Medically Important Fungi

Lecture contents

I. Introduction
II. Major groups of medically important fungi: Yeast
III.Major groups of medically important fungi: Mold
IV.Clinical classification of Mycoses
V. Laboratory diagnosis of fungal infections
Medically Important Fungi
Learning objective :
Define the terms ‛yeast’, ‛mold’ and ‛dimorphic fungi’.
Outline the main features of some clinically significant fungal infections:
•Tinea
•Candidiasis
•Endemic mycoses: Sporotrichosis
•Cryptococosis
List the major groups of medically important fungi
•Superficial mycoses
•Cutaneous mycoses
•Sub-cutaneous mycoses
•Systemic mycoses

Laboratory Investigations of fungal infections

•Types of specimens
•Direct microscopic examination
•Culture
• Histopathology

Outline the main features of opportunistic mycoses and their clinical consequences
 YEASTS FUNGI DIMORPHIC FUNGI
Candida Moulds at 25-30oC
Cryptococcus Yeasts at 35-37oC
Trichosporon Sporothrix schenckii
MOLDS
Geotrichum Histoplasma capsulatum
Malassezia Blastomyces dermatitidis
Rhodotorula Paracoccidioides brasiliensis
Saccharomyces Penicillium marneffei

Zygomycetes Dematiaceous fungi Hyalohyphomycetes Dermatophytes

Rhizopus Fonsecaea Aspergillus Microsporum
Mucor Phialophora Fusarium Trichophyton
Rhizomucor Cladosporium Penicillium Epidermophyton
Absidia Scedosporium Paecilomyces
Saksenaea Exophiala Coccidioides
Cokeromyces Madurella Sepedonium
Cunninghamella Curvularia Acremonium
 INTRODUCTION
• Word Fungus
• Mycology
• Eukaryotic
• Rigid cell wall
• Cell membrane
• yeast/molds
• hypha
• mycelium
• Reproduction
Fungal pathogenesis
● Fungal pathogenesis
● Mechanisms not clear
● Not as well studied as in bacteria

● Fungal entry
● rare in immunocompetent hosts
● accidental penetration of host barriers
● immunologic defects
● debilitating conditions
 Fungal pathogenesis
Source of Clinical Mechanism of entry
fungus classification
Endogenous Opportunistic Iatrogenic (indwelling lines,
catheters, etc.)

Exogenous Superficial Trauma (personal hygiene?)

Cutaneous Trauma

Subcutaneous Trauma

Systemic Inhalation

Opportunistic Inhalation, iatrogenic, trauma

 Virulence factors :
1.cell wall adhesins – adherence

2.ability to grow at 37oC

3.dimorphism (e.g. yeasts, hyphae, spherules and sclerotic bodies)

a) hyphae to yeast: Histoplasma capsulatum, Blastomyces
dermatitidis, Paracoccidioides brasiliensis, Coccidioides immitis
(spherule), Penicillium marneffei and Sporothrix schenckii
b) yeast to hyphae: Candida spp. When engulfed, tubular germ
tubes penetrate the membrane of the macrophage, causing its
death

4.enzymes – e.g. keratinase, protease, phospholipase, elastase, ?

phenyl oxidase

5.capsule – resist phagocytic engulfment, such as the yeast

Cryptococcus neoformans and the yeast form of Histoplasma
capsulatum.
I. Introduction :Yeast
Colony is usually single, round, raised or convex, may be white, red or black in color.
• Vegetative structure is a single unicellular cells, 4-8 µ in diameter.
• May produce pseudohyphae or true hyphae.
• Reproduces by budding.
II. Mold
•The colony is fuzzy or cottony in appearance.
• A single growing. vegetative structure is known as hypha or hyphae
•The hyphae can be non-septated, or septated and branched.
•The mycelium growing on the surface of the agar medium is called aerial mycelium and
those growing down into the agar are called vegetative mycelium.
•A mold colony is therefore made up of aerial and vegetative mycelia, which are referred to
as thallus.
 CLASSIFICATION OF FUNGI
Based on morphology
1.Yeast
2.Yeast-like
3.Molds
4.Dimorphic fungi
 Dimorphic fungi
• Molds reproduce as yeast-like cells on enriched
media when incubated at 37°C or in tissue.

• The fungi are in mold-form on SDA when

incubated at a lower temperature i.e 30°C.

• This phenomenon of changing vegetative

structures is called dimorphism.

• Temperature is a critical factor in the formation of

dimorphic characteristic, the phenomenon is
also called thermal dimorphism
 III. Major groups of medically important fungi: yeast
Yeasts:
**Candida species **Cryptococcus
species Malassezia species*

Microscopic examination of
yeasts :

Gram-stain:
Candida species: yeast-like, 4-8 ųm, budding, psedomycedium present or absent
Cryptococcus species: yeast-like, budding, no pseudomycelium.
Malassezia species: budding yeast cells present, predominantly oval form and some
spherical cells.

* Lipophilic yeast, growth must be stimulated by overlaying the Sabouraud's Dextrose agar (SDA) with olive oil.
 Candida species
• Characterized by globose to elongate yeast-like cells or blastoconidia that reproduce by multilateral
budding.

• All Candida species assimilate glucose as carbon source.

• Most Candida species produce pseudohyphae, however this characteristic is absent in

Candida glabrata.

• Clinical manifestations include oral thrush, systemic infections in immunocompromised patients.

• Yeast-like fungi on culture and in tissue appeared as filamentous (pseudomycelium) and

unicellular oval or spherical budding cells.

Important species isolated in the laboratory

Candida albicans, Candida krusei Candida dubliniensis, Candida parapsilosis,

Candida tropicalis , Candida rugosa Candida glabrata, Candida guilliermondii ,
Candida lucitaniae Candida haemulonii and ** candida auris.
 Candida albicans
• Grow rapidly, colonies white to cream, smooth or glistening
• Microscopic morphology shows round or short-oval budding cells. Growth at 45ºC, produce
terminal chlamydospores.
• Produces germ tubes formed with serum incubated at 35ºC for 2.5-3 hours.
• Candida dubliniensis: germ tube positive, do not grow at high temperature.
Cryptococcus neoformans
• It is traditionally divided into 2 varieties and 4 serotypes (A, B, C, D)

1. C. neoformans var. neoformans :

serotype A: C. neoformans var. grubii
and serotype D: C. neoformans var. neoformans.
Serotype A and serotype D are differentiated by molecular assay.

2. C.neoformans var. gattii : serotype B and C.

• The 2 varieties can be differentiated by Canavanine-glycine-bromthymol blue

(CGB) agar.
• C. neoformans var. gattii isolates turned agar blue within 2-5 days.
• C. neoformans var.neoformans the color of medium unchanged.
IV. Major groups of medically important fungi: mold

Hyaline Hyphomycetes

Aspergillus species, Penicillium species,

Fusarium species
Dermatophytes
Dimorphic Fungi
Zygomycetes

Dematiaceous Hyphomycetes

Curvularia species Cladosporium species

Hortaea werneckii

Uncultural fungi

Pneumocystis jiroveci (Pneumocystis carinii)

Aspergillus species
septated hyphae.
• colonies rapid growing, floccose, velvety to granular, woolly to cottony.
• Color may be white, yellow, yellow brown, brown to black or shades of green.

characterized by the conidiophores terminate in a swollen vesicle.

• The vesicle is covered with either a single layer of phialides/conidiogenous cells (uniseriate) or a layer
of subtending cells (metulae) with whorls of phialide cells on the top (biseriate) producing conidia.

•The arrangement of phialides or metulae on vesicles is an important key in identification.

•Conidia hyaline or pigmented, one-celled, smooth- or rough-walled forming long divergent chains (radiate) or
aggregated in compact columns (columnar).

•Conidial head is formed by the vesicle, phialides, metulae (if present) and conidia.
Aspergillus species
Aspergillus fumigatus

•Colonies grow rapidly, initially white, becoming blue-green in color with characteristic
terminally branched radial folds at the periphery of the colony.

•Conidiophores short and broad, smooth- to rough-walled, vesicles conical-shaped,

single row of phialides on the upper two thirds of the vesicle .

•Conidial heads are typically columnar.

Penicillium species
• Colonies grow rapidly, velvety consisting of low compacted aerial mycelium, initially
white and later become green, greenish-grey or olive grey.

• Chains of single-celled conidia are produced by flask-shaped phialides.

• Phialides and metulae form a brush-like appearance commonly known as a penicillus.
• A branch refers to all cells (i.e conidia, phialide) between the metulae and the stipes of
conidiophores
Penicillium species
 Talaromyces marneffei
•Exhibits thermal dimorphism, produces distinctive diffusible red-pigment around the
colonies.

•Colonies grow rapidly, velvety in texture, initially white becoming granular and greenish
yellow.

•Septated hyline hyphae and penicilli composing of branching biverticillate-symmetrical

metulae and phialides which produce spherical conidia in chains

•Produces red pigments diffuse into the medium

Talaromyces marneffei
Fusarium species
• Colonies are usually fast growing, pale, grey or olive grey, may be red colored depending on
the species.

• Produces both macro- and microconidia from slender phialides.

• Macroconidia are hyaline, two- to several-celled, fusiform- to sickle-shaped, mostly with an

elongated apical cell and pedicellate basal cell.

• Microconidia are 1- to 2-celled, hyaline, pyriform, fusiform to ovoid, straight or curved.

• Important species: Fusarium solani , Fusarium oxysporium

 Dermatophytes

•Consists of 3 genera which can be differentiated by the microscopic morphology of the micro and/or
macroconidia.
•Also known as keratinophilic fungi because they are able to grow on keratin such as hair,
nail and skin.
•In human, the disease caused by these fungi is generally known as ringworm or tinea
•This group of fungi has never been reported as opportunistic pathogens.
•Can be antrophilic (human host), zoophilic (animal host) and geophilic (soils).

Three important genera:

1. Epidermophyton species
Macroconidia numerous, smooth thin-walled, club-shape with blunt tip, no microconidia.
2. Microsporum species

•Macroconidia present solitary or in clusters alongside the septated hyphae, rough walls or
spindle-shaped. Microconidia absent or rare.

3. Trichophyton species

• Microconidia one-celled, pyriform in shape, solitary or in clusters, often predominantly present.

• Macroconidia smooth-walled, hyaline, cigar- or pencil-shaped, multi-celled.
• Spiral hyphae and chlamydospores are present in some species
• Important species: Trichophyton mentagrophytes, Trichophyton rubrum.
 Dimorphic Fungi
• Fungi can exist in molds/filamentous or yeast forms depending on the growth temperatures.
• At 37ºC or in tissues, the fungus exists as yeast form, at room temperature or 30ºC, the fungus
exists as mould form.
• Three dimorphic fungi isolated in Malaysia:
*** Histoplasma capsulatum, Sporothrix schenckii and Penicillium marneffei

1. Histoplasma capsulatum

• Hyphae hyaline, septate with short conidiophores bearing a characteristic large, rounded, tuberculated
macroconidia.
• Microconidia small, round on short conidiophores branched directly from the sides of the hyphae.
• Thermo-dimorphism can be demonstrate by inoculating the fungus on enriched medium e.g brain heart
infusion blood agar incubated at 37º C with the production of white and smooth yeast-like colonies.
• Histoplasma isolates that show no thermal dimorphism is Sepedonium species.
Penicillium marneffei / Talaromyces marneffei
• At room temperature (25ºC) , colonies grow moderately rapid, velvety with raised centre,
producing a distinctive pink pigment diffused into the medium.
• Hyphae septate, penicilli biverticillate with long smooth conidiophores.
• At 37◦C on enriched medium, colonies yeast-like, small, rough and white in color.
• Gram-stain shows ellipsoidal to spherical yeast-like cells and long pseudomycelium.

A B

C D
Dimorphic Fungi_3
Sporothrix schenckii
• At room temperature (25ºC), colonies slow growing, surface folded and wrinkled, light
grey to black.
• Conidiophores erect, short and thin, usually single arise from the septated hyphae.
• Conidia in clusters or single with tiny denticles proliferate at the apex of the conidiophores.
• On blood agar incubated at 37ºC, colonies are yeast-like, punctuated centre, white in color.
• On gram-stained, consisting of spherical or oval budding yeast cells with pseudohyphae.

B
A

D
C
 Zygomycetes_1
• Colonies grow rapidly, cottony, white to light grey in color.
• Hyphae hyaline, broad and nonseptated.
• Asexual reproductions include long simple or branched sporangiophores bearing a
sporangium containing sporangiospores.
• Dome-like columellae is present at the apex of sporangiophre in some species.
• Stolons bearing rhizoids may be presented.
• The identification of the genus is based on the morphology and characteristics of asexual spores
and the presence or absence of rhizoids.
• Spcies frequently isolated from clinical specimens in the laboratory include:
Mucor, Rhizopus, Basidiobolus, Cunninghamella, Syncephalestrum

Mucor
• Colonies grow rapidly, cottony, initially white becoming dark grey.
• Hyphae hyaline, broad and non-septated.
• Sporangiophores long, erect, simple or branched bearing globose to spherical
sporangium at the terminal, columellae well developed but no apophyses.
• Stolons and rhizoids are absent.
Zygomycetes_2

Rhizopus species

• Colonies fast growing, initially white cottony becoming brownish grey to blackish- grey
due to abundant sporangium.
• Hyphae broad, hyaline, non-septated with stolons producing groups of
sporangiophores and rhizoids.
• Sporangiophres arising from the opposite of rhizoids and stolons at the nodal
region.
• Sporangiophores smooth walled, simple, unbranched and long bearing globose
sporangium, columella and apophysis are present the apices of sporangiphores.
• Sporangiospores subglobose to ellipsoidal, after releasing the spores, the
sporangium collapsed leaving an umbrella-like structure.
Dematiaceous Hyphomycetes

• Fungi that produce dark brown, green-black, or black colonies; they

are the causative agents of phaeohyphomycosis

Curvularia lunata

• Colonies grow rapidly, black, expanding, floccose.

• Conidiophores septate, erect and unbranched, geniculate with conidia in
sympodial patterns.
• Conidia smooth-walled, 3-septate, obovoidal, curved with subterminal cell
larger than the others.
Dematiaceous Hyphomycetes_1

Cladosporium species

•Colonies growing rapidly, velvety to powdery, olivaceous

black, Reverse of the colony is
black.
•Hyphae are dark and segmented. Conidiophores
variable in length, branched or unbranched, nodose, or
geniculate producing ramoconidia.
Dematiaceous Hyphomycetes_2

Hortaea werneckii
• Colonies grow rapidly, olivaceous black both front and the reverse.
• Exhibit both a yeastlike and hyphal morphology.
• Yeast cells with thick septum, the budding may be polar, bipolar or lateral.
• On Gomori methanamine silver nitrate stain (GMS), surface of some of the
yeast cells is marked by conspicuous rings or collarette intercalary or
laterally.
• Halophilic black yeast grows abundantly in 10% Nacl incubated at room
temperature.
Uncultural fungi

Pneumocystis jiroveci (Pneumocystis carinii)

• presence of cup-shaped or hat-shaped forms, small round structure

with thick walled.
IV. Clinical classification of Mycoses

Skin mycology
Superficial mycoses
Cutaneous mycoses
Subcutaneous mycoses

Infectious disease mycology

Dimorphic systemic mycoses (Endemic mycoses)
Opportunistic systemic mycoses
Sources of fungal infections

• Endogenous
Source: man or animal
Transmission: direct or indirect formites
In general: no strict geographical delimitation
Occupation: no importance with respect to infection.
No seasonal incidence
No dimorphism

• Exogenous
Source: soil or decaying vegetation
Non contagious – non epidemic
Infection may or may not lead to disease
Strict geographical delimitation may occur.
Occupation may be of importance
Seasonal variation may occur
Dimorphism prominent
Fungi: two forms: 1. Yeast or Yeast like
2. Filamentous–mold.
Fungal Infections
1) Superficial mycoses
Pityriasis versicolor, tinea nigra, black & white piedra
2) Cutaneous mycoses
Dermatophytosis, cutaneous candidosis
3) Subcutaneous mycoses
Sporotrichosis, chromoblastomycosis, phaeohyphomycosis,
eumycetoma, basidiobolomycosis, conidiobolomycosis,
lobomycosis
4) Predominantly endemic deep organ mycoses
Histoplasmosis, coccidioidomycosis, blastomycosis,
paracoccidioidomycosis, penicillosis
5) Systemic mycoses with worldwide distribution
Candidosis (candidiasis), cryptococcosis, aspergillosis,
zygomycosis, fusariosis, scedosporiosis, pneumocystosis
A. Superficial mycoses

• involving the most superficial layers of the epidermis or the hair shaft
• portal of entry: skin

Types of dermatomycoses

• **Pityriasis vesicolor (tinea versicolor)

• Piedra
- black piedra
- white piedra
• Tinea nigra
• **Dermatophytoses
• **Cutaneous candidiasis
• Onychomycosis
• keratitis
Pityriasis vesicolor (tinea versicolor)

• Etiology agents: Malassezia furfur

• A lipophilic yeast-like species that is a member of the normal flora of the human skin.
• Pityriasis versicolor is characterized by asymptomatic patches of hypo- or hyper-pigmented
macules, varying in size, shape, and color.
• The most common sites are the chest, upper back, shoulders, upper arms, and abdomen.
• Hair shafts and nails are do not infected
• Culture is not helpful in differential diagnosis of pityriasis versicolor because Malassezia furfur
is part of the normal flora on adult skin.

Diagnosis: direct demonstration (wet mount)

Dermatophytoses
• The etiologic agents of dermatophytoses are Epidermophyton, Microsporum, and
Trichophyton, depending on their macroconidial characteristics.

• The infections are known as tinea or ringworm.

• Ringworm has different clinical manifestations in different areas of the body. Inflammation
is often greatest at the advancing margin, leaving a central area with some clearing.
Division of the disease into anatomical areas.

The nomenclature of the infection is based on the site.

Tinea Pedis

• Ringworm of the feet, particularly of the interdigital webs and soles.

• Symptoms are often slight, in the toe webs, scaling, fissuring, maceration, and erythema
may be
associated with an itching or burning sensation.

Tinea Capitis

• Microsporum audouionii, M. canis, M. equinum, and M. ferrugineum invade hair

shafts and produced a small-spored ectothrix infection , caused partial alopecia.
• Trichophyton infection : produced endothrix infections i.e hyphae form arthrospores within the
hair shaft , create
Tinea Cruris

• Infection of the groin is more common in men, involving the perineum, scrotum, perianal
area and in other intertriginous areas, such as under pendulous breasts, in the axilla, and
around the umbilicus of obese patients.
Cutaneous candidiasis
• cutaneous candidiasis: diaper rash in infants, intertrigo of the scrotum and
perineum
• oropharyngeal candidiasis: sign of HIV infection
• vulvovaginal: common among sexually active women.
• onychomycosis .
• aetiological agents: C albicans etc
Onychomycosis

• fungal infections of nails.

• a progressive, recurring fungal infection that begins in the nail bed and progresses to the nail plate.
• The types of microorganisms that cause onychomycosis can be broadly classified into 2
groups: dermatophytes and nondermatophytes.

Dermatophytes : T rubrum and T mentagrophytes

Nondermatophytes: yeasts (Candida parapsilosis and C albicans)

molds (Aspergillus species, dematiaceous
fungi)
B. Subcutaneous or cutaneous mycoses
• The inoculation mycoses
• Skin is the portal of entry
• Trauma a prerequisite
• No epidemics
• Most of the cases are observed in rural areas and particularly in low socioeconomic groups.
• Most systemic endemic mycoses occur after inhalation of conidia, while subcutaneous mycoses are
caused by the inoculation of vegetable matter or soil.

Sporotrichosis:

• worldwide in distribution
• a chronic infection usually limited to the cutaneous and subcutaneous tissue
• characterised by an localized erythematous, ulcerated, or verrucous nodule, relatively painless.
• No systemic symptoms are present.
• may subsequent spread along lymphangitic channels.
• other sporotrichosis: pulmonary, osteoarticular
• etiology: Sporothrix schenckii , dimorphic fungi
Chromomycosis (Chromoblastomycosis)

• Subcutaneous disease may be caused by nearly 30 different fungal species, the

most frequent being dematiaceous fungi: Fonsecaea, Phialophora,
and Cladosporium spp.
Chromomycosis

• In tissue, appeared as sclerotic bodies: brown, oval, nonbudding thick-walled

cells with horizontal and vertical septa (muriform cells).
• When cultured at 30 or 37°C, the organisms are filamentous.
• Dematiaceous fungi
• A chronic slow-progressing granulomatous disease of cutaneous and
subcutaneous tissues.
• Characterised by marked hyperplasia and hyperkeratosis, development of
warty nodules, tumor-like masses or raised, rough cauliflower-like
lesions containing the sclerotic bodies.
• The lesion usually developed in the subcutaneous tissue of the lower
extremities.
• Lesion increased by direct extension.

Phaeohyphomycosis

• Histopathologic diagnosis, subcutaneous and systemic infections

caused by dematiaceous fungi, other members hyphomycetes and
Coelomycetes of Deuteromycota as well as Ascomycota.
• In tissue, organisms are thick walled, dark, septate hyphae with yeast-like cells, may
be in chains.
Chromomycosis (Chromoblastomycosis)

Dematiaceous fungi on SDA

Dark brown sclerotic cells seen

in tissue biopsy

Melanised (brown/black) cell wall hyphae

seen in dermaticeous fungi that are
causative agents of Brown pigmented, rounded
chromoblastomycosis sclerotic bodies from skin
Systemic mycoses
inhalative: portal entry – respiratory tract

Clinical manifestations: multi-systems and multi-organs infection

A. Endemic mycoses (Histoplasmosis, Coccidioidomycosis, Blastomycosis, Penicillium marneffei)

` B. Cryptococosis: meningitis, skin

Endogenous
Candidiasis
Malassezia furfur

Opportunistic mycoses
Risk factors: chronic diseases, steroid therapy, AIDS

Yeasts: Candida, Cryptococcus, Trichosporon

Molds: Aspergillus, Penicillium, Histoplasma, Pneumocystis carinii

Zygomycetes: Rhizopus, Mucor, Cunninghamella.

Dematiaceae: Curvularia species, Clasosporium species ,Hortaea werneckii

Laboratory diagnosis of fungal infections at a glance…

Mycology Unit
 Fungus

Yeast / yeast- Mold

like fungus Organisms:
- Dematophytes(Microsporum
sp, Trichophyton sp,
**Candida sp Rhodotorula )
**Cryptococcus
- Dimorphic (Sporothrix sp.,
sp Histoplasma sp.)
Specimen: Specimen:
-Blood, Urine, Nail - Cerebrospinal - Subcutaneous
clipping, Hair, Skin fluid (CSF), - Superficial (Trichosporon sp,
Norcadia
swab, mouth, Vaginal Blood Specimen:sp, Malassezia furfur)
swab, Tissue/ -- Invasive (Aspergillus sp, T.
Nail clipping, Hair, Skin
Biopsies/ Bone Culture: marneferii)
scrapping, Tissues/ Biopsies
- Sabouraud
dextrose agar Culture:
(SDA) - Sabouraud dextrose agar
- Brain Heart (SDA)
Infusion Agar - Potato dextrose agar (PDA)
(BHIA)
* Skin scrapping sample –
cultured onto 2 SDA medium –
one layer with olive oil and
other without olive oil (both
SPECIMEN COLLECTION AND TRANSPORT
Acc to Epstein and Pearsall et al. guidelines for
specimen collection are
• Specimen should be collected from active lesion.
Old burn out lesions don’t contain viable
organisms
• Specimen should be collected under aseptic
conditions
• Collect sufficient specimen
• Use sterile collection devices and containers
• Specimen should be labelled appropriately
 Identification of Candida sp

Brilliance Candida Germ tube test

Agar/
Sabouraud dextrose agar
Chromogenic agar

Urease test
- Negative
- Remain yellow *Gram stain
- Positive
Biochemical tests
• Carbohydrate assimilation test can be performed using laboratory own preparation or
commercial API 20 C AUX system.
• The API system consists of 20 cupules containing dehydrated substrates which enable the
performance of 19 assimilation tests.
• The cupules are inoculated with a semi-solid minimal medium and the yeasts will only grow in
cupules if they are capable of utilizing each substrate as the sole carbon source.
• The reactions are read by comparing them to the controls and identification is obtained by referring
to the Analytical Profile Index or using identification software.
Importantindentistry:
OralCandidiasis
• Also known as moniliasis or
thrush or candidosis

• Caused by the infection with

yeast like fungus Candida
albician.
• Other causative organism
may be Candida tropicalis,
Candida famata, Candida
krusei
 Classification
• Primary Oral Candidiasis
– ACUTE
• Pseudomembranous
• Erythematous
– CHRONIC
• Hyperblastic
• Erythematous
• Pseudomembranous
– CANDIDA ASSOCIATED LESSION
• Denture stomatitis
• Angular stomatitis
• Median rhomboid glositis

– Keratinized primary lesion super infected with candida

• Leukaplakia
• Lichen planus
• Lupus erythematous

• Secondary candidiasis
– Manifestation of Systematic mucocutaneous candidiasis – thymic aplasia
and candida endocrinopathy syndrome
Predisposing Factor
• Change in oral microbial flora
– Administration of antibiotics specially broad
spectrum
– Xerostomia secondary to anticholinergic agents
– Salivary gland disease
• Local Irritation
– Denture, orthodontic appliance
– Heavy smoking
Predisposing Factor
• Drug therapy
– Corticosteroid or cyto-toxic
drug or immunosuppressive
drug
– Radiation therapy
• Other systemic disease
– Leukemia
– Lymphoma
– Diabetes
– Tuberculosis
– Epithelial dysplesia
Predisposing Factor
• Malnutrition status
– Low serum vit A
– Pyridoxine
– Iron level
• Age
• Infancy
– Pregnancy
– Old age
Predisposing Factor
• Endocrine deficiency
– Hypoparathyroidism
– Hypothyroidism
– Addison’s disease
• Others
– Tight fitting garments
– Indwelling catheter
 Pseudomembranous candidiasis

• Thrush

• Superficial infection of upper

layer of oral mucous
membrane
• Fungal growth – desquamation of
epithelial cell and accumaltion of
bacteria, keratin and necrotic
tissue forming pseudomembrane
 Clinical features: Infants
– 6th and 10th day after
birth
– Infection from maternal
vaginal canal
– Soft white/bluish whit,
adherent patches on oral
mucos
– Painless
– Removed with little
difficulty
 Clinical features : Adult
– Site : roof of mouth, retromolar
area, Mucobuccal fold
– Sex: female
– Prodromal symptom : rapid
onset of bad taste and
discomfort from spicy food
– Burnig sensation
– White plaque
• pearly white or bluish white –
resemble cottage cheese or
curdled milk
• Composed of tangled mass of
hyphae, yeast, desquammated
epithelial cell and debris
• Easily wiped out –
erythematous/atrophic area
which is painful
 Diagnosis
• White lesion which can be scraped off easily
• Diffrential diagnosis
– Plaque from lichen planus
– Leukolplakia
– Chemical burn
– Gangrenous stomatitis
 Acute atrophic candidiasis
• Antibiotics sore mouth
• It may be squeal of
pseudomembranous
candidiasis after white
patch has been shed off
• AIDS patient
• Prolonged drug therapy
• Topical steroid
• Broad spectrum
antibiotics
• Denture wearers
 Clinical feature
• Any site but mainly
involves tongue or area
facing prosthesis
• Red or erythematous
• Vague pain or burning
sensation
• Careful examination –
white thickened foci
that can be rubbed off
 Diagnosis
• Erythematous area with diminished host resistance
• Differential diagnosis
– Chemical burn
– Drug reaction
– Syphilitic mucus patches
– Necrotic ulcer and gangrenous stomatitis
– Traumatic ulcer
 Chronic hyperplastic candidiasis
• Candidal leukoplakia
• Firm adherent white
patches
• Predominantly in men
of middle age or above
– heavy smokers
• Site: cheek, lip and
tongue
• Appearance: firm and
white leathery plaque
 Clinical features
• Persist without any pain
for years
• Doesn’t rubs off with
lateral pressure
• Slightly white to dense
white with cracks and
fissures occasionally
• Vague border –
epithelial dysplasia
 Diagnosis
• Firm and white leathery appearance which is
difficult to rub
• Diffrential diagnosis
– Lichen planus
– Hairy leukoplakia
– Superficial bacterial infection – microscopic culture
 Id Reaction
• Secondary response
characterized by
localized or generalized
sterile vesicopapular
rash that is believed to
be allergic response –
candida antigen
(monoloids)
 Chronic atrophic candidiasis
• Also known as Denture
stomatitis
• Manifestation of
Erythematous candidiasis
• Found under complete
denture or partial denture
– mostly under the palate
• Speckeled curd like white
lesion – patchy distribution
• Soreness and dryness of
mouth
 Clinical sign

• Bright red palatal

tissue – edematous
and granular
• Sharply outline of
redness
• Multiple pinpoint foci
of hyperemia usually
involving the maxilla
 Diagnosis

• An erythematous are under complete denture

• Diffrential diagnosis
– Allergic reaction due to denture base
– Erosive lichen planus
– Dermatitis herpetiform
 Treatment of oral Candidiasis

• Topically or systematic
• 7 days treatment
• Oral symptoms disappears in 2-5 days
• Relapse common – underlying immunodeficiency
• Removal of causative factors
– Ill fitting denture
– Withdrawal or change of antibiotics
– Proper cleaning of denture and use of antifungal agent
 Topical treatment

• Preferred – less systemic

absorption
• Effectiveness depends –
entirely on patient
compliance
• Clotrimazole
– antibacterial as well as
antifungal property
– 10 mg tablets – soluble in
water – 5times a day
• 1% genitian violet
• Not ideal – causes unaesthetic
staining
 Topical Treatment
• Nystatin
– 2,00,000 unit Oral pastille – 5
times a day – dissolved in
mouth
– 1,00,000 unit oral
suspension – 5 times a day
– oral rinse in 20 ml of
water
• Amphotericin B
– 0.1 mg/ml, 5- 10 ml oral
rinse and expectorated –
tds
– Elixir containing tetracycline
and amphotericin B – acute
atrophic candidiasis
– Triamcinolene + Nystatin -
angular cheilitis
 Topical Treatment
• Mycostatin cream
– 1,00,000 placed under
tongue – tds
– Oral rinse - tds
– Adsorbable corticosteroid
and antibiotic agent +
mycostatin cream –
accelerates symptomatic
relief
• Idoquinol
– Antifungal and
antibacterial property
– Combined with
corticosteroid – effective
in angular chelitis
 Systemic Treatment

• Nystatin
– 250 mg tds – 2 week
followed by 1 troche per
day for 3rd week
• Ketaconazole
– 200 mg tab with food, OD
– Liver side effect – so
continous monitoring
needed in long term dose.
– Acidic environment for
absorption
 Systemic Treatment

• Itraconazole
– 100/200 mg capsule –
b.d. for 2 week
• Fluconazole
– 100 mg – o.d. for 2
week
– Effective prophylactic
agent
Identification of Cryptococcus sp
Cryptococcal Ag
Lateral Flow Assay
-
Immunochromatograp
hic assay
- Detect capsular
polysaccharide Ag

CGB agar India ink

L-Canavanineglycine
bromothymol blue (CGB)
Urease test
- Positive
- Color change from
yellow to pink
*Germ tube test –
Negative
Cryptococcal Ag Lateral Flow Assay
 Identification of mold
Slide culture Tease mount
Parker’s ink
-Use potato dextrose -Used for matured
with KOH
agar as a sporulation fungal culture grown
- For nail
media on the SDA medium
clipping, hair,
-Lactophenol cotton
skin samples
blue (LCB) stain
Mold on SDA

A. fumigatus A. niger Fusarium sp.

3. Cultural procedures

• Blood culture
• Sabouraud’s dextrose agar (SDA) slide culture technique
• Identification of the isolates based on cultural characteristics
 Laboratory diagnosis of fungal infections

●1.The collection of specimens

• Skin and nail scraping, hair, sputum, tissue or caseous materials, urine, blood.

●2. Direct microscopic examination

• treated the skin scraping with 20% KOH
• lactophenol cotton blue wet mount: Cotton blue is an acid dye that stains the chitin in fungal cell
● walls.
• Acid-fast stain (for partially acid fast Norcadia sp)
• India ink (for Cryptococcus neoformans):contains carbon black particles.
• They block out all the light except the polysaccharide coating produced by fungi or bacteria.
GERM TUBE TEST- Candida spp

• Presumptive identification
of candida albicans and C.
dubliensis
• Reynaulds-braude
phenomenon
• 5%-C.albicans negative, false
positives
• Additional tests
• Human/sheep serum,
incubated 2 hrs
• Long tube like process
5. Histopathology
• especially for Aspergillus, Candida, Penicillium marneffei,
zygomycosis, Cryptococosis
 FUNGAL STAINS
DIFFERENTIAL STAINS

●WET PREPARATIONS
• Grams stain
• H and E stain
• KOH mount • Giemsa
• *India ink stain • PAS
• Nigrosin stain • Gomori’s methamine stain
• Calcoflour white stain • Acridine orange stain
• Lactophenol Cotton blue
• Fluorescent antibody staining
• Neutral RED stain
 • India ink stain
INDIA INK STAIN
(Negative stain)
Polysaccharide capsule
repels opaque
medium India ink 150 ml Distinct halo
Merthiolate 3ml
Tween 80 0.1 ml As it is a negative stain

Ink should be free from

NIGROSIN STAIN Shelf life 1 yr Irregular, encapsulated, spherical yeast cells

Nigrosin
granules 10g
Formalin 100ml
 FUNGAL CULTURE
• Basal Media
• Nutritional deficient media
• Enriched and selective media
• Differential agar media
• Media for stimulation of Ascospores
• Media used for biochemical tests
 Basal Media
SABOURAUD DEXTROSE AGAR /SGA Peptone 10g
Dextrose 40g
pH -5.6 Agar 20g
Distilled water 1000ml

Commonly used
Primary isolation

SDA+ANTIBIOTICS SDA+
Cycloheximide 500mg
Chloramphenicol 50mg
Gentamicin 20mg

Avoid bacterial contamination

CANDIDA
Basal Media
BLASTOMYCOSIS-wavy

ASPERGILLOSIS-,dryPowdery colonies
 Nutritional deficient media
CORN MEAL AGAR/CORN Corn meal 8g/zein 40g/100ml
MEAL TWEEN AGAR Tween80 2g
Agar 4g
Distilled water 200ml
Large,highly refractile,thick walled
 Enriched and selective media

BIRD SEED AGAR/ Niger seed extract 200 ml Primary isolation of

NIGER SEED AGAR Glucose 1g Crytococcus neoformans
Chloramphenicol 400mg
Gentamicin 25mg
Diphenyl solution 10ml
Agar 20g
CHOCLATE AGAR Distilled water 800 ml Candida appear as – yellow
white colonies
 Differential media
CHROMAGAR Presumptive identification
Direct detection of enzymatic activity
Ph- Fluorochromes are added
Multiple species in a specimen
C.albicans –light green
C.tropicalis-blue,pink halo
C.Parapsilosis-cream
C.Krusei-pink
C.Glabrata-purple
C.dubliensis-dark blue
 MOLECULAR TECHNIQUES & AUTOMATION IN LAB.

●•PCR –genome DNA is amplified and sequence typing is

●done
●•Shorter period
●•Genetic markers
●RFLP (or Restriction fragment length polymorphism)
AFLP (or Amplified fragment length polymorphism)

●What is VITEK 2 in diagnostic of candida spp in lab?

● Principles of MALDI-TOF Mass Spectrometry?
UMMC- Blood and body fluids
Supplemented Middlebrook 7H9 and Brain Heart Infusion Broth
UMMC- Directory
UMMC- Directory
 The common medically
important fungal infection in
Clinical practice…
SAQ
❖ A 57-year-old obese female with diabetes mellitus
complains of a sore mouth and white patches on
the tongue.
➢ What would you expect to see on microscopic
examination of a KOH prepared specimen
taken from the tongue lesions?
Budding yeast cells +/- true hyphae, +/-
pseudohyphae +/- chlamydospores

➢ What test would you do to confirm the

identification of the most likely causative
agent causing this infection?
Germ tube test

Candida albicans on KOH

➢ Name another Candida species that can also
preparation showing budding
give the same result as C. albicans on the germ
tube test. yeasts, true hyhae, pseudohyphae
Candida dubliniensis
Candida albicans on SDA
Diagnosis: Oropharyngeal candidiasis or oral thrush
Causative/aetiological agent: Candida albicans

Candida albicans on Gram stain

SAQ
❖ An AIDS/HIV patient complains of headache and neck stiffness and
appears confused. A urease-positive fungus was isolated from his
cerebrospinal fluid specimen as shown.

➢ What is the most likely diagnosis?

Cryptococcosis
➢ Name the stain used to identify this organism.
India ink

OBA
➢ Which one of the following statements is true regarding
cryptococcosis :
A. Pneumonia is the most frequently encountered clinical
manifestation of cryptococcosis in HIV-infected patients
B. The most common Cryptococcus species causing human infections is
Cryptococcus gattii
C. The causative agent produces germ tubes (germ tube positive)
D. Latex agglutination test can be used to detect cryptococcal antigen
in both serum and cerebrospinal fluid (CSF)
E. Human to human transmission can occur
F. It occurs mainly in patients with reduced humoral immunity
SAQ
❖ A 55-year-old lady with a history of tuberculosis 3 years prior,
underwent a bone marrow transplant 3 months ago and now
develops fever, cough, chest pain and shortness of breath. An
organism was seen on her lung biopsy specimen, as shown in
the picture. Her chest x-ray is also shown.
➢ What is the mode of transmission of the causative agent of
this infection?
● The most likely infection is aspergillosis and the
causative agent is Aspergillus species.
● Transmission is via inhalation of airborne conidia
Tissue from lung biopsy stained
OBA with Gomori methenamine silver
➢ The following statements regarding aspergillosis and showing V-shaped
Aspergillus species are true EXCEPT for: (dichotomously) branched (acute
A. Aspergillus species are ubiquitous in nature angle 45° branching), narrow
B. Most invasive infections are caused by members of the septate hyphae with parallel walls
Aspergillus fumigatus species complex.
C. It can produce aspergilloma (fungus ball) within cavities in
the lung
D. Aspergillus species is a rapidly growing fungus in the
laboratory and is often visible in culture within 1-3 days of
incubation.
E. Detection of galactomannan and beta-D-glucan can be used
to diagnose invasive aspergillosis
F. Growth of Aspergillus species in culture always indicates an
infection Aspergilloma or fungus ball in the
upper lobe of the right lung.
ASPERGILLOSIS
● The term "aspergillosis" refers to illness due to allergy, airway or

lung invasion, cutaneous infection, or extrapulmonary

dissemination caused by species of Aspergillus, most commonly A.
fumigatus, A. flavus, and A. terreus.

● Aspergillus species are ubiquitous in nature, and inhalation of

infectious conidia is a frequent event.

● Tissue invasion is uncommon and occurs most frequently in the

setting of immunosuppression associated with therapy for
hematologic malignancies, hematopoietic cell transplantation, or
solid organ transplantation.
 Aspergillus fumigatus mold colonies on SDA

Lactophenol cotton blue (LPCB) stain of Aspergillus fumigatus species

SAQ
❖ A 20-year-old HIV-infected man presents with fever and
cough. Pneumocystis pneumonia (PCP) was suspected.
➢ What is the causative agent of this infection?

Pneumocystis jirovecii
➢ What is the recommended laboratory diagnostic Pneumocystis jirovecii cysts on immunofluorescent
staining:
method for diagnosis of this infection? apple-green fluorescence observed

● Immunofluorescent staining - Microscopic

examination of immunofluorescent-stained (using a
fluorescein-conjugated monoclonal antibody)
respiratory specimens for visualisation of the cystic/ Pneumocystis jirovecii cysts in lung tissue

trophic forms of P. jirovecii

● Immunofluorescent staining is the “gold standard”
technique for diagnosis of PCP as it can visualise
both cysts and trophic forms and is more sensitive
than other stains.
SHORT ANSWER QUESTION (SAQ)
❖ A 37-year-old HIV-positive male presented with fever,
cough, weight loss, skin lesions, hepatosplenomegaly
and lymphadenopathy. An organism was isolated
from cultures of his blood, bone marrow, lymph Talaromyces marneffei in tissue
nodes and skin lesions, as shown in the pictures. (yeast form) - Elongated sausage-
➢ What infection does this patient have? shaped yeast cells with transverse
septum (septated yeasts)
Penicilliosis
➢ State the causative agent of this infection
Talaromyces marneffei

Talaromyces marneffei on SDA

Talaromyces marneffei (mold form) seen on lactophenol cotton blue (LPCB) stain
- hyaline septate hyphae producing typical brush-like clusters of conidia chains
at the tips of the phialides
SAQ
❖ A 65-year-old diabetic female patient is brought to A&E
with fever, headache, sudden swelling on the right side of
the face and bleeding from the right nostril. The facial
lesion eventually becomes necrotic, as shown in the
picture. Histopathologic examination of a tissue biopsy
taken from the facial lesion as well as the organism
isolated in culture are shown in the pictures. This patient
eventually died 2 days later.
➢ What is the diagnosis?
Zygomycosis (mucormycosis) - rhinocerebral Microscopic examination of
mucormycosis tissue biopsy showing broad/wid
➢ Name 3 types of fungi (to the genus level) that most nonseptate hyphae
commonly cause this infection
Mucor, Rhizopus and Rhizomucor
➢ Which Phylum, Class and Order do these 3 genera of
fungi belong to?
Phylum Glomerulomycota
Class Phycomycetes
Order Mucorales Rhizopus on SDA – cotton candy colonies

TRUE/FALSE STATEMENTS

➢ Diabetes especially diabetic ketoacidosis and iron overload

are risk factors for zygomycosis/mucormycosis

TRUE
➢ Rhinocerebral and thoracic (pulmonary) are

the most common sites for zygomycosis infection

Rhizopus on lactophenol
cotton blue stain
Questions/ Discussion
● What specimen to be collected if candida infection is
suspected?
● Details on how to identify Candida spp in routine
diagnostic lab?
● Classification of Oral candidiasis?
● What is Molds?
● Dimorphic fungus?
● Describe differences between fungus, bacteria and
virus?
● Common antifungal drugs used to treat fungal
infection?
● Fungal opportunistic infection in AIDS patient, Discuss.
●Thank you… for mycology
sessions..
Introduction to Prions
- Pronounced “pree-on”

- Shortened term for:

Proteinaceous Infections
Particle

- Causes TSE (Transmissible Spongiform

Disease) which attacks the central nervous
system (the brain).
 1982
Dr. Stanley Prusiner
coins the term
"prion" (PROteinac
eous INfectious
particle).
Highly purified
PrP-res is shown to
be infectious.
He goes on to win
the Nobel Prize in
Medicine in 1997.
 Prion Diseases
Human Animal

● Kuru ● Scrapie

● Fatal Familial Insomnia ● Bovine Spongiform

(FFI) Encephalopathy (BSE)

● Creutzfeldt-Jakob disease ● Chronic Wasting Disease

(CJD) (CWD)
The Mystery of Kuru
In the 1950s, a district medical
officer working in the highlands
of New Guinea observed a fatal
disease among the people of
the Fore (FOR-ay) tribe.
The Fore people called this
sickness kuru, which means
"trembling in fear."
After intially becoming unable to
walk, victims of kuru lost the
ability to swallow or chew.
Drastic weight loss would
inevitably lead to death.
Today we know that kuru is one
of several diseases in humans
and animals caused by prion
(PREE-on) proteins.
Basic Structure
Normal prions
contain about
200-250 amino
acids twisted into
three telephone
chord-like coils
known as helices,
with tails of more
amino acids.
Basic Structure
The mutated, and
infectious, form is
built from the same
amino acids but
take a different
shape.
100 times smaller
than the smallest
known virus. Normal Mutated
Prions (PREE-ons) are
proteins that are unique
in their ability to
reproduce on their
own and become
infectious.

They can occur in two

forms called PrP-sen and
PrP-res.
Differences From Bacteria & Viruses
Prions do not contain nucleic acid; they don’t
have DNA or RNA.

They are extremely resistant to heat and

chemicals.

Prions are very difficult to decompose biologically;

they survive in soil for many years.
Both PrP-sen and PrP-res are made up of the exact
same string of amino acids, the building blocks that
make up proteins.
However, the two forms have different shapes.
PrP-sen is produced by normal healthy cells.

The sen stands for “sensitive” because this version

of the protein is sensitive to being broken down.

PrP-sen is present mainly in neurons in the brain, but

is also found in other cell types.
Scientists don’t know the exact function of PrP-sen,
but there is evidence that it may be involved in
communication between neurons, cell death, and
controlling sleep patterns.

Interestingly, mice that are genetically engineered to

produce no PrP-sen seem to be healthy.

The second type of prion protein, known as PrP-res,

is the disease-causing form.

Organisms with it develop spongiform disease. “res”

stands for “resistant” because this version of PrP is
resistant to being broken down.
Unlike other infectious agents, prions do not contain
genetic material.
However, once they infect an individual, prions can
replicate. How is this possible?

Scientists are still working out the details, but evidence

supports the idea that when PrP-sen comes into
contact with PrP-res it is converted to PrP-res.

The result is a chain reaction that multiplies copy after

copy of the infectious prion.
Because of their abnormal shape, PrP-res proteins
tend to stick to each other.
Over time, the PrP-res molecules stack up to form
long chains called “amyloid fibers”.
Amyloid fibers are toxic to cells, and ultimately
kill them.
Cells called astrocytes crawl through the brain
digesting the dead neurons, leaving holes
where neurons used to be.
The amyloid fibers remain.
How it effects humans??

• Sporadic Beef, Milk,

Animal prot ein,
• Inherited
Yogurt
• Transmissible: Foodstuffs
Direct contact
Handling of
Perinatal meat, infected
Iatrogenic animal
Hormones, bone products
grafts, vaccines,
Corneal
transplant,
 Any relation with
Dentist
Causative!!!? or Risk?? / Both?

Oral infectivity
Pot ent ial area of
Saliva is a risk factor??
cross
Tonsils, posterior border
contamination
of tongue, trigeminal
Resist ant t o ganglion are potential
sterilization sources
Bone graft s Gingiva has its highest
Surgical handling of presence
risk group
 Transmissible Spongiform
Encephalopathies
Sporadic/ Classical Kuru
CJD: Acquired
Congenital, 85% of cases Cannibalistic activity
Effects middle aged or elderly Women and young adults
Characterized by
- Rapidly progressive
are effected
multifocal dementia Long incubation period
- Ataxia, myoclonus
- Evident EEG changes
- Speech loss and finally death
Transmissible Spongiform
Encephalopathies

Iatrogenic TSE
Special interest to Dentist.
Risk of cross infection from instruments
Most of infections occurred after
- Neurosurgery
- Duramater transplant
- Corneal grafting, growth hormone, xenogenic grafts, tonsillar
surgery
- Manipulation of post 1/3 of tongue
 Transmissible Spongiform
Encephalopathies
tfCJD
Effects adolescents and young adults
Associat ed wit h int ake of infect ed animal
products
Long course of illness
Hallucinat ions, dysphagia, dysart hria,
paraesthesia,
Delirium, dementia and akinesia
Ameloid deposit ion in lymphat ic t issue
Absence of EEG changes
Oral manifestat ions of prion
diseases
Most common manifestations:
- Dysphagia (may be initial symptom)

- Oro-facial Paraesthesia/ dysesthesia

- Dysarthria

- Motor incoordinations

- Involvement of trigeminal ganglion

 1950s
High levels of kuru
appear among the Fore
people of New Guinea.

1960s
Scientists
experimentally transmit
Kuru and CJD to
chimpanzees,
demonstrating the
transmissible nature of
these diseases.
 1980s
60 people die from
CJD after being
infected by
contaminated
surgical
instruments.
85 people die after
receiving prion-
infected growth
hormone injections.
 Overview of Prions disease

***Classic CJD or Creutzfeldt-Jakob disease

(human)
The most prevalent of the spongiform diseases
Occurs spontaneously in 1out of a million people
10% of cases are inherited mutations in the PRPN gene
Usually strikes people age 50 to 75
Symptoms: dementia, muscle twitching, vision
problems
Fatal Familial Insomnia (human)
All cases are inherited mutations in the PrP
gene
Usually strikes people age 36 to 61
Disruption of sleep/wake cycle leads to
coma, then death
Scrapie (goats, sheep)
Occurs as infection in genetically susceptible
sheep
There is no evidence of spread to humans
 Overview of Prions disease

BSE or Bovine Spongiform

Encephalopathy (cattle)
Also known as "Mad Cow Disease"
because infected animals act strangely
and can be aggressive
Spread rapidly through Britain by rendering
Chronic Wasting Disease (deer, elk)
Infectious disease in wild deer and elk
primarily in the western United States
Drooling, difficulty swallowing, weight loss

Kuru (human)
Struck members of the Fore tribe in the
1950s and 1960s
Muscle weakness, loss of coordination,
tremors, inappropriate episodes of laughter
or crying
Transmitted by ritual cannibalism as part
of funeral ceremonies
 DiagnosisDiagnosis
can be made by:
1. Clinical signs and Symptoms.

2. Detection of Scrapie
Associated fibrils.
3. Detection of Abnormal Prion
protein (PrPsc) by Western blotting.

4. Two dimensional Gel Electrophoresis.

Scrapie Associated
5. Imunodiagnosis of Prion disease. fibrils.
6. Bioassay in Mice.
Advisory committee on Dangerous
pathogens:

General infect ion cont rol pract ices are sufficient if the work
does not involve neurovascular tissue

Proper infect ion cont rol measures in high risk pt s involving

invasive procedures

Single use items-disposable needles, gloves – safest

Quarant ining t he inst rument s, linen, gowns, gloves and

masks in rigid leak proof combustible waste