OPPORTUNISTIC MYCOSES

General features
Saprophyte in nature/found in normal flora
HOST : Immunosupressed /other risk factors

1. Candidiasis
2. Cryptococcosis
3. Aspergillosis
4. Zygomycosis
5. Other: Trichosporonosis, fusariosis, penicillosis

CANDIDIASIS
Most commonly encountered opportunistic mycoses worldwide
Cellular immunity protects against mucocutaneous candidiasis, neutrophiles protect against
invasive candidiasis
Endogenous inf.
Candida spp. Most common:
1. C. albicans
2. C. tropicalis
3. C. parapsilosis
4. C. kefyr
5. C. glabrata
5. C. krusei
6. C. guillermondii
7. C. lusitaniae
MORPHOLOGICAL FEATURES
Micr. Budding yeast cells
Pseudohyphae, true hyphae
Macr. Creamy yeast colonies (SDA)
Germ tube (C. albicans, C. dubliniensis)
Chlamydospore (C. albicans, C. dubliniensis)
Identification Germ tube, fermentation and assimilation reactions
PATHOGENICITY
1. Attachment (Germ tube is more adhesive than yeast cell)
2. Adherence to plastic surfaces (catheter, prosthetic valve..)
3. Protease
4. Phospholipase
Risk factors
1. Physiological. Pregnancy, elderly, infancy
2. Traumatic. Burn, infection
3. Hematological. Cellular immune deficiency, AIDS, chronic granulamatous disease, aplastic
anemia, leukemia, lymphoma...
4. Endocrinological. DM, hypoparathyroidism, Addison disease
5. Iatrogenic. Oral contraceptives, antibiotics, steroid, chemotherapy, catheter...
Clinical manifestations
1. CUTANEOUS and SUBCUTANEOUS
Oral
Vaginal
Onychomycosis
Dermatitis
Diaper rash
Balanitis
2. SYSTEMIC
Esophagitis
Pulmonary inf.
Cystitis
Pyelonephritis
Endocarditis
Myocarditis
3. CHRONIC MUCOCUTANEOUS
Candida inf. of skin and mucous membranes
Verrucose lesions
Impaired cellular immunity
Autosomal recessive trait
 Hypoparathyroidism, iron deficiency
Diagnosis
Direct micr.ic examination
Yeast cells, pseudohyphae, true hyphae
Culture
SDA, routine bacteriological media
Serology
Detection of mannan antigen
(ELISA, RIA, IF, latex agglutination)
Treatment
CUTANEOUS
Topical antifungal: Ketoconazole, miconazole, nystatin
SYSTEMIC
Amphotericin B , Fluconazole, itraconazole
CHRONIC MUCOCUTANEOUS
Amphotericin B , Fluconazole, itraconazole

CRYPTOCOCCOSIS
Underlying cellular immunodeficiency
(AIDS, lymphoma)
Exogenous inf.
Pathogenesis Inhalation of yeasts
Etio. Cryptococcus neoformans

General properties
Natural reservoir Soil, bird droppings
Micr. Encapsulated yeast (India ink)
Macr. Creamy, mucoid colonies (SDA)
Serotypes A-D (most frequently A)

Pathogenicity factors
a. Capsule
b. Diphenol oxidase (+) (Bird seed agar/ caffeic acid medium)
c. Ability to grow at 37°C
Clinical manifestations
PULMONARY
Asymptomatic/flu-like/hilar lap/cavitation
DISSEMINATED
**Meningitis (acute/chronic)
Cryptococcoma
Skin lesions
Diagnosis
Samples CSF, sputum, aspiration from skin lesion
Direct exam. India ink
Culture SDA
Serology*** Detection of capsule antigen in CSF and serum by latex agglutination test

Treatment
Amphotericin B (+ flucytosine)
Life-long fluconazole prophylaxis following primary treatment (in AIDS patients)

ASPERGILLOSIS
Etio: Aspergillus spp.(most common:A. fumigatus)
Risc factors and pathogenesis
1. Immunosupression, DM..àexogenous inf. (inhalation of spores)
2. Inhalation of spores by atopic host àHypersensitivity reactions (allergy)
3. Ingestion of products contaminated with Aspergillus toxins à Mycotoxicosis / hepatocellular and
colon carcinoma

GENERAL FEATURES
Natural reservoir: air, soil
Pathogenicity factors: hypha, phospholipase
Infected tissue: vascular invasion, thrombus, infarct, bleeding
 Macr: powdery mould colonies
(color of the spores varies from one species to other)
Micr: septate hyphae (dichotomous branching), vesicule, phialides, microconidia

Clinical manifestations
I. ALLERGIC ASPERGILLOSIS
1. Asthma (Type I)
2. Allergic bronchopulmonary aspergillosis (Types I, III)
II. NONINVASIVE LOCAL COLONIZATION
1. Aspergilloma (Fungus ball) (lungs, paranasal sinuses)
2. Otomycosis (external otitis)
3. Onychomycosis
4. Eye inf. (conjunctival, corneal, intraocular)
III. INVASIVE ASPERGILLOSIS
1. Pulmonary
2. Disseminated: GIT, brain, liver, kidney, heart, skin, eye
IV. MYCOTOXICOSIS

Diagnosis
Samples Sputum, BAL, tissue...
Direct exam. Septate hyphae and conidia in sputum; intravascular hyphae in tissue
Culture SDA (without cycloheximide)
(should grow at least in 2 cultures !)
Serology
Allergy (detection of specific IgE in serum--RAST)
Invasive inf. (detection of galaktomannan antigen in serum--ELISA)
Treatment
ALLERGIC Steroid
ASPERGILLOMA (if symptomatic) Surgery, amphotericin B
LOCAL, SUPERFICIAL INF. Nystatin
INVASIVE INF.
Surgical debridement
Amphotericin B, itraconazole
***High mortality rate

ZYGOMYCOSIS
Causative agents
Rhizopus, Rhizomucor, Mucor...
Natural reservoir Air, water, soil

Risk factors Diabetic ketoacidosis, immunosuppression

Pathogenesis Inhalation of sporangiospores
Infected tissue vascular invasion, thrombus, infarct, bleeding
Clinical manifestations
I. RHINOCEREBRAL
Nose, paranasal sinuses, eye, brain and meninges are involved
Orbital cellulitis
II. THORACIC
Pulmonary lesions, parenchymal necrosis
III. LOCAL
Posttraumatic kidney inf.
Skin inf. following burn or surgery
Diagnosis
Samples Sputum, BAL, biopsy of paranasal sinuses..
Direct exam. Nonseptate, ribbon-like hyphae which branch at right angles, sporangium
Culture SDA (cotton candy appearence)
Treatment
Surgical debridement
Amphotericin B
***High mortality rate