microscopy of sterile body fluids, such as CSF, vitreous humor, joint fluid and peritoneal
fluid is relatively insensitive and positive culture will usually be required to make a
diagnosis.
3. Culture:
Colonies are typically white to cream colored with a smooth, glabrous to waxy surface.
20
o
Interpretation:
A positive culture from blood, or other sterile body fluid, or tissue biopsy should be
considered significant. Lysis centrifugation is currently the most sensitive method for the
isolation of Candida from blood. However, positive culture from non-sterile specimens such
as sputum, bronchial lavage, esophageal brushings, urine, stool, and surgical drains are of
little diagnostic value. Similarly, culture of skin or mucous membrane lesions without
supporting evidence from direct microscopy is not diagnostic. Candida species are commonly
isolated from the mouth, vagina, anus, and less often, moist skin surfaces of normal
individuals who do not have candidiasis.
4. Serology:
Various serological procedures have been devised to detect the presence
of Candida antibodies, ranging from immunodiffusion to more sensitive tests such as counter
immunoelectrophoresis (CIE), enzyme-linked immunosorbent assay (ELISA), and
radioimmunoassay (RIA). However, these are often negative in the immunocompromised
patient, especially at the beginning of an infection. The production of four or more precipitin
lines in CIE tests has been reported to be diagnostic of candidiasis in the predisposed patient .
Tests for circulating antigen by immunological or non-immunological means have also been
developed. Of the non-immunological techniques, use of gas liquid chromography (GLC) to
detect mannose derivatives of the cell wall or a metabolic by-product, D-arabinitol, have
proved the most useful. The detection of antigen by immunological methods such as ELISA
or RIA have been used, however for the small laboratory latex agglutination tests for
glycoprotien antigen have proved to be the most useful, although variable results have been
reported.
It must be stressed that the interpretation of serological tests for Candida, especially in the
neutropenic patient, is often difficult and must be correlated with other diagnostic methods.
False-negatives and false-positive results do occur. Hopwood and Evans (1991) provide an
excellent review of the current serological methods available.
5. Identification:
The genus Candida is characterized by globose to elongate yeast-like cells or blastoconidia
that reproduce by multilateral budding. Most Candida species are also characterized by the
presence of well developed pseudohyphae, however this characteristic may be absent,
especially in those species formally included in the genus Torulopsis. Arthroconidia,
ballistoconidia and colony pigmentation are always absent. Within the genus Candida,
fermentation, nitrate assimilation and inositol assimilation may be present or absent,
however, all inositol positive strains produce pseudohyphae.
Causative agents:
Candida albicans
Candida catenulata
Candida dubliniensis
Candida glabrata complex
Candida haemulonii
Candida inconspicua
21
Candida parapsilosis complex
Candida rugosa
Candida tropicalis
Clavispora lusitaniae (formerly Candida lusitaniae)
Cyberlindnera fabianii (formerly Candida fabianii)
Debaryomyces hansenii (formerly Candida famata)
Kluyveromyces marxianus (formerly Candida kefyr)
Meyerozyma guilliermondii (formerly Candida guilliermondii)
Pichia kudriavzevii (formerly Candida krusei)
Pichia norvegensis (formerly Candida norvegensis)
Torulaspora delbrueckii (formerly Candida colliculosa)
Wickerhamomyces anomalus (formerly Candida pelliculosa)
Yarrowia lipolytica (formerly Candida lipolytica)
Management: see treatment guidelines section.
traumatic implantation of the aetiologic agent. The causative fungi are all soil saprophytes of
regional epidemiology whose ability to adapt to the tissue environment and elicit disease is
extremely variable.
Sporotrichosis Sporothrix spp. Rare
Fonsecaea, Phialophora,
Chromoblastomycosis Rare
Cladophialophora etc.
Cladophialophora, Exophiala,
Phaeohyphomycosis Rare
Bipolaris, Exserohilum etc
Scedosporium, Madurella, Trematosphaeria,
Mycotic mycetoma Rare
Acremonium, Exophiala etc.
Subcutaneous zygomycosis Basidiobolus ranarum
Rare
(Entomophthoromycosis) Conidiobolus coronatus
Subcutaneous zygomycosis Rhizopus, Mucor, Rhizomucor,
Rare
(Mucormycosis) Lichtheimia, Saksenaea etc.
Lobomycosis Loboa loboi Rare
Rhinosporidiosis Rhinosporidium seeberi Rare
traumatic implantation of the aetiologic agent. The causative fungi are all soil saprophytes of
regional epidemiology whose ability to adapt to the tissue environment and elicit disease is
extremely variable.
Sporotrichosis Sporothrix spp. Rare
Fonsecaea, Phialophora,
Chromoblastomycosis Rare
Cladophialophora etc.
Cladophialophora, Exophiala,
Bipolaris, Exserohilum etc
Scedosporium, Madurella, Trematosphaeria,
Mycotic mycetoma Rare
Acremonium, Exophiala etc.
22
Subcutaneous zygomycosis Basidiobolus ranarum
Rare
(Entomophthoromycosis) Conidiobolus coronatus
Subcutaneous zygomycosis Rhizopus, Mucor, Rhizomucor,
Rare
(Mucormycosis) Lichtheimia, Saksenaea etc.
Lobomycosis Loboa loboi Rare
Rhinosporidiosis Rhinosporidium seeberi Rare
Sporotrichosis
Sporotrichosis is primarily a chronic mycotic infection of the cutaneous or subcutaneous
tissues and adjacent lymphatics characterized by nodular lesions which may suppurate and
ulcerate. Infections are caused by the traumatic implantation of the fungus into the skin, or
very rarely, by inhalation into the lungs. Secondary spread to articular surfaces, bone and
muscle is not infrequent, and the infection may also occasionally involve the central nervous
system, lungs or genitourinary tract.
Fixed cutaneous sporotrichosis:

Primary lesions develop at the site of implantation of the fungus, usually at more exposed
sites mainly the limbs, hands and fingers. Lesions often start out as a painless nodule which
soon become palpable and ulcerate often discharging a serous or purulent fluid. Importantly,
lesions remain localised around the initial site of implantation and do not spread along the
lymphangitic channels. Isolates from these lesions usually grow well at 35C, but not at 37C.
Lymphocutaneous sporotrichosis:
Primary lesions develop at the site of implantation of the fungus, but secondary lesions also
appear along the lymphangitic channels which follow the same indolent course as the primary
lesion ie they start out as painless nodules which soon become palpable and ulcerate. No
systemic symptoms are present. Isolates from these lesions usually grow well at both 35C and
37C.
Pulmonary sporotrichosis:
This is a rare entity usually caused by the inhalation of conidia but cases of haematogenous
dissemination have been reported. Symptoms are nonspecific and include cough, sputum
23
production, fever, weight loss and upper-lobe lesion. Haemoptysis may occur and it can be
massive and fatal. The natural course of the lung lesion is gradual progression to death.
Osteoarticular sporotrichosis:
Most patients also have cutaneous lesions and present with stiffness and pain in a large joint,
usually the knee, elbow, ankle or wrist. Osteomyelitis seldom occurs without arthritis; the
lesions usually confined to the long bones near affected joints.
Other rare forms of sporotrichoisis include endophthalmitis, chorioretinitis and meningitis.
1. Clinical material:
A tissue biopsy is the best specimen.
Gram stain.
Interpretation:
Look for 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.
3. Culture:
dextrose agar and Brain heart infusion agar supplemented with 5% sheep blood.
Interpretation:
A positive culture from a biopsy should be considered significant.
4. Serology:
Serological tests are of limited value in the diagnosis of Sporotrichosis.
5. Identification:
Hyphomycete characterized by thermal dimorphism and clusters of ovoid, denticulate conidia
produced sympodially on short conidiophores.
6. Causative agents:
Sporothrix schenckii complex.
Chromoblastomycosis
A mycotic infection of the cutaneous and subcutaneous tissues characterised by the
development in tissue of dematiaceous (brown-pigmented), planate-dividing, rounded
sclerotic bodies. Infections are caused by the traumatic implantation of fungal elements into
the skin and are chronic, slowly progressive and localised. Tissue proliferation usually occurs
around the area of inoculation producing crusted, verrucose, wart-like lesions. World-wide
distribution but more common in bare footed populations living in tropical regions.
Aetiological agents include various dematiaceous hyphomycetes associated with decaying
vegetation or soil, especially Phialophora verrucosa, Fonsecaea spp., and Cladophialophora
carrionii.
Lesions of chromoblastomycosis are most often found on exposed parts of the body and
usually start a small scaly papules or nodules which are painless but may be itchy. Satellite
24
lesions may gradually arise and as the disease develops rash-like areas enlarge and become
raised irregular plaques that are often scaly or verrucose. In long standing infections, lesions
may become tumorous and even cauliflower-like in appearance. Other prominent features
include epithelial hyperplasia, fibrosis and microabscess formation in the epidermis.
Chromoblastomycosis must be distinguished from other cutaneous fungal infections such as
blastomycosis, lobomycosis, paracoccidioidomycosis and sporotrichosis. It may also mimic
protothecosis, leishmaniasis, verrucose tuberculosis, certain leprous lesions and syphilis.
Mycological and histopathological investigations are essential to confirm the diagnosis.
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.
Skin scrapings and/or biopsy.
(a) Skin scrapings should be examined using 10% KOH and Parker ink or calcofluor white
mounts; (b) Tissue sections should be stained using H&E, PAS digest, and Grocott's
methenamine silver (GMS).
Interpretation:
The presence in tissue of brown pigmented, planate-dividing, rounded sclerotic bodies from a
patient with supporting clinical symptoms should be considered significant. Remember direct
microscopy or histopathology does not offer a specific identification of the causative agent.
Note: direct microscopy of tissue is necessary to differentiate between chromoblastomycosis
and phaeohyphomycosis where the tissue morphology of the causative organism is mycelial.
25
3. Culture:
dextrose agar.
Interpretation:
The dematiaceous hyphomycetes involved are well recognised as environmental fungi,
therefore a positive culture from a non-sterile specimen, such as sputum or skin, needs to be
supported by clinical history and direct microscopic evidence in order to be considered
significant. Culture identification is the only reliable means of distinguishing these fungi.
4. Serology:
There are currently no commercially available serological procedures for the diagnosis of
chromoblastomycosis.
5. Identification:
Culture characteristics and microscopic morphology are important, especially conidial
morphology, the arrangement of conidia on the conidiogenous cell and the morphology of the
conidiogenous cell. Cellotape flag and/or slide culture preparations are recommended.
Cladophialophora carrionii, Fonsecaea species complex, Phialophora verrucosa
Phaeohyphomycosis
A mycotic infection of humans and lower animals caused by a number of dematiaceous
(brown-pigmented) fungi where the tissue morphology of the causative organism is mycelial.
This separates it from other clinical types of disease involving brown-pigmented fungi where
the tissue morphology of the organism is a grain (mycotic mycetoma) or sclerotic body
(chromoblastomycosis). The etiological agents include various dematiaceous hyphomycetes
especially species of Exophiala, Phialophora, Bipolaris, Exserohilum, Cladophialophora,
Verruconis, Aureobasidium, Cladosporium, Curvularia and Alternaria. Ajello (1986) listed 71
species from 39 genera as causative agents of phaeohyphomycosis.
Clinical forms of phaeohyphomycosis range from localized superficial infections of the
stratum corneum (tinea nigra) to subcutaneous cysts (phaeomycotic cyst) to invasion of the
brain.
1. Subcutaneous phaeohyphomycosis:
Subcutaneous infections occur worldwide, usually following the traumatic implantation of
fungal elements from contaminated soil, thorns or wood splinters. Exophiala jeanselmei and
Wangiella dermatitidis are the most common agents and cystic lesions occur most often in
adults. Occasionally, overlying verrucous lesions are formed, especially in the
immunosuppressed patient.
26
2. Paranasal sinus phaeohyphomycosis:
Sinusitis caused by dematiaceous fungi, especially species of Bipolaris, Exserohilum,
Curvularia and Alternaria is increasingly being reported, especially in patients with a history
of allergic rhinitis or immunosuppression.
3. Cerebral phaeohyphomycosis:
Cerebral phaeohyphomycosis is a rare infection, occurring mostly in immunosuppressed
patients following the inhalation of conidia. However, cerebral infections caused by
Cladophialophora bantiana have been reported in a number of patients without any obvious
predisposing factors. This fungus is neurotropic and dissemination to sites other than the CNS
is rare.
Skin scrapings and/or biopsy; sputum and bronchial washings; cerebrospinal fluid, pleural
(a) Skin scrapings, sputum, bronchial washings and aspirates should be examined using 10%
KOH and Parker ink or calcofluor white mounts; (b) Exudates and body fluids should be
centrifuged and the sediment examined using either 10% KOH and Parker ink or calcofluor
white mounts, (c) Tissue sections should be stained using H&E, PAS digest, and Grocott's
Interpretation:
The presence of brown pigmented, branching septate hyphae in any specimen, from a patient
with supporting clinical symptoms should be considered significant. Biopsy and evidence of
tissue invasion is of particular importance. Remember direct microscopy or histopathology
does not offer a specific identification of the causative agent.
27
Note:
Direct microscopy of tissue is necessary to differentiate between chromoblastomycosis which
is characterized by the presence in tissue of brown pigmented, planate-dividing, rounded
sclerotic bodies and phaeohyphomycosis where the tissue morphology of the causative
organism is mycelial.
3. Culture:
dextrose agar.
Interpretation:
The dematiaceous hyphomycetes involved are well recognized as common environmental
airborne contaminants, therefore a positive culture from a non-sterile specimen, such as
sputum or skin, needs to be supported by direct microscopic evidence in order to be
considered significant. A supporting clinical history in patients with appropriate predisposing
conditions, is also helpful. Culture identification is the only reliable means of distinguishing
these fungi.
4. Serology:
There are currently no commercially available serological procedures for the diagnosis of any
of the infections classified under the term phaeohyphomycosis.
5. Identification:
Alternaria sp., Aureobasidium pullulans, Bipolaris sp., Cladophialophora bantiana,
Verruconis gallopava, Curvularia sp., Exophiala sp., Exserohilum sp., Phialophora
verrucosa.
Mycetoma
A mycotic infection of humans and animals caused by a number of different fungi and
actinomycetes characterized by draining sinuses, granules and tumefaction. The disease results
from the traumatic implantation of the aetiologic agent and usually involves the cutaneous and
subcutaneous tissue, fascia and bone of the foot or hand. Sinuses discharge serosanguinous
fluid containing the granules which vary in size, colour and degree of hardness, depending on
the aetiologic species, and are the hallmark of mycetoma. World-wide distribution but most
common in bare-footed populations living in tropical or subtropical regions. Aetiological
agents include Madurella, Acremonium, Pseudallescheria, Exophiala, Leptosphaeria,
Curvularia, Fusarium, Aspergillus etc.
Mycetoma is a chronic, suppurative infection of the subcutaneous tissue and contiguous bone.
The clinical features are fairly uniform, regardless of the organism involved. The feet are the
most coomon site for infection and account for at least two-thirds of cases. Other sites include
the lower legs, hands, head, neck, chest, shoulder and arms. Most cases start out as a small hard
28
painless nodule which over time begins to soften on the surface and ulcerate to discharge a
viscous, purulent fluid containing grains. The infection slowly spreads to adjacent tissue,
including bone, often causing considerable deformity. Sinuses continue to discharge
serosanguinous fluid containing the granules which vary in size, colour and degree of hardness,
depending on the aetiologic species. These grains are the hallmark of mycetoma.
Tissue biopsy or excised sinus, serosanguinous fluid containing the granules which vary in
size, colour and degree of hardness, depending on the aetiologic species.
Serosanguinous fluid containing the granules should be examined using either 10% KOH and
Parker ink or calcofluor white mounts, and tissue sections should be stained using H&E, PAS
digest, and Grocott's methenamine silver (GMS).
Interpretation:
The presence of white to yellow or black pigmented grains, from a patient with supporting
clinical symptoms should be considered significant. Biopsy and evidence of tissue invasion is
of particular importance. Remember direct microscopy or histopathology does not offer a
specific identification of the causative agent.
3. Culture:
dextrose agar.
4. Serology:
mycetoma.
5. Identification:
Acremonium sp., Aspergillus nidulans, Madurella grisea, Madurella mycetomatis,
Scedosporium apiospermum.
Zygomycosis
29
The term zygomycosis describes in the broadest sense any infection due to a member of the
Zygomycetes. These are primitive, fast growing, terrestrial, largely saprophytic fungi with a
cosmopolitan distribution. To date, some 665 species have been described although infections
in humans and animals are generally rare. Medically important orders and genera include:
1. Mucorales and Mortierellales, causing subcutaneous and systemic zygomycosis

(Mucormycosis) - Rhizopus, Lichtheimia, Rhizomucor, Mucor, Cunninghamella, Saksenaea,
Apophysomyces, Cokeromyces and Mortierella.
2. Entomophthorales, causing subcutaneous zygomycosis (Entomophthoromycosis)
- Conidiobolus and Basidiobolus.
 Zygomycosis
 Entomophthoromycosis
Zygomycosis in the debilitated patient is the most acute and fulminate fungal infection known.
The disease typically involves the rhino-facial-cranial area, lungs, gastrointestinal tract, skin,
or less commonly other organ systems. It is often associated with acidotic diabetes, starvation,
severe burns, intravenous drug abuse, and other diseases such as leukemia and lymphoma,
immunosuppressive therapy, or the use of cytotoxins and corticosteroids, therapy with
desferrioxamine (an iron chelating agent for the treatment of iron overload) and other major
trauma. The infecting fungi have a predilection for invading vessels of the arterial system,
causing embolization and subsequent necrosis of surrounding tissue. A rapid diagnosis is
extremely important if management and therapy are to be successful.
1. Rhinocerebral zygomycosis:
Predisposing factors include uncontrolled diabetes mellitus or acidosis, steroid induced
hyperglycemia, especially in patients with leukemia and lymphoma, renal transplant and
concomitant treatment with corticosteroids and azathioprine. Infections usually begin in the
paranasal sinuses following the inhalation of sporangiospores and may involve the orbit, palate,
face, nose or brain.
2. Pulmonary zygomycosis:
Predisposing conditions include haematological malignancies, lymphoma and leukemia, or
severe neutropenia, treatment with cytotoxins and corticosteroids, desferrioxamine therapy;
diabetes and organ transplantation. Infections result by inhalation of sporangiospores into the
bronchioles and alveoli, leading to pulmonary infraction and necrosis with cavitation.
3. Gastrointestinal zygomycosis:
A rare entity, usually associated with severe malnutrition, particularly in children, and
gastrointestinal diseases which disrupt the integrity of the mucosa. Primary infections
probable result following the ingestion of fungal elements and usually present as necrotic
ulcers.
4. Cutaneous zygomycosis:
Local traumatic implantation of fungal elements through the skin, especially in patients with
30
extensive burns, diabetes or steroid induced hyperglycemia and trauma. Lesions vary
considerably in morphology but include plaques, pustules, ulcerations, deep abscesses and
ragged necrotic patches.
5. Disseminated zygomycosis:
May originate from any of the above, especially in severely debilitated patients with
haematological malignancies, burns, diabetes or uraemia.
6. Central Nervous System alone:
Intravenous drug abuse. Traumatic implantation leading to brain abscess.
Skin scrapings from cutaneous lesions; sputum and needle biopsies from pulmonary lesions;
nasal discharges, scrapings and aspirates from sinuses in patients with rhinocerebral lesions;
and biopsy tissue from patients with gastrointestinal and/or disseminated disease.
Warning: zygomycetous fungi have primitive coenocytic hyphae that will often be damaged
and become non-viable during the biopsy procedure (especially scrapings and aspirates), or by
the chopping up or tissue grinding process in the laboratory. This is why zygomycetous fungi
that are clearly visible in direct microscopic or histopathological mounts are often difficult to
grow in culture from clinical specimens. If on clinical and/or radiological evidence
zygomycosis is suspected then try to avoid excessive tissue damage when collecting the
specimen and in the laboratory gently tease the tissue apart and inoculate it directly onto the
isolation media. If you are not sure hold the specimen in saline or BHI broth until the results
of the direct microscopy or frozen histology sections are known. If zygomycetous hyphae are
present proceed as above, otherwise homogenised the specimen and plate out.
(a) Scrapings, sputum and exudates should be examined using 10% KOH & Parker ink or
Calcofluor mounts; and (b) Tissue sections should be stained with H&E and GMS. Examine
specimens for broad, infrequently septate, thin-walled hyphae, which often show focal
bulbous dilations and irregular branching.
Interpretation:
As a rule, a positive direct microscopy, especially from a sterile site, should be considered
significant, even if the laboratory is unable to culture the fungus.
31
3. Culture:
Inoculate specimens onto primary isolation media, like Sabouraud's dextrose agar. Most
zygomycetes are sensitive to cycloheximide (actidione) and this agent should not be used in
culture media. Look for fast growing, white to grey or brownish, downy colonies.
Interpretation:
Despite being recognised as common laboratory contaminants, zygomycetes are infrequently
isolated in the clinical laboratory. Therefore, in patients with any of the above predisposing
conditions, especially diabetes or immunosuppression and/or clinical symptoms, the isolation
of any zygomycete fungus should be regarded as potentially significant. Obviously, in
patients without predisposing conditions, the isolation of a zygomycete from a non-sterile
site, such as skin or sputum, must be interpreted with caution, especially in the absence of
direct microscopy.
4. Serology:
zygomycosis. Although some laboratories have developed ELISA tests for the detection of
antibodies to Zygomycetes.
5. Identification:
Zygomycetes are usually fast growing fungi characterised by primitive coenocytic (mostly
aseptate) hyphae. Asexual spores include chlamydoconidia, conidia and sporangiospores
contained in sporangia borne on simple or branched sporangiophores. Sexual reproduction is
isogamous producing a thick-walled sexual resting spore called a zygospore.
Most isolates are heterothallic i.e. zygospores are absent, therefore identification is based
primarily on sporangial morphology. This includes the arrangement and number of
sporangiospores, shape, colour, presence or absence of columellae and apophyses, as well as
the arrangement of the sporangiophores and the presence or absence of rhizoids. Growth
temperature studies (25,37,45C) can also be helpful. Tease mounts are best, use a drop of
95% alcohol as a wetting agent to reduce air bubbles. Laboratory identification of some
zygomycetous fungi, especially Apophysomyces elegans and Saksenaea vasiformis may be
difficult or delayed because of the mould's failure to sporulate on the primary isolation media
or on subsequent subculture onto potato dextrose agar. Sporulation may be stimulated by the
use of nutrient deficient media, like cornmeal-glucose-sucrose-yeast extract agar, Czapek
Dox agar, or by using the agar block method on water agar.
Lichtheimia corymbifera, Apophysomyces elegans, Cunninghamella bertholletiae,
Mortierella wolfii, Mucor sp., Rhizomucor pusillus, Rhizopus arrhizus, Rhizopus sp.,
Saksenaea vasiformis.
Lobomycosis
Lobomycosis is a chronic, localised, subepidermal infection characterised by the presence of
keloidal, verrucoid, nodular lesions or sometimes by vegetating crusty plaques and tumours.
The lesions contain masses of spheroidal, yeast-like cells of Lacazia loboi. There is no
32
systemic spread. The disease has been found in humans and dolphins and is restricted to the
Amazon Valley in Brasil.
The initial infection is thought to be caused by traumatic implantation such as an arthropod

sting, snake bite, sting-ray sting, or wound acquired while cutting vegetation. The lesions
begin as small, hard nodules resembling keloids and may spread slowly in the dermis and
continue to develop over a period of many years. Older lesions become verrucoid and may
ulcerate. The disease may be transfered to other areas of of the skin by further trauma or
autoinoculation. Thus the areas of involvement may become quite extensive. Lesions are
usually found on the arms, legs, face or ears.
90% of cases are men, mostly in farmers and other high risk groups exposed to various harsh
conditions as well as aquatic habitats.
Tissue sample obtained by curettage or surgical biopsy.
(a) Tissue can be macerated and mounted in 10% KOH and Parker ink or calcofluor white
mounts or (b) Tissue sections should be stained using PAS digest, Grocott's methenamine
silver (GMS) or Gram stains.
Interpretation:
The presence of chains of darkly pigmented, spheroidal, yeast-like organisms tentatively
referred to as Loboa loboi is typical for lobomycosis.
3. Culture:
The aetiologic agent known as Loboa loboi remains to be cultured.
4. Serology:
There are currently no serological tests available.
5. Identification:
Clinical features, geographic location and microscopic morphology are important.
Lacazia loboi
Rhinosporidiosis
33
Rhinosporidium seeberi, first described by Malbran in 1892, is the causative agent of
rhinosporidiosis, a chronic subcutaneous mycosis. The infection is characterized by formation
of polypoid masses at nasal mucosa, conjunctiva, genitalia, and rectum. Fish and aquatic insects
are the natural reservoirs of R. seeberi.
The taxonomic classification of R. seeberi has long been controversial so far and has been
based solely on morphological properties. Microscopically, R. seeberi produces spherules in
infected tissue and these spherules are filled with endospores. Most interestingly, and
complicating the issue, this microorganism cannot be cultured in vitro on artificial media.
Based on these findings, while some investigators classified it as an ascomycetous fungus,
others preferred the term "fungus-like".
The taxonomy of R. seeberi was studied in more detail recently by molecular phylogenetic
analysis. Interestingly, the results of these studies revealed that the sequence of 18S SSU rDNA
from the R. seeberi isolates of two infected humans, a dog, and a swan proved to be identical
to each other and related to a group of fish parasites.
Of note, R. seeberi was placed within the DRIP clade (Dermatocystidium, rosette agent,
Ichtyophonus, and Psorospermium) in 1996. DRIP clade was later renamed as the class
Ichtyosporea in 1998, and most recently as the class Mesomycetozoea in 2002. The class
Mesomycetozoea includes a heterogeneous group of microorganisms that are at the animal-
fungal boundary and consists of two orders; Dermocystida and Ichthyophonida.
While the microorganisms included in the order Dermocystida are either pathogens of fish
(Dermocystidium spp. and the rosette agent) or of mammals and birds (R. seeberi), those in the
order of Ichthyophonida are either pathogens of fish or are saprophytic microorganisms. Thus,
R. seeberi now appears as the only microorganism that is classified in the class
Mesomycetozoea and is pathogenic to mammals and birds.
Future studies will hopefully provide more information about the morphological features and
pathogenicity of R. seeberi.
Dimorphic Systemic Mycoses

These are fungal infections of the body caused by fungal pathogens which can overcome the
physiological and cellular defences of the normal human host by changing their morphological
form. They are geographically restricted and the primary site of infection is usually pulmonary,
following the inhalation of conidia.
Blastomycosis Blastomyces dermatitidis Rare*
Coccidioidomycosis Coccidioides immitis Rare*
Histoplasmosis Histoplasma capsulatum Rare*
Paracoccidioidomycosis Paracoccidioides brasiliensis Rare*
Talaromyces marneffei infection Talaromyces marneffei Rare*
*more common in endemic areas.
34
Histopathology is especially useful and is one of the most important ways of alerting the
laboratory that they may be dealing with a potential pathogen.
Tissue morphology of dimorphic pathogens:
Mycosis Tisue morphology
Blastomycosis Large broad base unipolar budding yeast cells (8-10um).
Coccidioidomycosis Spherules (10-80um) with endospores (2-5um).
Small narrow base budding yeast cells (1-5um; 5-2um in var.
Histoplasmosis
duboisii)
Paracoccidioidomycosis Large narrow base, multi-budding yeast cells (20-60um).
Talaromyces marneffei Small, oval to ellipsoidal yeast-like cells (3 µm in diameter).
Sporotrichosis Small narrow base budding yeast cells (2-5um).
WARNING: Cultures of Blastomyces dermatitidis, Coccidioides immitis, Histoplasma
capsulatum and Talaromyces marneffei represent a severe biohazard to laboratory
personnel and must be handled with extreme caution in an appropriate pathogen
handling cabinet.
In the past microscopic morphology, conversion from the mould form to the yeast or spherule
form, and animal pathogenicity have all been used; however culture identification by either
exoantigen test or DNA sequencing is now preferred to minimise exposure to the infectious
propagules.
 Blastomycosis
Blastomycosis is a chronic granulomatous and suppurative disease having a primary
pulmonary stage that is frequently followed by dissemination to other body sites, chiefly the
skin and bone. Although the disease was long thought to be restricted to the North American
continent, in recent years autochthonous cases have been diagnosed in Africa, Asia and Europe.
All available clinical and epidemiological evidence indicates that humans and lower animals
contract blastomycosis from some source in nature. However, the natural habitat of B.
dermatitidis has yet to be clearly delineated, despite some reports of its isolation from soil.
Pulmonary blastomycosis: In most individuals pulmonary lesions are asymptomatic and are
not detected until the infection has spread to other organs. Others develop symptoms after an
incubation period of 3-15 weeks. In most cases blastomycosis is indolent in onset and patients
present with chronic symptoms such as cough, fever, malaise and weight loss. The lesions
become more extensive, with continued suppuration and eventual necrosis and cavitation.
Occasional patients present with an acute onset of infection, with development of high fever,
chills, productive cough, myalgia, arthralgia and pleuritic chest pain. Often these patient appear
to recover after 2-12 weeks of symptoms, but some will return months later with lesions at
other sites. Other patients with acute onset will fail to recover and will develop a chronic chest
infection or disseminated infection. Chest radiographic findings are variable and are not
diagnostic.
Cutaneous blastomycosis: Haematogenous spread gives rise to cutaneous lesions in over 70%
of patients. These tend to be painless and present either as raised verrucous lesions with
irregular borders, or as ulcers. The face, upper limbs, neck and scalp are the most frequent sites
involved.
35
Osteoarticular blastomycosis: Occurs in about 30% of patients with the spine, pelvis, cranial
bones, ribs and long bones most commonly involved. Patients often remain asymptomatic until
the infection spreads into contiguous joints, or into adjacent soft tissue causing subcutaneous
abscesses. Radiological findings are often non-specific and arthritis occurs in up to 10% of
patients.
Other forms include genitourinary blastomycosis involving the prostrate, epididymis or testis;
haematogenous spread to the brain causing meningitis, and spinal or brain abscess. Other
organs may also be involved and choroiditis and endophthalmitis have been reported.
AIDS patient have developed fulminant blastomycosis with widespread dissemination
following endogenous reactivation of previous infection.
Skin scrapings, sputum and bronchial washings, cerebrospinal fluid, pleural fluid and blood,
bone marrow, urine and tissue biopsies from various visceral organs.
either 10% KOH and Parker ink or calcofluor white mounts, (c) Tissue sections should be
stained using PAS digest, Grocott's methenamine silver (GMS) or Gram stain.
Note: Tissue sections need to be stained by Grocott's methenamine silver method to clearly
see the yeast-like cells, which are often difficult to observe in H&E preparations.
Interpretation:
As a rule, a positive direct microscopy demonstrating characteristic yeast-like cells from any
specimen should be considered significant.
3. Culture:
Interpretation:
A positive culture from any of the above specimens should be considered significant.
36
WARNING:
Cultures of Blastomyces dermatitidis represent a severe biohazard to laboratory personnel
and must be handled with extreme caution in an appropriate pathogen handling cabinet.
4. Serology:
Serological tests are of limited value in the diagnosis of Blastomycosis.
5. Identification:
In the past microscopic morphology, conversion from the mould form to the yeast form, and
animal pathogenicity have all been used; however however culture identification by either
exoantigen test or DNA sequencing is now preferred to minimise exposure to the infectious
propagules.
Blastomyces dermatitidis
Coccidioidomycosis
Coccidioidomycosis is initially, a respiratory infection, resulting from the inhalation of conidia,
that typically resolves rapidly leaving the patient with a strong specific immunity to re-
infection. However, in some individuals the disease may progress to a chronic pulmonary
condition or to a systemic disease involving the meninges, bones, joints and subcutaneous and
cutaneous tissues. Coccidioides immitis is a soil inhabiting fungus endemic in south-western
U.S.A., northern Mexico and various centres in South America. Several cases have now been
diagnosed in Australia, all in patients with a history of travel to endemic areas.
60% of individuals suffer a benign and transient chest infection that does not require medical
attention. Of the 40% who develop symptoms, most will have an acute febrile "flu-like" illness
starting 7-28 days (average 10-16 days) after exposure and most patients will recover
completely. The main symptoms are fever, pleuritic chest pain, cough, malaise, headache,
myalgia, night sweats and loss of appetite. Many patients also develop a mild, diffuse
erythematous or maculopapular rash on the trunk and limbs. However, 5-10% of patients that
do develop symptoms are left with pulmonary residual nodule or cavity that is usually detected
several months or years later. Another 5% of patients may develop metapulmonary
dissemination to the meninges, bones, joints and subcutaneous and cutaneous tissues, within
the first few weeks to months after the onset of primary infection .
37
Interpretation:
As a rule, a positive direct microscopy demonstrating spherules (10-80um) with endospores
(2-5um) from any specimen should be considered significant.
3. Culture:
Interpretation:
WARNING:
Cultures of Coccidioides immitis represent a severe biohazard to laboratory personnel and
must be handled with extreme caution in an appropriate pathogen handling cabinet. .
4. Serology:
Immunodiffusion and/or complement fixation tests for the detection of antibody have proven
to be useful in the diagnosis of Coccidioidomycosis especially in immunocompetent patients.
However, detection of antibodies in immunosuppressed patients is often difficult, with
between 20-50% of patients testing negative.
5. Identification:
In the past microscopic morphology, conversion from the mould form to the yeast or spherule
form, and animal pathogenicity have all been used; however however culture identification
by either exoantigen test or DNA sequencing is now preferred to minimise exposure to the
infectious propagules.
Coccidioides immitis
Histoplasmosis
Histoplasmosis is an intracellular mycotic infection of the reticuloendothelial system caused
by the inhalation of conidia from the fungus Histoplasma capsulatum. Histoplasmosis has a
world wide distribution, however, the Mississippi-Ohio River Valley in the U.S.A. is
recognized as a major endemic region. Africa, Australia and parts of East Asia, in particular
India and Malaysia are also endemic regions.
38
Environmental isolations of the fungus have been made from soil enriched with excreta from
chicken, starlings and bats. Three varieties of Histoplasma capsulatum are recognised,
depending on the clinical disease: var. capsulatum is the common cause of histoplasmosis; var.
duboisii is the African type and var. farciminosum causes lymphangitis in horses. Histoplasma
isolates may also resemble species of Sepedonium and Chrysosporium. Traditionally, positive
identification required conversion of the mould form to the yeast phase by growth at 37C on
enriched media, however for laboratory safety, culture identification by either exoantigen test
or DNA sequencing is now preferred.
o
Approximately 95% of cases of histoplasmosis are inapparent, subclinical or benign. Five
percent of the cases have chronic progressive lung disease, chronic cutaneous or systemic
disease or an acute fulminating fatal systemic disease. All stages of this disease may mimic
tuberculosis.
Interpretation:
As a rule, a positive direct microscopy demonstrating characteristic yeast-like cells from any
specimen should be considered significant.
39
3. Culture:
Interpretation:
WARNING:
Cultures of H. capsulatum represent a severe biohazard to laboratory personnel and must be
handled with extreme caution in an appropriate pathogen handling cabinet.
4. Serology:
Immunodiffusion and/or complement fixation tests for the detection of antibody have proven
to be useful in the diagnosis of Histoplasmosis, especially in immunocompetent patients.
However, detection of antibodies in immunosuppressed patients is often difficult, with
between 20-50% of patients testing negative.
5. Identification:
Three varieties of Histoplasma capsulatum are recognised, depending on the clinical disease:
var. capsulatum is the common cause of histoplasmosis; var. duboisii is the African type and
var. farciminosum causes lymphangitis in horses. Histoplasma isolates may also resemble
species of Sepedonium and Chrysosporium. Traditionally, positive identification required
conversion of the mould form to the yeast phase by growth at 37C on enriched media,
however for laboratory safety, culture identification by either exoantigen test or DNA
sequencing is now preferred.
Histoplasma capsulatum
Paracoccidioidomycosis
Paracoccidioidomycosis is a chronic granulomatous disease that characteristically produces a
primary pulmonary infection, often inapparent, and then disseminates to form ulcerative
granulomata of the buccal, nasal and occasionally the gastrointestinal mucosa. The disease in
its inception and development is similar to blastomycosis and coccidioidomycosis. The only
etiological agent, Paracoccidioides brasiliensis is geographically restricted to areas of South
and Central America.
Clinical manifestions vary from subclinical infections that are detected only by skin-test
positivity; to chronic unifocal infection where only a single organ is involved; to chronic
multifocal infection where more than one organ is involved. A subacute juvenile infection is
also recognised.
Pulmonary paracoccidioidomycosis:
Most cases have an indolent onset and patients present with chronic symptoms such as cough,
fever, night sweats, malaise and weight loss. Chest x-rays are characteristic but not
diagnostic. The infection must be distinguished from histoplasmosis and tuberculosis.
40
Mucocutaneous paracoccidioidomycosis:
The mouth and nose are the most usual mucosal sites of infection. Painful ulcerated lesions
develop on the gums, tongue, lips or palate and can progress over weeks or months.
Perforation of the palate or nasal septum may occur. Cutaneous lesions often appear on the
face around the mouth and nose, although patient with severe infection can have widespread
lesions.
Lymphonodular paracoccidioidomycosis:
Lymphadenitis is common in younger patients. Cervical and submandibular chains are the
most obvious manifestation and lymph nodes may progress to form abscesses with draining
sinuses.
Disseminated paracoccidioidomycosis:
Haematogenous spread of P. brasiliensis can resulkt in widespread disseminated disease;
including lesions of the small or large intestine, hepatic lesions, adrenal gland destruction,
osteomyelitis, arthritis, endophthalmitis and meningoencephalitis or focal cerebral lesions.
bone marrow, and tissue biopsies from various visceral organs.
Interpretation:
As a rule, a positive direct microscopy demonstrating the presence of large, 20-60 um, round,
narrow base budding yeast cells with multiple budding "steering wheels" from any specimen
should be considered significant.
3. Culture:
41
Interpretation:
4. Identification:
Clinical history, tissue pathology, culture identification with conversion to the yeast phase at
37C are important characters.
Paracoccidioides brasiliensis
Talaromyces marneffei infection

Talaromyces marneffei exhibits thermal dimorphism by growing in living tissue or in culture
at 37C as a yeast-like fungus or in culture at temperatures below 30C as a mould. It has a
propensity to cause disease in the normal host, as well as in immunosuppressed patients, but
significantly, it has now become a major opportunistic pathogen in HIV positive patients in
Indochina. Over 300 cases have been reported with the majority of these coming from Chiang
Mai in northern Thailand. Other predisposing factors include lymphoproliferative disorders,
bronchiectasis and tuberculosis, autoimmune diseases and corticosteroid therapy. To date, all
naturally occurring infections have been in residents of, or travellers to, southeast Asia;
especially northern Thailand, Vietnam, Hong Kong, Taiwan and southern China. Imported
cases of P. marneffei infections have been reported from Australia, France, Italy, Netherlands,
UK and USA.
In patients with normal immunity, T. marneffei infection may either be disseminated or focal.
In the latter, both clinical and histological appearances may strongly resemble tuberculosis (eg.
suppurative lymphadenopathy). In HIV patients, T. marneffei infection is usually disseminated
at diagnosis. Commonly the skin, reticuloendothelial system, lung and gut are infected.
Fungaemia is present in the majority of cases and other organ systems including kidney, bones,
joints and pericardium may also be involved. Patients usually present with non-specific
symptoms of fever, anaemia and weight loss. Skin lesions are most commonly papules often
with a central necrotic umbilication similar in appearance to those seen in molluscum
contagiosum and are usually located on the face, trunk and extremities. In many cases
numerous subcutaneous abscesses ulcerate over time. It is important to note that the clinical
symptoms of disseminated infection by T. marneffei mimic those seen in AIDS patients with
disseminated cryptococcal infection or disseminated histoplasmosis.
Finally, little is known about the ecology, epidemiology or pathogenesis of T.

marneffei infection. Although bamboo rats are known to be asymptomatic carriers of the
fungus, it is unclear whether they are an important reservoir for human infection or only a
sentinel animal that is susceptible to infection from an environmental source. Human infections
have been reported following traumatic implantation, enteric spread following the eating of
bamboo rats as "game cuisine" and by inhalation of spores from soil or possibly a specific host
plant. T. marneffei has been isolated from bamboo rat burrows and the current consensus would
favour soil as the most likely reservoir with transmission to humans via the respiratory route,
42
similar to that seen with other dimorphic fungi. However this remains to be proven and for now
the natural habitat of the fungus and an explanation for its geographic restriction remain
unknown.
Talaromyces marneffei is the only dimorphic member of the genus Talaromyces and is
readily detected by direct microscopy and culture of infected tissues, especially skin lesions,
bone marrow, blood and lymph nodes.
A Giemsa stained touch smear of a skin biopsy or bone marrow aspirate is a rapid and
sensitive diagnostic method that readily demonstrates the presence of typical yeast-like cells
with a central septa, either within histiocytes or scattered through the tissue. The yeast-cells
are spherical to ellipsoidal, 2 to 6 um in diameter, and divide by fission rather than budding, a
characteristic visible on stained touch smears that distinguishes T.
marneffei from Histoplasma capsulatum.
Tissue sections show small, oval to elliptical yeast-like cells, 3um in diameter, either packed
within histiocytes or scattered through the tissue. Occasional, large, elongated sausage shaped
cells, up to 8 um long, with distinctive septa may be present. Note: tissue sections need to be
stained by Grocott's methenamine silver method to clearly see the yeast-like cells, which are
often difficult to observe in H&E preparations.
3. Culture:
dextrose agar.
4. Serology:
Talaromyces marneffei infection.
5. Identification:
Clinical history, tissue morphology and culture identification.
Talaromyces marneffei
Opportunistic Systemic Mycoses
43
These are fungal infections of the body which occur almost exclusively in debilitated patients
whose normal defence mechanisms are impaired.
The organisms involved are cosmopolitan fungi which have a very low inherent virulence. The
increased incidence of these infections and the diversity of fungi causing them, has parallelled
the emergence of AIDS, more aggressive cancer and post-transplantation chemotherapy and
the use of antibiotics, cytotoxins, immunosuppressives, corticosteroids and other macro
disruptive procedures that result in lowered resistance of the host.
Candida, Debaryomyces, Kluyveromyces,
Candidiasis Common
Meyerozyma, Pichia, etc.
Cryptococcosis Cryptococcus spp. especially C. neoformans/C. gattii Rare/Common
Aspergillus fumigatus complex, A. flavus, complex,
Aspergillosis Rare
A. terreus complex etc.
Scedosporiosis
Scedosporium and Lomentospora. Rare
(Pseudallescheriasis)
Zygomycosis Rhizopus, Mucor, Rhizomucor,
Rare
(Mucormycosis) Lichtheimia etc.
Penicillium, Paecilomyces,
Hyalohyphomycosis Beauveria, Fusarium, Rare
Scopulariopsis etc.
Cladophialophora, Exophiala, Bipolaris,
Exserohilum etc.
 Candidiasis
Candidiasis is a primary or secondary mycotic infection caused by members of the
genus Candida and other related genera. The clinical manifestations may be acute, subacute or
chronic to episodic. Involvement may be localized to the mouth, throat, skin, scalp, vagina,
fingers, nails, bronchi, lungs, or the gastrointestinal tract, or become systemic as in septicemia,
endocarditis and meningitis. In healthy individuals, Candida infections are usually due to
impaired epithelial barrier functions and occur in all age groups, but are most common in the
newborn and the elderly. They usually remain superficial and respond readily to treatment.
Systemic candidiasis is usually seen in patients with cell-mediated immune deficiency, and
those receiving aggressive cancer treatment, immunosuppression, or transplantation therapy.
1. Oropharyngeal candidiasis: including thrush, glossitis, stomatitis and angular
cheilitis.
44
Acute oral candidiasis is rarely seen in healthy adults but may occur in up to 5% of newborn
infants and 10% of the elderly. However, it is often associated with severe immunological
impairment due to diabetes mellitus, leukemia, lymphoma, malignancy, neutropenia and HIV
infection where it presents as a predictor of clinical progression to AIDS. The use of broad-
spectrum antibiotics, corticosteroids, cytotoxic drugs, and radiation therapy are also
predisposing factors. Clinically, white plaques that resemble milk curd form on the buccal
mucosa and less commonly on the tongue, gums, the palate or the pharynx. Symptoms may be
absent or include burning or dryness of the mouth, loss of taste, and pain on swallowing.
2. Cutaneous candidiasis: including intertrigo, diaper candidiasis, paronychia and
onychomycosis.
Intertriginous candidiasis is most commonly seen in the axillae, groin, inter- and sub-mammary
folds, intergluteal folds, interdigital spaces, and umbilicus. Moisture, heat, friction and
maceration of the skin are the principle predisposing factors in the normal patient, however
obesity, diabetes mellitus, warm water immersion or occlusion of the skin and the use of broad-
spectrum antibiotics are additional factors. Lesions consist of a moist, macular erythematous
rash with typical satellite lesions present on the surrounding healthy skin.
Diaper candidiasis is common in infants under unhygienic conditions of chronic moisture and
local skin maceration associated with ammonitic irritation due to irregularly changed unclean
diapers. Once again characteristic erythematous lesions with erosions and satellite pustules are
produced, with prominent involvement of the skin folds and creases.
Paronychia of the finger nails may develop in persons whose hands are subject to continuous
wetting, especially with sugar solutions or contact with flour, that macerates the nail folds and
cuticle. Lesions are characterized by the development of a painful, erythematous swelling about
the affected nails. In chronic cases the infection may progress to cause onychomycosis with
total detachment of the cuticle from the nail plate.
45
Chronic Candida onychomycosis often causes complete destruction of nail tissue and is seen
in patients with chronic mucocutaneous candidiasis or other underlying factors that affect either
the hormonal or immunologic status of the host. These include diabetes mellitus,
hypoparathyroidism, Addison's disease, dysfunction of the thyroid, malnutrition,
malabsorption and various malignancies. The use of steroids, antibiotics and antimitotics may
also be contributing factors.
3. Vulvovaginal candidiasis and balanitis:
Vulvovaginal candidiasis is a common condition in women, often associated with the use of
broad-spectrum antibiotics, the third trimester of pregnancy, low vaginal pH and diabetes
mellitus. Sexual activity and oral contraception may also be contributing factors and infections
may extend to include the perineum, the vulva and the entire inguinal area. Chronic refractory
vaginal candidiasis, associated with oral candidiasis, may also be a presentation of HIV
infection or AIDS. Symptoms include intense vulval pruritus, burning, erythema and
dyspareunia associated with a creamy white, curd-like discharge.
In cases of balanitis, diabetes mellitus should be excluded and the sexual partner should be
investigated for vulvovaginitis. The symptoms include erythema, pruritus and vesiculopustules
on the glan penis or prepuce. Infections are more commonly seen in uncircumcised men and
poor hygiene may also be a contributing factor.
4. Chronic mucocutaneous candidiasis:
Chronic mucocutaneous candidiasis is a form of persistent candidiasis, usually caused by C.
albicans, of the skin, nails and mucous membranes that occurs in patients with various
metabolic disturbances to cell-mediated immunity. These include defects in leukocyte function
or endocrine disorders such as hypoparathyroidism, Addison's disease, hypothyroidism,
diabetes, dysfunction of the thyroid and polyglandular autoimmune disease. The patients are
usually children. Candida granuloma is a severe localized form which may occur with or
without endocinopathy characterized by marked hyperkeratic granulomatous lesions.
5. Neonatal and congenital candidiasis:
Low birthweight and age, prolonged intravascular catheterization and the use of antibiotic
drugs are the principle predisposing conditions for systemic candidiasis in neonates. Blood
cultures are often positive and there is also a high incidence of meningitis. Renal complications
due to fungus ball formation in the ureters or renal pelvis may also occur. Congenital
candidiasis acquired in utero is usually confined to the skin in the form of a generalized
erythematous vesicular rash, however intrauterine candidiasis may also result in abortion.
6. Oesophageal candidiasis:
Oesophageal candidiasis is frequently associated with AIDS and severe immunosuppression
following treatment for leukemia or solid tumors. Concomitant oral candidiasis is often present.
Oesophagitis may also lead to septicemia and disseminated candidiasis. Symptoms include
burning pain in the substernal area, dysphagia, nausea and vomiting. The clinical diagnosis
relies on radiological and endoscopic findings, which usually shows white mucosal plaques
with erythema resembling those seen in oral candidiasis. Herpes simplex or cytomegalovirus
(CMV) infection may also be present and the clinical diagnosis may need to be confirmed by
histopathology and culture.
46
7. Gastrointestinal candidiasis:
Patients with acute leukemia or other hematological malignancies may have numerous
ulcerations of the stomach and less commonly the duodenum and intestine. Perforation can
lead to peritonitis and hematogenous spread to the liver, spleen and other organs. Colonization
and invasion of the stomach or intestinal mucosa is often accompanied by the excretion of large
numbers of yeasts which may be detected in stools.
8. Pulmonary candidiasis:
Pulmonary candidiasis can be acquired by either hematogenous dissemination causing a diffuse
pneumonia or by bronchial extension in patients with oropharyngeal candidiasis. Aspiration of
yeasts from the oral cavity has also been reported in infants. Pulmonary candidiasis is difficult
to diagnose due to non-specific radiological and culture findings and most patients, especially
those with granulocytopenia, present at autopsy. The presence of yeasts in alveolar lavage or
sputum specimens is not specific and blood cultures may also be negative. Unfortunately, only
histopathology can provide a definitive diagnosis and this is not always possible in patients
with coagulation problems.
9. Peritonitis:
Candida peritonitis can result from colonization of indwelling catheters used for peritoneal
dialysis (CAPD) or gastrointestinal perforation due to ulcers, diverticular colitis, surgery or
intra-abdominal neoplasm. Symptoms include fever, abdominal pain, tenderness and a cloudy
peritoneal dialysate containing greater than 100 leukocytes/mm3. Candida peritonitis usually
remains localized to the abdominal cavity unless patients are severely immunosuppressed.
10. Urinary tract candidiasis:
Transient asymptomatic candiduria may occur during antibiotic or corticosteroid treatment
which promotes the growth of Candida, throughout the gastrointestinal and genital tracts, and
most lower urinary tract infections result from local spread of yeasts from these sites. This
condition is most common in women. Candida cystitis or bladder colonization may be caused
by prolonged catheterization with concomitant antibiotic treatment, diabetes and glycosuria,
anatomical uropathy, previous bladder endoscopy or surgery, diabetic neurogenic bladder,
chronic outlet obstruction from prostatic hypertrophy, or pelvic irradiation for cervical cancer.
Renal candidiasis (pyelonephritis) is usually the result of either an ascending infection or more
frequently, hematogenous dissemination from another organ focus. Symptoms include fever,
rigors, lumbar pain and abdominal pain. The development of a fungus ball in the renal pelvis,
although rare may complicate the infection. Predisposing factors for this include constriction
of the urinary tract, localized papillary necrosis, urethral or bladder catheters and diabetes.
Even though, up to 80% of patients with disseminated candidiasis also have renal infection and
associated candiduria, urine cultures alone are not a reliable method for diagnosis of
disseminated infection.
The practical problem in a patient with candiduria is to distinguish between colonization and/or
contamination and infection. Therefore, it is important to determine whether renal function is
present or whether infection is confined to the bladder. Mycological findings are usually
inconclusive which makes the clinical parameters important. The following criteria are
suggestive of renal infection; the isolation of yeasts in urine specimens obtained by suprapubic
aspiration, positive blood cultures and a positive immunodiffusion precipitin test result or
serological conversion in a patient with iatrogenic predisposing factors and/or an underlying
illness.
It should be noted that many clinicians do not recommend suprapubic aspirates as they are
invasive and require additional expertise, especially in immunocompromised patients.
Laboratories are also advised on the need to report the isolation of any yeasts from urine
specimens obtained from high risk immunosuppressed patients.
11. Meningitis:
47
Candida meningitis is a rare entity, predominantly seen in low birthweight neonates with
septicemia and in patients with hematological malignancies, complicated neurosurgery or
intracerebral prosthetic devices such as ventriculoperitoneal shunts. Symptoms include a
feverish meningeal irritation. Diagnosis in the neonate requires a high index of suspicion by
the clinician to the possibility of meningitis as a sequel to septicemia. The detection
of Candida cells in smears and its isolation from CSF is often difficult.
12. Hepatic and hepatosplenic candidiasis:
Hepatosplenic candidiasis occurs in patients with severe neutropenia, usually acute leukemia.
Symptoms include fever, hepatosplenomegaly and increased blood concentrations of alkaline
phosphatases. Histopathology shows diffuse hepatic and/or splenic necrotic lesions or
abscesses containing small numbers of pseudohyphae. However, blood and biopsy cultures are
usually culture negative. A definitive diagnosis is often difficult due to the inability to
adequately biopsy these patients.
13. Endocarditis, myocarditis and pericarditis:
Endocarditis is the most common form of cardiac candidiasis. Pre-existing valvular disease
with concomitant intravenous catheterization and antibiotic treatment, intravenous drug abuse,
heart surgery and valve prosthesis are the most common predisposing factors. Clinical
symptoms include fever, murmur, congestive heart failure, anemia and splenomegaly. Blood
cultures are often positive and echocardiology and serology for the detection of Candida
antibodies (immunodiffusion precipitin tests) are other useful diagnostic procedures.
Myocardial abscesses, arterial emboli and purulent pericarditis are additional rare
complications of Candida septicemia or surgery.
14. Candidemia (Candida septicemia) and disseminated candidiasis:
Candidemia has been defined as the presence of yeasts in the blood with or without visceral
involvement. Hematogenous dissemination may then occur to one or more other organ systems
with the formation of numerous microabscesses. Candida species have been reported to cause
up to 15% of cases of septicemia seen in hospital patients.
Predisposing factors include intravenous catheters, use of antibacterial drugs, urinary catheters,
surgical procedures, corticosteroid therapy, neutropenia, severe burns, parental nutrition, and
chemotherapy induced impairment of oropharyngeal or gastrointestinal mucosa. A
characteristic presentation is antibiotic resistant fevers in the neutropenic patient with
tachycardia and dyspnea. Hypotension is also common and skin lesions may also occur.
When yeasts are isolated from blood or from tissue biopsies a diagnosis is straightforward,
however this is not often the case. Blood cultures often remain negative even in patients dying
from proven disseminated candidiasis, especially in the granulocytopenic patient. If at all
possible, suspected foci should be aspirated, including articular, peritoneal, CSF, or even vitreal
specimens; and liver and/or lung biopsies should also be performed. However histopathology
is more often not a viable option because biopsies are contraindicated due to the patients
underlying illness. Finally, the detection of yeasts from more accessible no-sterile sites, like
urine, is too common to be of diagnostic value. In this situation, of clinically suspected
unproven disseminated candidiasis, only cutaneous and/or ocular lesions can rapidly confirm
the diagnosis. Specific, reliable serological tests are still not generally available. Empiric
antifungal treatment is usually initiated in these cases.
48
15. Ocular candidiasis:
Candida endophthalmitis is often associated with candidemia, indwelling catheters or drug
abuse, however it is rare in patients with severe neutropenia. Lesions are often localized near
the macula and patients complain of cloudy vision. Exogenous Candida endophthalmitis is
rare, but cases have been reported following ocular trauma or surgery. Similarly, conjunctival
and corneal infections have also been recorded following trauma.
16. Osteoarticular candidiasis:
Arthritis may be a late sequel of candidemia in neonates or neutropenic patients. Prosthetic or
rheumatoid joints are also prone to infection by Candida either by hematogenous spread or
direct inoculation during surgery or intra-articular corticosteroid injection. The knee is the main
site involved with pain on weight bearing or on full extension. The diagnosis depends on the
isolation of yeasts from joint fluid obtained by needle aspiration or from synovial biopsies.
17. Other forms of candidiasis:
As candidiasis is an iatrogenic, nosocomial infection which is usually endogenous in origin
many other clinical manifestations may occur, especially in the debilitated patient. For
example, the reported cutaneous, ocular and arthritic manifestations reported in heroin addicts;
fever, rash and myalgia associated with leukemia patients;
Candida cholecystitis; Candida prostatitis; pancreatic abscesses; epiglottitis and osteomyelitis,
to name a few.
Summary of clinical groups and/or predisposing factors for invasive candidiasis.
Neutropenia (especially >7 days).
Hematological malignancy.
Solid tumor malignancy.
Postsurgical intensive care patients.
Prolonged intravenous catheterization.
Broad-spectrum or multiple antibiotic therapy.
Diabetes mellitis.
Parental nutrition.
Severe burns.
Neonates.
Corticosteroid therapy.
Intravenous drug abuse.
49
(a) Skin and nails should be examined using 10% KOH and Parker ink or calcofluor white
either 10% KOH and Parker ink or calcofluor white mounts and/or gram stained smears; (c)
Gram stain. Note Candida may be missed in H&E stained sections. Examine specimens for the
presence of small, round to oval, thin-walled, clusters of budding yeast cells (blastoconidia)
and branching pseudohyphae. Candida pseudohyphae may be difficult to distinguish from
Aspergillus hyphae when blastoconidia are not observed as often happens in liver biopsies.
Interpretation:
As a rule, a positive direct microscopy from a sterile site, especially a tissue biopsy, should be
considered significant, even if the laboratory is unable to culture the yeast. Further, the
demonstration of pseudohyphae in scrapings or smears from cutaneous, oral, esophageal and
vaginal lesions should be considered significant, provided the clinical manifestations support
the diagnosis. However, the finding of just budding yeast cells in such material is of little
diagnostic importance. Note, pseudohyphae will not be observed in smears when C.
glabrata is involved and the diagnosis will require additional supporting evidence. Direct
microscopy of sterile body fluids, such as CSF, vitreous humor, joint fluid and peritoneal fluid
is relatively insensitive and positive culture will usually be required to make a diagnosis.
3. Culture:
Colonies are typically white to cream colored with a smooth, glabrous to waxy surface.
Interpretation:
A positive culture from blood, or other sterile body fluid, or tissue biopsy should be considered
significant. Lysis centrifugation is currently the most sensitive method for the isolation
of Candida from blood. However, positive culture from non-sterile specimens such as sputum,
bronchial lavage, esophageal brushings, urine, stool, and surgical drains are of little diagnostic
value. Similarly, culture of skin or mucous membrane lesions without supporting evidence
from direct microscopy is not diagnostic. Candida species are commonly isolated from the
mouth, vagina, anus, and less often, moist skin surfaces of normal individuals who do not have
candidiasis.
4. Serology:
Various serological procedures have been devised to detect the presence
of Candida antibodies, ranging from immunodiffusion to more sensitive tests such as counter
50
immunoelectrophoresis (CIE), enzyme-linked immunosorbent assay (ELISA), and
radioimmunoassay (RIA). However, these are often negative in the immunocompromised
patient, especially at the beginning of an infection. The production of four or more precipitin
lines in CIE tests has been reported to be diagnostic of candidiasis in the predisposed patient .
Tests for circulating antigen by immunological or non-immunological means have also been
developed. Of the non-immunological techniques, use of gas liquid chromography (GLC) to
detect mannose derivatives of the cell wall or a metabolic by-product, D-arabinitol, have
proved the most useful. The detection of antigen by immunological methods such as ELISA or
RIA have been used, however for the small laboratory latex agglutination tests for glycoprotien
antigen have proved to be the most useful, although variable results have been reported.
It must be stressed that the interpretation of serological tests for Candida, especially in the
neutropenic patient, is often difficult and must be correlated with other diagnostic methods.
False-negatives and false-positive results do occur. Hopwood and Evans (1991) provide an
excellent review of the current serological methods available.
5. Identification:
The genus Candida is characterized by globose to elongate yeast-like cells or blastoconidia
that reproduce by multilateral budding. Most Candida species are also characterized by the
presence of well developed pseudohyphae, however this characteristic may be absent,
especially in those species formally included in the genus Torulopsis. Arthroconidia,
ballistoconidia and colony pigmentation are always absent. Within the genus Candida,
fermentation, nitrate assimilation and inositol assimilation may be present or absent, however,
all inositol positive strains produce pseudohyphae.
Causative agents:
 Candida albicans
Candida catenulata
Candida dubliniensis
Candida glabrata complex
Candida haemulonii
Candida inconspicua
Candida parapsilosis complex
Candida rugosa
Candida tropicalis
Clavispora lusitaniae (formerly Candida lusitaniae)
Cyberlindnera fabianii (formerly Candida fabianii)
Debaryomyces hansenii (formerly Candida famata)
Kluyveromyces marxianus (formerly Candida kefyr)
Meyerozyma guilliermondii (formerly Candida guilliermondii)
Pichia kudriavzevii (formerly Candida krusei)
Pichia norvegensis (formerly Candida norvegensis)
Torulaspora delbrueckii (formerly Candida colliculosa)
Wickerhamomyces anomalus (formerly Candida pelliculosa)
Yarrowia lipolytica (formerly Candida lipolytica)
Management: see treatment guidelines section.
Cryptococcosis
Cryptococcosis is a chronic, subacute to acute pulmonary, systemic or meningitic disease,
initiated by the inhalation of infectious propagules (basidiospores and/or desiccated yeast cells)
from the environment. Primary pulmonary infections have no diagnostic symptoms and are
usually subclinical. On dissemination, the fungus usually shows a predilection for the central
51
nervous system, however skin, bones and other visceral organs may also become involved.
Although C. neoformans and C. gattii are regarded as the principle pathogenic
species, Cryptococcus albidus and C. laurentii have on occasion also been implicated in
human infection.
Cryptococcus is an encapsulated basidiomycete yeast-like fungus with a predilection for the
respiratory and nervous system of humans and animals. Two species, C.
neoformans and C. gattii are distinguishable biochemically and by molecular techniques.
In humans, C. neoformans affects immunocompromised hosts predominantly and is the
commonest cause of fungal meningitis; worldwide, 7-10% of patients with AIDS are affected.
AIDS associated cryptococcosis accounts for 50% of all cryptococcal infections reported
annually and usually occurs in HIV patients when their CD4 lymphocyte count is below
200/mm3. Meningitis is the predominant clinical presentation with fever and headache as the
most common symptoms. Secondary cutaneous infections occur in up to 15% of patients with
disseminated cryptococcosis and often indicate a poor prognosis. Lesions usually begin as
small papules that subsequently ulcerate, but may also present as abscesses, erythematous
nodules, or cellulitis. This variety is found worldwide.
In contrast, the distribution of cryptococcosis due to Cryptococcus gattii is geographically
restricted, non-immunocompromised hosts are usually affected, large mass lesions in lung
and/or brain (cryptococcomas) are characteristic and morbidity from neurological disease is
high. Human disease is endemic in Australia, Papua New Guinea, parts of Africa, the
Mediterranean region, India, south-east Asia, Mexico, Brazil, Paraguay and Southern
California.
1. Pulmonary Cryptococcosis:
Asymptomatic carriage of Cryptococcus has been reported from the respiratory tract,
especially sputum and from skin in healthy people as a result of normal environmental
exposure. In addition, patients with chronic lung disease, such as bronchitis and bronchiectasis,
may also have asymptomatic colonization, with Cryptococcus being isolated from their sputum
over many years.
Subclinical cryptococcosis may result of environmental exposure, normal individuals may
experience a self-limiting pneumonia with accompanying sensitization. Most primary
infections of this type have no diagnostic symptoms and are usually discovered only by routine
chest x-ray. When present, symptoms include cough, low-grade fever and pleuritic pain.
Invasive pulmonary cryptococcosis may occur in some patients when primary infections may
not readily resolve in some patients, leading to a more chronic pneumonia progressing slowly
over several years. Patients may become pyrexic and have an accompanying cough, however
many pulmonary lesions are often asymptomatic, especially when chronic granulomas are
formed. Chronic pulmonary cryptococcosis also increases the risk of dissemination to the
central nervous system.
2. Central Nervous System:
52
Dissemination to the brain and meninges is the most common clinical manifestation of
cryptococcosis and includes meningitis, meningoencephalitis or expanding cryptococcoma.
Meningitis is the most common clinical form, accounting for up to 85% of the total number of
cases, however the clinical signs are rarely dramatic. Symptoms usually develop slowly over
several months, and initially include headache, followed by drowsiness, dizziness, irritability,
confusion, nausea, vomiting, neck stiffness and focal neurological defects, such as ataxia.
Diminishing visual acuity and coma may also occur in later stages of the infection. Acute onset
cases may also occur, especially in patients with widespread disease, and these patients may
deteriorate rapidly and die in a matter of weeks.
Meningoencephalitis due to invasion of the cerebral cortex, brain stem and cerebellum is an
uncommon, rapid fulminate infection, often leading to coma and death within a short time.
Symptoms include slow response to treatment and signs of cerebral edema or hydrocephalitis,
especially papilledema.

Cryptococcoma is a rare entity, characterized by localized, solid, tumor-like masses, usually
found in the cerebral hemispheres or cerebellum, or more rarely in the spinal cord. Symptoms
are consistent with an expanding intracranial mass and include headache, drowsiness, nausea,
vomiting, mental changes, slurred speech, double vision, unsteadiness of gait, coma, paralysis
and hemiparesis. These symptoms may mimic cerebral neoplasm which may delay a true
diagnosis.
3. Cutaneous Cryptococcosis:
Primary cutaneous cryptococcosis in the form of ulcerated lesions or cellulitis occasionally
occurs, especially in immunosuppressed patients. These lesions may resolve spontaneously or
with systemic antifungal treatment. However, all patients with skin lesions should be monitored
carefully for possible dissemination to the central nervous system.
Secondary cutaneous infections occur in up to 15% of patients with disseminated
cryptococcosis and often indicate a poor prognosis. Lesions usually begin as small papules that
subsequently ulcerate, but may also present as abscesses, erythematous nodules, or cellulitis.
In patients with AIDS, skin manifestations represent the second most common site of
disseminated cryptococcosis. Lesions often occur on the head and neck and may present as
papules, nodules, plaques, ulcers, abscesses, cutaneous ulcerated plaques, herpetiform lesions,
lesions simulating both molluscum contagiosum and Kaposi's sarcoma. Anal ulceration may
also occur.
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4. Cryptococcosis of Bone:
Osseous cryptococcosis occurs in up to 10% of disseminated cases and may involve bony
prominences, cranial bones and vertebrae. The lesions are lytic without periosteal reaction and
symptoms of dull pain on movement are reported. Occasional cases of arthritis have also been
reported, mostly involving the knee joint.
5. Ocular Cryptococcosis:
Ocular manifestations of cryptococcosis most commonly include papilledema and optic
atrophy, due to raised intracranial pressure. Other ocular signs of cryptococcosis are
uncommon and usually occur as a result of dissemination.
6. Other forms of Cryptococcosis:
Cryptococcus neoformans is often isolated from urine of patients with disseminated infection.
Occasionally, signs of pyelonephritis or prostatitis may be observed. Other rare forms of
cryptococcosis include adrenal cortical lesions, endocarditis, hepatitis, sinusitis, and localized
oesophageal lesions.
Cerebrospinal fluid (CSF), biopsy tissue, sputum, bronchial washings, pus, blood and urine.
(a) For exudates and body fluids make a thin wet film under a coverslip using India ink to
demonstrate encapsulated yeast cells. Sputum and pus may need to be digested with 10% KOH
prior to India ink staining. (b) For tissue sections use PAS digest, GMS and H&E, mucicarmine
stain is also useful to demonstrate the polysaccharide capsule. Examine for globose to ovoid,
budding yeast cells surrounded by wide gelatinous capsules. Note, non-encapsulated variants,
although rare, may also occur.
Interpretation:
The demonstration of encapsulated yeast cells in CSF, biopsy tissue, blood or urine should be
considered significant, even in the absence of clinical symptoms. Positive sputum specimens
should be considered potentially significant, even though Cryptococcus may also occur in
respiratory secretions as a saprophyte. Basically, all patients with a positive microscopy for
cryptococci, from any site should be investigated for disseminated disease, especially by
culture and antigen detection.
3. Culture:
Inoculate specimens onto primary isolation media, like Sabouraud's dextrose agar. Look for
translucent, smooth gelatinous colonies, later becoming very mucoid and cream in color.
54
Interpretation:
The isolation of C. neoformans or C. gattii from any site should be considered significant and
patients without clinical symptoms should be thoroughly investigated for disseminated disease.
Positive culture of CSF is definitive. However, positive culture of respiratory secretions,
especially in patients without clinical symptoms, needs to be interpreted with some caution,
until additional supporting evidence is available. Isolation of Cryptococcus albidus or C.
laurentii, should also be interpreted with caution as these species are infrequent pathogens and
once again, additional supporting clinical and microscopic evidence is necessary.
4. Serology:
It should be noted that the detection of cryptococcal capsular polysaccharide antigen in spinal
fluid is now the method of choice for diagnosing patients with cryptococcal meningitis. In
AIDS patients, cryptococcal antigen can be detected in the serum in nearly 100% of cases.
However, in non-AIDS patients antigen detection in serum is less sensitive with only about
60% of patients with cryptococcosis reported as being positive. Note, serum specimens should
be pretreated with pronase to enhance detection of antigen and avoid false negative results.
5. Identification:
The genus Cryptococcus is characterized by globose to elongate yeast-like cells or
blastoconidia that reproduce by multilateral budding. Pseudohyphae are absent or rudimentary.
On solid media the cultures are generally mucoid or slimy in appearance. Red, orange or yellow
carotenoid pigments may be produced, but young colonies of most species are usually non-
pigmented, and are cream in color. Most strains have encapsulated cells with the extent of
capsule formation depending on the medium. Under certain conditions of growth the capsule
may contain starch-like compounds which are released into the medium by many strains.
Within the genus Cryptococcus, fermentation of sugars is negative, assimilation of nitrate is
variable and assimilation of inositol is positive. The genus Cryptococcus is similar to the
genus Rhodotorula. The distinctive difference between the two is the assimilation of inositol,
which is positive in Cryptococcus.
Cryptococcus albidus, Cryptococcus laurentii, Cryptococcus neoformans, Cryptococcus
gattii.
Aspergillosis
Aspergillosis is a spectrum of diseases of humans and animals caused by members of the
genus Aspergillus. These include (1) mycotoxicosis due to ingestion of contaminated foods;
(2) allergy and sequelae to the presence of conidia or transient growth of the organism in body
orifices; (3) colonisation without extension in preformed cavities and debilitated tissues; (4)
invasive, inflammatory, granulomatous, narcotising disease of lungs, and other organs; and
55
rarely (5) systemic and fatal disseminated disease. The type of disease and severity depends
upon the physiologic state of the host and the species of Aspergillus involved. The etiological
agents are cosmopolitan and include Aspergillus fumigatus complex, A. flavus complex, A.
niger complex, A. nidulans and A. terreus complex.
1. Pulmonary Aspergillosis: including allergic, aspergilloma and invasive aspergillosis.
The clinical manifestations of pulmonary aspergillosis are many, ranging from harmless
saprophytic colonisation to acute invasive disease.
Allergic aspergillosis is a continuum of clinical entities ranging from extrinsic asthma to
extrinsic allergic alveolitis to allergic bronchopulmonary aspergillosis (hypersensitivity
pneumonitis) caused by the inhalation of Aspergillus conidia. Features include asthma,
intermittent or persistent pulmonary infiltrates, peripheral eosinophilia, positive skin test
to Aspergillus antigenic extracts, positive immunodiffusion precipitin tests for antibody
to Aspergillus, elevated total IgE, and elevated specific IgE against Aspergillus. Plug
expectoration and a history of chronic bronchitis are also common. Symptoms may be mild
and without sequelae, but recurrent episodes frequently progress to bronchiectasis and fibrosis.
Non-invasive aspergillosis or aspergilloma (fungus ball), is caused by the saprophytic
colonisation of pre-formed cavities, usually secondary to tuberculosis or sarcoidosis. Features
often include hemoptysis with blood stained sputum, positive immunodiffusion precipitin tests
for antibody to Aspergillus, and elevated specific IgE against Aspergillus. However, many
cases are asymptomatic and are usually found by routine chest roentenogram.
Acute invasive pulmonary aspergillosis. Predisposing factors include prolonged neutropenia,

especially in leukemia patients or in bone marrow transplant recipients, corticosteroid therapy,
cytotoxic chemotherapy and to a lesser extent patients with AIDS or chronic granulomatous
disease. Clinical symptoms may mimic acute bacterial pneumonia and include fever, cough,
pleuritic pain, with hemorrhagic infarction or a narcotising bronchopneumonia. The typical
patient is granulocytopenic and receiving broad-spectrum antibiotics for unexplained fever.
Radiological features may be non-specific and tests for serum antibody precipitins are also
usually negative. Clinical recognition is essential as this is the most common form of
aspergillosis in the immunosuppressed patient.
Chronic narcotising aspergillosis is an indolent, slowly progressive, "semi-invasive" form of
infection seen in mildly immunosuppressed patients, especially those with a previous history
of lung disease. Diabetes mellitus, sarcoidosis and treatment with low-dose glucocorticoids
may be other predisposing factors. Common symptoms include fever, cough and sputum
production; positive serum antibody precipitins may also be detected.
2. Disseminated Aspergillosis:
Hematogenous dissemination to other visceral organs may occur, especially in patients with
severe immunosuppression or intravenous drug addiction. Abscesses may occur in the brain
(cerebral aspergillosis), kidney (renal aspergillosis), heart, (endocarditis, myocarditis), bone
(osteomyelitis), and gastrointestinal tract. Ocular lesions (mycotic keratitis, endophthalmitis
56
and orbital aspergilloma) may also occur, either as a result of dissemination or following
local trauma or surgery.
3. Aspergillosis of the paranasal sinuses:

Two types of paranasal sinus aspergillosis are generally recognised. (1) A non-invasive
"aspergilloma" form, primarily seen in non-immunosuppressed individuals. Predisposing
factors include a history of chronic sinusitis and poorly draining sinuses with excessive mucus.
(2) An invasive form, usually seen in the immunosuppressed patient. This form has a similar
clinical setting to that seen in rhinocerebral zygomycosis; and symptoms include fever, rhinitis
and signs of invasion into the orbit.
4. Cutaneous Aspergillosis:
Cutaneous aspergillosis is a rare manifestation that is usually a result of dissemination from
primary pulmonary infection in the immunosuppressed patient. However, cases of primary
cutaneous aspergillosis also occur, usually as a result of trauma or colonisation. Lesions
manifest as erythematous papules or macules with progressive central necrosis.
Sputum, bronchial washings and tracheal aspirates from patients with pulmonary disease and
tissue biopsies from patients with disseminated disease.
(a) Sputum, washings and aspirates make wet mounts in either 10% KOH & Parker ink or
Calcofluor and/or Gram stained smears; (b) Tissue sections should be stained with H&E, GMS
and PAS digest. Note Aspergillus hyphae may be missed in H&E stained sections. Examine
specimens for dichotomously branched, septate hyphae.
Interpretation:
The presence of hyaline, branching septate hyphae, consistent with Aspergillus in any
specimen, from a patient with supporting clinical symptoms should be considered significant.
Biopsy and evidence of tissue invasion is of particular importance. Remember direct
microscopy or histopathology does not offer a specific identification of the causative agent.
3. Culture:
dextrose agar. Colonies are fast growing and may be white, yellow, yellow-brown, brown to
black or green in colour.
57
Interpretation:
Aspergillus species are well recognised as common environmental airborne contaminants,
therefore a positive culture from a non-sterile specimen, such as sputum, is not proof of
infection. However, the detection of Aspergillus (especially A. fumigatus and A. flavus) in
sputum cultures, from patients with appropriate predisposing conditions, is likely to be of
diagnostic importance and empiric antifungal therapy should be considered. Unfortunately,
patients with invasive pulmonary aspergillosis, often have negative sputum cultures making a
lung biopsy a prerequisite for a definitive diagnosis.
4. Serology:
Immunodiffusion tests for the detection of antibodies to Aspergillus species have proven to be
of value in the diagnosis of allergic, aspergilloma, and invasive aspergillosis. However, they
should never be used alone, and must be correlated with other clinical and diagnostic data.
Several antigen tests for the detection of Aspergillus from blood, urine and CFS are now
available. The (1→3)- β-D- glucan test detects a wide variety of fungal pathogens including
Aspergillus, Candida, Fusarium, Trichosporon and several commercial kits (FungiTec G,
Fungitell) are available.
However the most widely used system is the Aspergillus galactomannan ELISA test (Platelia®
Aspergillus ELISA kit). The Aspergillus galactomannan (GM) test has a reported specificity
of 89-93%; sensitivity of 61-71%; NPV of 95-98%; PPV of 26-53% (Meta-analysis 27 studies
Pfeiffer et al. CID 2006). However as galactomannan is rapidly eliminated from blood - serial
screening twice weekly for optimal diagnosis is recommended.
5. Identification:
Aspergillus colonies are usually fast growing, white, yellow, yellow-brown, brown to black or
shades of green, and they mostly consist of a dense felt of erect conidiophores. Conidiophores
terminate in a vesicle covered with either a single palisade-like layer of phialides (uniseriate)
or a layer of subtending cells (metulae) which bear small whorls of phialides (the so-called
biseriate structure). The vesicle, phialides, metulae (if present) and conidia form the conidial
head. Conidia are one-celled, smooth- or rough-walled, hyaline or pigmented and are
basocatenate, forming long dry chains which may be divergent (radiate) or aggregated in
compact columns (columnar). Some species may produce Hülle cells or sclerotia.
58
Aspergillus spp. Aspergillus flavus complex, Aspergillus fumigatus complex, Aspergillus
nidulans complex, Aspergillus niger complex, Aspergillus terreux complex.
Scedosporiosis (Pseudallescheriasis)
Scedosporium and Lomentospora infection
A spectrum of disease similar in terms of variety and severity to those caused
by Aspergillus. The vast majority of infections are mycetomas, the remainder include
infections of the eye, ear, central nervous system, internal organs and more commonly the
lungs. Infections result from either inhalation of air-borne conidia or by the traumatic
implantation of fungal elements due to a penetrating injury. The etiological agents
are Scedosporium apiospermum, Scedosporium aurantiacum, Scedosporium
boydii and Lomentospora prolificans.
1. Scedosporium apiospermum, Scedosporium boydii and Scedosporium
aurantiacum infections:
Non-invasive colonization of the external ear and pulmonary colonization in patients with
poorly draining bronchi or paranasal sinuses and "fungus ball" formation in pre-formed cavities
are similar to those seen in Aspergillus.
Invasive infections in normal patients are usually caused by traumatic implantation. Mycetoma,
where the fungus exists in tissue as resistant microcolonies or grains is the most common
infection in the normal patient. This is followed by penetrating joint injuries, especially to the
knee, resulting in arthritis and osteomyelitis. Other manifestations include mycotic keratitis
and non-mycetoma like cutaneous and subcutaneous infections.
Invasive infections have also been reported in patients receiving treatment with corticosteroids
and immunosuppressive therapy for organ transplantation, leukemia, lymphoma, systemic
lupus erythematous or Crohn's disease. Infections include invasive sinusitis, pneumonia,
arthritis with osteomyelitis, cutaneous and subcutaneous granulomata, meningitis, brain
abscesses, endophthalmitis, and disseminated systemic disease.
2. Lomentospora prolificans infections:
The spectrum of clinical manifestations are similar to that described above
for Scedosporium. Disseminated disease has been reported in immunosuppressed patients
especially those with prolonged neutropenia and post-transplantation therapy. Colonization of
the external ear, paranasal sinuses and lung, including "fungus ball" have been reported. Cases
of onychomycosis and mycotic keratitis have also been documented. However, localized
invasive infections, especially septic arthritis and osteomyelitis following penetrating injuries
to joints, are now an emerging clinical problem, accounting for 80% of the reported cases.
Culture identification is important, because this fungus is often resistant to antifungal therapy
and treatment may require surgical intervention.
Sputum, bronchial washings and tracheal aspirates from patients with pulmonary disease and
tissue biopsies from patients with subcutaneous and disseminated disease.
(a) Sputum, washings and aspirates make wet mounts in either 10% KOH & Parker ink or
Calcofluor and/or Gram stained smears; (b) Tissue sections should be stained with H&E, GMS
and PAS digest. Note hyphal elements of Scedosporium boydii and Scedosporium prolificans
are indistinguishable from those of Aspergillus hyphae and may be missed in H&E stained
sections. Examine specimens for branched, septate hyphae.
59
Interpretation:
The presence of branching septate hyphae in any specimen, from a patient with supporting
clinical symptoms should be considered significant. Biopsy and evidence of tissue invasion is
of particular importance. Remember culture is necessary for a specific identification of the
causative agent.
3. Culture:
Colonies are fast growing and are greyish-white, to olive-grey to black with a suede-like to
downy surface texture.
Interpretation:
S. apiospermum, S. boydii, S. aurantiacum and L. prolificans are common soil fungi, therefore
a positive culture from a non-sterile specimen, such as sputum or skin, needs to be supported
by direct microscopic evidence in order to be considered significant. A positive culture from a
biopsy or aspirated material from a sterile site should be considered significant. Culture
identification is the only reliable means of distinguishing these fungi from Aspergillus species.
4. Serology:
As in cases of aspergillosis immunodiffusion tests have become valuable in the diagnosis of
pseudallescheriasis. However, at present reagents are not commercially available and antigenic
extracts have to be made in the laboratory.
5. Identification:
conidiogenous cell, in this case an annellide.
Scedosporium apiospermum, Scedosporiun aurantiacum, Scedosporium
boydii, Lomentospora prolificans.
Zygomycosis (Mucormycosis)
The term zygomycosis describes in the broadest sense any infection due to a member of the
Zygomycetes. These are primitive, fast growing, terrestrial, largely saprophytic fungi with a
cosmopolitan distribution. To date, some 665 species have been described although infections
in humans and animals are generally rare. Medically important orders and genera include:
1. Mucorales and Mortierellales, causing subcutaneous and systemic zygomycosis
(Mucormycosis) - Rhizopus, Lichtheimia, Rhizomucor, Mucor, Cunninghamella, Saksenaea,
Apophysomyces, Cokeromyces and Mortierella.
2. Entomophthorales, causing subcutaneous zygomycosis (Entomophthoromycosis)
- Conidiobolus and Basidiobolus.
 Zygomycosis
 Entomophthoromycosis
Zygomycosis
Zygomycosis in the debilitated patient is the most acute and fulminate fungal infection known.
The disease typically involves the rhino-facial-cranial area, lungs, gastrointestinal tract, skin,
or less commonly other organ systems. It is often associated with acidotic diabetes, starvation,
severe burns, intravenous drug abuse, and other diseases such as leukemia and lymphoma,
immunosuppressive therapy, or the use of cytotoxins and corticosteroids, therapy with
desferrioxamine (an iron chelating agent for the treatment of iron overload) and other major
trauma. The infecting fungi have a predilection for invading vessels of the arterial system,
60
causing embolization and subsequent necrosis of surrounding tissue. A rapid diagnosis is
extremely important if management and therapy are to be successful.
1. Rhinocerebral zygomycosis:
Predisposing factors include uncontrolled diabetes mellitus or acidosis, steroid induced
hyperglycemia, especially in patients with leukemia and lymphoma, renal transplant and
concomitant treatment with corticosteroids and azathioprine. Infections usually begin in the
paranasal sinuses following the inhalation of sporangiospores and may involve the orbit, palate,
face, nose or brain.
2. Pulmonary zygomycosis:
Predisposing conditions include haematological malignancies, lymphoma and leukemia, or
severe neutropenia, treatment with cytotoxins and corticosteroids, desferrioxamine therapy;
diabetes and organ transplantation. Infections result by inhalation of sporangiospores into the
bronchioles and alveoli, leading to pulmonary infraction and necrosis with cavitation.
3. Gastrointestinal zygomycosis:
A rare entity, usually associated with severe malnutrition, particularly in children, and
gastrointestinal diseases which disrupt the integrity of the mucosa. Primary infections probable
result following the ingestion of fungal elements and usually present as necrotic ulcers.
4. Cutaneous zygomycosis:
Local traumatic implantation of fungal elements through the skin, especially in patients with
extensive burns, diabetes or steroid induced hyperglycemia and trauma. Lesions vary
considerably in morphology but include plaques, pustules, ulcerations, deep abscesses and
ragged necrotic patches.
5. Disseminated zygomycosis:
May originate from any of the above, especially in severely debilitated patients with
haematological malignancies, burns, diabetes or uraemia.
61
6. Central Nervous System alone:
Intravenous drug abuse. Traumatic implantation leading to brain abscess.
Skin scrapings from cutaneous lesions; sputum and needle biopsies from pulmonary lesions;
nasal discharges, scrapings and aspirates from sinuses in patients with rhinocerebral lesions;
and biopsy tissue from patients with gastrointestinal and/or disseminated disease.
Warning: zygomycetous fungi have primitive coenocytic hyphae that will often be damaged
and become non-viable during the biopsy procedure (especially scrapings and aspirates), or by
the chopping up or tissue grinding process in the laboratory. This is why zygomycetous fungi
that are clearly visible in direct microscopic or histopathological mounts are often difficult to
grow in culture from clinical specimens. If on clinical and/or radiological evidence
zygomycosis is suspected then try to avoid excessive tissue damage when collecting the
specimen and in the laboratory gently tease the tissue apart and inoculate it directly onto the
isolation media. If you are not sure hold the specimen in saline or BHI broth until the results
of the direct microscopy or frozen histology sections are known. If zygomycetous hyphae are
present proceed as above, otherwise homogenised the specimen and plate out.
(a) Scrapings, sputum and exudates should be examined using 10% KOH & Parker ink or
Calcofluor mounts; and (b) Tissue sections should be stained with H&E and GMS. Examine
specimens for broad, infrequently septate, thin-walled hyphae, which often show focal bulbous
dilations and irregular branching.
Interpretation:
As a rule, a positive direct microscopy, especially from a sterile site, should be considered
significant, even if the laboratory is unable to culture the fungus.
3. Culture:
Inoculate specimens onto primary isolation media, like Sabouraud's dextrose agar. Most
zygomycetes are sensitive to cycloheximide (actidione) and this agent should not be used in
culture media. Look for fast growing, white to grey or brownish, downy colonies.
Interpretation:
Despite being recognised as common laboratory contaminants, zygomycetes are infrequently
isolated in the clinical laboratory. Therefore, in patients with any of the above predisposing
conditions, especially diabetes or immunosuppression and/or clinical symptoms, the isolation
of any zygomycete fungus should be regarded as potentially significant. Obviously, in patients
without predisposing conditions, the isolation of a zygomycete from a non-sterile site, such as
skin or sputum, must be interpreted with caution, especially in the absence of direct
microscopy.
4. Serology:
zygomycosis. Although some laboratories have developed ELISA tests for the detection of
antibodies to Zygomycetes.
62
5. Identification:
Zygomycetes are usually fast growing fungi characterised by primitive coenocytic (mostly
aseptate) hyphae. Asexual spores include chlamydoconidia, conidia and sporangiospores
contained in sporangia borne on simple or branched sporangiophores. Sexual reproduction is
isogamous producing a thick-walled sexual resting spore called a zygospore.
Most isolates are heterothallic i.e. zygospores are absent, therefore identification is based
primarily on sporangial morphology. This includes the arrangement and number of
sporangiospores, shape, colour, presence or absence of columellae and apophyses, as well as
the arrangement of the sporangiophores and the presence or absence of rhizoids. Growth
temperature studies (25,37,45C) can also be helpful. Tease mounts are best, use a drop of 95%
alcohol as a wetting agent to reduce air bubbles. Laboratory identification of some
zygomycetous fungi, especially Apophysomyces elegans and Saksenaea vasiformis may be
difficult or delayed because of the mould's failure to sporulate on the primary isolation media
or on subsequent subculture onto potato dextrose agar. Sporulation may be stimulated by the
use of nutrient deficient media, like cornmeal-glucose-sucrose-yeast extract agar, Czapek Dox
agar, or by using the agar block method on water agar.
Lichtheimia corymbifera, Apophysomyces elegans, Cunninghamella bertholletiae,
Mortierella wolfii, Mucor sp., Rhizomucor pusillus, Rhizopus arrhizus, Rhizopus sp.,
Saksenaea vasiformis.
Infections caused by entomophthoraceous fungi:

Zygomycosis due to entomophthoraceous fungi:
This is caused by species of two genera Basidiobolus and Conidiobolus. Infections are chronic,
slowly progressive and generally restricted to the subcutaneous tissue in otherwise healthy
individuals. Other characteristics that separate these infections from those caused by
mucoraceous fungi are a lack of vascular invasion or infarction and the production of a prolific
chronic inflammatory response, often with eosinophils and Splendore-Hoeppli phenomena
around the hyphae.
Zygomycosis caused by Basidiobolus ranarum:

This is a chronic inflammatory or granulomatous disease generally restricted to the
subcutaneous tissue of the limbs, chest, back or buttocks, primarily occurring in children and
with a predominance in males. Initially, lesions appear as subcutaneous nodules which develop
into massive, firm, indurated, painless swellings which are freely movable over the underlying
muscle, but are attached to the skin which may become hyperpigmented but not ulcerated.
63
Zygomycosis caused by Conidiobolus sp.:
This is a chronic inflammatory or granulomatous disease that is typically restricted to the nasal
submucosa and characterised by polyps or palpable restricted subcutaneous masses. Clinical
variants, including pulmonary and systemic infections have also been described. Human
infections occur mainly in adults with a predominance in males (80% of cases). Most cases
have been reported from the tropical rain forest areas of central and west and south and central
America. Infections usually begin with unilateral involvement of the nasal mucosa. Symptoms
include nasal obstruction, drainage and sinus pain. Subcutaneous nodules develop in the nasal
and perinasal regions and progressive generalised facial swelling may occur. Infections also
occur in horses usually producing extensive nasal polyps and other animals. Conidiobolus
coronatus is also a recognised pathogen of termites, other insects and spiders.
Skin biopsy tissue.
Tissue sections should be stained with H&E and GMS. Examine specimens for broad,
infrequently septate, thin-walled hyphae, which often show focal bulbous dilations and
irregular branching.
Infections caused by entomophthoraceous fungi:

Zygomycosis due to entomophthoraceous fungi:
This is caused by species of two genera Basidiobolus and Conidiobolus. Infections are chronic,
slowly progressive and generally restricted to the subcutaneous tissue in otherwise healthy
individuals. Other characteristics that separate these infections from those caused by
mucoraceous fungi are a lack of vascular invasion or infarction and the production of a prolific
chronic inflammatory response, often with eosinophils and Splendore-Hoeppli phenomena
around the hyphae.
64
Zygomycosis caused by Basidiobolus ranarum:
This is a chronic inflammatory or granulomatous disease generally restricted to the
subcutaneous tissue of the limbs, chest, back or buttocks, primarily occurring in children and
with a predominance in males. Initially, lesions appear as subcutaneous nodules which develop
into massive, firm, indurated, painless swellings which are freely movable over the underlying
muscle, but are attached to the skin which may become hyperpigmented but not ulcerated.
Zygomycosis caused by Conidiobolus sp.:

This is a chronic inflammatory or granulomatous disease that is typically restricted to the nasal
submucosa and characterised by polyps or palpable restricted subcutaneous masses. Clinical
variants, including pulmonary and systemic infections have also been described. Human
infections occur mainly in adults with a predominance in males (80% of cases). Most cases
have been reported from the tropical rain forest areas of central and west and south and central
America. Infections usually begin with unilateral involvement of the nasal mucosa. Symptoms
include nasal obstruction, drainage and sinus pain. Subcutaneous nodules develop in the nasal
and perinasal regions and progressive generalised facial swelling may occur. Infections also
occur in horses usually producing extensive nasal polyps and other animals. Conidiobolus
coronatus is also a recognised pathogen of termites, other insects and spiders.
Skin biopsy tissue.
Tissue sections should be stained with H&E and GMS. Examine specimens for broad,
infrequently septate, thin-walled hyphae, which often show focal bulbous dilations and
irregular branching.
65
Hyalohyphomycosis
A mycotic infection of man or animals caused by a number of hyaline (non-dematiaceous)
hyphomycetes where the tissue morphology of the causative organism is mycelial. This
separates it from phaeohyphomycosis where the causative agents are brown-pigmented fungi.
Hyalohyphomycosis is a general term used to group together infections caused by unusual
hyaline fungal pathogens that are not agents of otherwise-named infections; such as
Aspergillosis. Etiological agents include species of Penicillium, Paecilomyces, Acremonium,
Beauveria, Fusarium and Scopulariopsis.
The clinical manifestations of hyalohyphomycosis are many ranging from harmless
saprophytic colonization to acute invasive disease. Predisposing factors include prolonged
neutropenia, especially in leukemia patients or in bone marrow transplant recipients,
corticosteroid therapy, cytotoxic chemotherapy and to a lesser extent patients with AIDS. The
typical patient is granulocytopenic and receiving broad-spectrum antibiotics for unexplained
fever.
(a) Skin and nail scrapings, sputum, washings and aspirates should be examined using 10%
white mounts, (c) Tissue sections should be stained using PAS digest, Grocott's methenamine
silver (GMS) or Gram stains. Note hyphal elements are often difficult to detect in H&E stained
sections.
Interpretation: The presence of hyaline, branching septate hyphae, similar to Aspergillus in
any specimen, from a patient with supporting clinical symptoms should be considered
significant. Biopsy and evidence of tissue invasion is of particular importance. Remember
direct microscopy or histopathology does not offer a specific identification of the causative
agent.
3. Culture:
dextrose agar.
Interpretation:
The hyaline hyphomycetes involved are well recognized as common environmental airborne
contaminants, therefore a positive culture from a non-sterile specimen, such as sputum or
skin, needs to be supported by direct microscopic evidence in order to be considered
66
significant. A supporting clinical history in patients with appropriate predisposing conditions,
is also helpful. Culture identification is the only reliable means of distinguishing these fungi.
4. Serology:
of the infections classified under the term hyalohyphomycosis.
5. Identification:
conidiogenous cell.
Acremonium sp., Beauveria sp., Fusarium sp., Paecilomyces sp., Penicillium sp.,
Scopulariopsis sp. etc.
Phaeohyphomycosis
A mycotic infection of humans and lower animals caused by a number of dematiaceous
(brown-pigmented) fungi where the tissue morphology of the causative organism is mycelial.
This separates it from other clinical types of disease involving brown-pigmented fungi where
the tissue morphology of the organism is a grain (mycotic mycetoma) or sclerotic body
(chromoblastomycosis). The etiological agents include various dematiaceous hyphomycetes
especially species of Exophiala, Phialophora, Bipolaris, Exserohilum, Cladophialophora,
Verruconis, Aureobasidium, Cladosporium, Curvularia and Alternaria. Ajello (1986) listed 71
species from 39 genera as causative agents of phaeohyphomycosis.
Clinical forms of phaeohyphomycosis range from localized superficial infections of the stratum
corneum (tinea nigra) to subcutaneous cysts (phaeomycotic cyst) to invasion of the brain.
1. Subcutaneous phaeohyphomycosis:
Subcutaneous infections occur worldwide, usually following the traumatic implantation of
fungal elements from contaminated soil, thorns or wood splinters. Exophiala jeanselmei and
Wangiella dermatitidis are the most common agents and cystic lesions occur most often in
adults. Occasionally, overlying verrucous lesions are formed, especially in the
immunosuppressed patient.
2. Paranasal sinus phaeohyphomycosis:
67
Sinusitis caused by dematiaceous fungi, especially species of Bipolaris, Exserohilum,
Curvularia and Alternaria is increasingly being reported, especially in patients with a history
of allergic rhinitis or immunosuppression.
3. Cerebral phaeohyphomycosis:
Cerebral phaeohyphomycosis is a rare infection, occurring mostly in immunosuppressed
patients following the inhalation of conidia. However, cerebral infections caused by
Cladophialophora bantiana have been reported in a number of patients without any obvious
predisposing factors. This fungus is neurotropic and dissemination to sites other than the CNS
is rare.
Skin scrapings and/or biopsy; sputum and bronchial washings; cerebrospinal fluid, pleural
(a) Skin scrapings, sputum, bronchial washings and aspirates should be examined using 10%
white mounts, (c) Tissue sections should be stained using H&E, PAS digest, and Grocott's
Interpretation:
The presence of brown pigmented, branching septate hyphae in any specimen, from a patient
with supporting clinical symptoms should be considered significant. Biopsy and evidence of
tissue invasion is of particular importance. Remember direct microscopy or histopathology
does not offer a specific identification of the causative agent.
Note:
Direct microscopy of tissue is necessary to differentiate between chromoblastomycosis which
is characterized by the presence in tissue of brown pigmented, planate-dividing, rounded
sclerotic bodies and phaeohyphomycosis where the tissue morphology of the causative
organism is mycelial.
3. Culture:
dextrose agar.
68
Interpretation:
The dematiaceous hyphomycetes involved are well recognized as common environmental
airborne contaminants, therefore a positive culture from a non-sterile specimen, such as sputum
or skin, needs to be supported by direct microscopic evidence in order to be considered
significant. A supporting clinical history in patients with appropriate predisposing conditions,
is also helpful. Culture identification is the only reliable means of distinguishing these fungi.
4. Serology:
of the infections classified under the term phaeohyphomycosis.
5. Identification:
Alternaria sp., Aureobasidium pullulans, Bipolaris sp., Cladophialophora bantiana,
Verruconis gallopava, Curvularia sp., Exophiala sp., Exserohilum sp., Phialophora
verrucosa.
69

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Mycoses

Clinical Groupings for Fungal Infections

Opportunistic Systemic Mycoses

Seborrhoeic dermatitis and dandruff:

The Cutaneous Mycoses

 Dermatophytosis - Ringworm or Tinea

Tinea unguium (dermatophyte onychomycosis):

2. Cutaneous candidiasis: including intertrigo, diaper candidiasis, paronychia and

Fixed cutaneous sporotrichosis:

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

1. Mucorales and Mortierellales, causing subcutaneous and systemic zygomycosis

The initial infection is thought to be caused by traumatic implantation such as an arthropod

Dimorphic Systemic Mycoses

Talaromyces marneffei infection

Finally, little is known about the ecology, epidemiology or pathogenesis of T.

Opportunistic Systemic Mycoses

2. Central Nervous System:

Acute invasive pulmonary aspergillosis. Predisposing factors include prolonged neutropenia,

3. Aspergillosis of the paranasal sinuses:

Infections caused by entomophthoraceous fungi:

Zygomycosis caused by Basidiobolus ranarum:

Infections caused by entomophthoraceous fungi:

Zygomycosis caused by Conidiobolus sp.:

2. Paranasal sinus phaeohyphomycosis:

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