Systemic and Opportunistic Mycoses MYCO&VIRO

Prof. Roderick Balce LE 05

21 February 2022 TRANS 01

OUTLINE NEED-TO-KNOW
I. Body sites and possible systemic fungal pathogens • Dimorphic – key characteristics of systemic mycoses
II. Systemic Fungi agents. They exhibit both the yeast phase / parasitic phase
A. Histoplasma capsulatum / tissue phase and the mold phase / saprobic phase
B. Blastomyces dermatitidis → Yeast or parasitic phase is also called tissue phase
C. Paracoccidioides brasiliensis because it is the one isolated from clinical specimens
D. Coccidioides immitis • Yeast phase is exhibited at body temperature that’s why it is
E. Talaromyces marneffei (Penicillium marneffei) also called parasitic phase
III. Opportunistic Fungi • Conidia/Spores – represent the infective forms of these
A. Aspergillus spp. systemic fungi
B. Mucorales (Zygomycetes) → Conidia identification is important in establishing a
C. Fusarium spp. definitive species identification
D. Candida albicans → If you will only take note of the appearance of the
E. Cryptococcus neoformans structures that make up the mold form, there are other
F. Pneumocystis jirovecii species which might be confused with the mold forms
I. BODY SITES AND POSSIBLE SYSTEMIC (REGULAR) / of the systemic fungi
OPPORTUNISTC FUNGAL PATHOGENS • When you say thermally dimorphic fungi, you can include
Body Site Pathogens another species to the lists: Sporothrix schenckii
Genital Tract Candida albicans (yeast) → Primarily an agent of subcutaneous mycoses rather
(vaginal/cervical) than systemic
Throat Candida albicans A. Histoplasma capsulatum
Geotrichum candidum
1. IDENTIFYING CHARACTERISTICS
Blood/Bone Candida spp. a. MOLD PHASE
Marrow Cryptococcus neoformans
Histoplasma capsulatum • Conidiophores are at 90-degree angles to hyphae;
Blastomyces dermatitis – isolated from the → From each hypha arises the conidiophores bearing
blood or bone marrow macroconidia
Fusarium spp. • Macroconidia have knob-like projections describe as
tuberculate
Cerebrospinal Cryptococcus neoformans → Resembles those of Sepedonium spp.
Fluid Candida spp. • Microconidia are small pyriform (tear-drop or pear shape) on
Histoplasma capsulatum short branches or directly on hyphal stalk
Coccidioides immitis

Lungs (sputum, Pneumocystis jiroveci (non-filamentous

bronchial fungus)
washings, Candida albicans
transtracheal Talaromyces spp.
Figure 1. Mold phase of H. capsulatum.
aspirates) Histoplasma capsulatum
Blastomyces dematitidis b. YEAST PHASE
Paracoccidioides brasiliensis • Small round to oval single-budding cells
Coccidioides immitis • Often found inside monocytes and macrophages
Aspergillus spp. (molds) (reticuloendothelial cells)
Rhizopus spp. (molds)
• They characteristically have narrow neck between the mother
Mucor spp. (molds)
and daughter cell (bud) compared to the broad neck of B.
dermatitidis (refer to figure 2 and 4)
NICE-TO-KNOW
• Candida albicans is quite common, including non-albicans
species. It is also indicated in systemic infections as well as
opportunistic cases among immunocompromised
individuals
II. SYSTEMIC FUNGI
Figure 2. Yeast phase of H. capsulatum
• Mode of transmission: Often acquires via inhalation of
spores/conidia and can disseminate to any of the body’s organ NEED-TO-KNOW
systems • In clinical specimens, they are commonly found
→ Initially in the lungs but can later on disseminate to other intracellularly and may be mistaken for amastigotes of
organ systems of the body Leishmania spp.
• Most are thermally dimorphic exhibiting a yeast phase at 35- → Almost the same size as the amastigotes of Leishmania
37C or body temperature while the mold phase is observed at spp., which are also found within reticuloendothelial
a room temperature or 25-30C cells
• To establish the identity of a specific isolate, Conidia 2. PATHOGENESIS
identification is necessary
• It causes histoplasmosis, also called Darling’s Disease or
Spelunker’s Disease

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 5.01 Systemic and Opportunistic Mycoses
• Can be self-limiting or fatal pulmonary infection that can affect
the spleen, liver, kidneys, bone marrow, and heart
→ It can be multi-systemic
• Mode of Transmission: Acquired by spore inhalation from
barns, chicken houses, and bat caves
B. Blastomyces dermatitidis
1. IDENTIFYING CHARACTERISTICS
a. MOLD PHASE
• Hyaline, septate hyphae with single smooth-walled, round to
oval conidia at the ends of short conidiophores resembling
lollipops
• Mold forms can be confused with Scedosporium apiospermum,
and also with Chrysosporium
Figure 3. Macroconidia or oval conidia at the tip of short Conidiophores
NEED-TO-KNOW
• Septate hyphae – with cross walls or septations
• Scedosporium apiospermum – under subcutaneous
mycoses. This is an amorph or asexual form of
Pseudallescheria boydii which is the teleomorph or sexual
form (both of them represent the same species)
→ P. boydii is one of the causes of eumycetoma (one of
the agents of mycetoma)
• Chrysosporium – commonly considered a contaminant
b. YEAST PHASE
• Large, round budding yeast with broad-based blastoconidia
(broad neck between the mother and daughter cell); and thick,
doubly refractive wall
Figure 4. The base of the blastoconidia is broad
2. PATHOGENESIS
• It causes North American blastomycosis or Gilchrist Disease,
usually contracted by farmers from soil;
• Since MOT is inhalation, it begins in the lungs and may become
systemic
C. Paracoccidioides brasiliensis
1. IDENTIFYING CHARACTERISTICS
a. MOLD PHASE
• Hyphae with intercalary and terminal chlamydoconidia
resembling Blastomyces
• Mold forms of B. dermatitidis and P. brasiliensis really look the
same, having macroconidia at the tip of a conidiophore.
Figure 5.
NEED-TO-KNOW
• If P. brasiliensis mold form resembles that of the B.
dermatitidis, there are now 4 spp. the resembles each
other’s mold forms including S. apiospermum and
Chrysosporium
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b. YEAST PHASE
• Large, round, double-walled, with multiple budding yeast cells
with very narrow necks resembling or described as Mariner’s
wheel / Ship’s wheel
Figure 6.
NEED-TO-KNOW
• The main difference of the yeast phase of P. brasiliensis
from the 2 previous species, is that is has multiple budding
yeast cells around the parent cell
2. PATHOGENESIS
• Paracoccidioidomycosis or South American Blastomycosis,
a chronic granulomatous disease of the lungs and skin that can
spread to the liver and spleen
D. Coccidioides immitis
• Most infectious of all the fungi (in this topic)
• Considered a major biohazard to laboratory personnel so
certain precautionary measures must be observed namely:
→ Preferred to use screw capped tubed media/test tubes
rather than plates
▪ The cap must be sealed with tape
→ Use of cotton plug is not advice because of high infectious
nature of this species.
→ When you are processing specimens suspected of
containing C. immitis, BSC III must be used
▪ BSC III is the recommended BSC level for
performing culture involving C. immitis
1. IDENTIFYING CHARACTERISTICS
a. MOLD PHASE
• Septate hyphae branching at right angles and consist of thick-
walled, rectangular or barrel-shaped arthroconidia that
alternate with empty disjunctor cells (clear non-viable ghost
cells)
Figure 7.
b. YEAST PHASE
• Round, thick-walled spherule filled with small endospores that
resembles yeast cells
→ endospores: does not bud
→ yeast cells: produce buds
Figure 8.
2. PATHOGENESIS
• Coccidioidomycosis or San Juaquin Valley Fever or Desert
fever, an infection of the lungs, bones, joints, skin, lymph
nodes, central nervous system, and adrenal glands
→ A lung infection that may disseminate in the other parts of
the body such as lungs, bones, joints, skin, lymph nodes,
central nervous system, and adrenal glands
E. TALAROMYCES MARNEFFEI (PENICILLIUM
MARNEFFEI)
• Unique among penicillium species because of its:
→ Dimorphic nature and,
→ Is a true pathogen
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1. IDENTIFYING CHARACTERISTICS
a. MOLD PHASE
• Brush-like structures typical of the genus Penicillium;
• Green aerial mycelium and reddish-brown hyphae are
produced along with a red diffusible pigment
→ Red diffusible pigment: characteristic of T. Marneffei
o Seen on agar surface following incubation at 25 oc
o Best observed by viewing the reverse of the colony/
bottom of the plate
Figure 9.
b. YEAST PHASE
• Oval and small yeast cells, around 3-8 um in diameter, some
have cross-walls, and resemble H. capsulatum
Figure 10. Mold and yeast phase of T.marneffei
2. PATHOGENESIS
• Common cause of disease in HIV-positive patients in
Southeast Asia
→ Endemic in Southeast Asia
• The disease is characterized by cutaneous and
mucocutaneous that can progress into a disseminated disease
NEED-TO-KNOW
• Begins in the skin or subcutaneous tissues and then may
disseminate to other area of the body. Especially if the
patient is immunocompromised
• Immunocompromised individuals: not only HIV/AIDS
patients. Also includes:
→ Patients with hematologic malignancies such as
leukemias and lymphomas;
→ Those with autoimmune disorders;
→ Even recipients of organ transplants that are on
immunosuppressive therapy
→ Individuals taking corticosteroids
III. OPPORTUNISTIC FUNGI
• Most are saprobes or saprophytic fungi;
→ They are not regular pathogens
→ Do not typically cause infections among
immunocompetent individuals
• Generally acquired through inhalation of spores
• Inhibited by many antimicrobial agents
→ Such as cycloheximide
→ Must be taken in consideration when trying to isolate these
species
→ The media should not contain these agents, otherwise we
will not be able to isolate them
• Identification is based on microscopic morphology
A. ASPERGILLUS SPP.
1. IDENTIFYING CHARACTERISTICS
a. COLONY MORPHOLOGY
• Aspergillus spp. form granular/fluffy or powdery growth
within 2 days on SABHI.
→ SABHI: Sabouraud Dextrose with Brain Heart Infusion
Agar
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Table 1. Pigmentation varies according to species
A. fumigatus Green to gray with tan reverse
A. flavus Yellow to yellow-green with red-brown reverse
A. niger Yellow to black with buff or cream reverse
A. terreus Tan or cinnamon with yellow reverse
b. MICROSCOPIC APPEARANCE
• Septate hyaline hyphae (non-melanized)
• Conidiophores arise from a foot cell and terminate in a large
spherical vesicle bearing flask-shaped phialides which may
be uniseriate or biseriate producing chains of phialoconidia
NEED-TO-KNOW
• Uniseriate or biseriate: meaning single or double row of
phialides
→ Uniseriate: there is one layer of phialides attached
directly to the vesicle
→ Biseriate: with supporting structures called metulae
from which phialides arise
• Typical structure of Aspergillus spp.
→ Foot cells: from which a conidiophore arise
→ At the tip of the conidiophore is a vesicle
→ Attached to the vesicles are either phialides or metulae
o Depends on whether the species is uniseriate or
biseriate
o A. fumigatus is uniseriate meaning you have single
row of phialides that are directly attached to the
vesicles
o A. versicolor is biseriate because instead of
phialides attached to the vesicle, you have here
metulae which are supporting structures, short hyphal
structures that cover the vesicle, part or the entire of
the vesicle
o It’s the metulae that gives rise to the phialides and in
turn the phialides give rise to conidia
→ Conidia: produced from the phialides
→ A. fumigatus and A. versicolor: the sporulation is from the
upper half or 2/3 of the vesicle
→ A. flavus and A. niger: the phialides cover the entire vesicle
and is described as radiate arrangement
o The phialides point out in all directions
o A. flavus can be uniseriate, biseriate or both
Figure 11.
2. PATHOGENESIS
• Cause aspergillosis, which can affect the skin, heart, lungs,
and central nervous system.
• A. fumigatus is the most common cause of aspergillosis;
• A. niger causes otomycosis, a superficial mycotic infection of
the outer ear canal characterized by inflammation, pruritus, and
scaling.
• A. terreus is innately resistant to amphotericin b
→ It forms aleuroconidia which are large cells seen on
submerged hyphae
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B. MUCORALES (ZYGOMYCETES)
• Also known as Mucormycetes
• Common environmental isolates from soil and plants
• This are commonly seen as contaminants in grains, bread and
fruits but may cause in or among immunocompromised
individuals
1. IDENTIFYING CHARACTERISTICS
a. COLONY MORPHOLOGY
• Growth after several days is dense;
• Colonies show a cotton candy texture, and pigmentation Figure 13. Illustrations of Rhizopus, Mucor, and Lichtheimia spp.
ranges from white, to gray, to brown NEED-TO-KNOW
→ The colonies are described as fluffy • Take note of the new Genus name for Abisidia
→ The characteristic pigmentation is actually derived from the (previous name), it is now Lichtheimia spp.
color of conidia
• Because the growth is so rapid, this species is sometimes c. PATHOGENESIS
referred to as “lid lifters” • Zygomycetes cause zygomycoses or mucormycoses,
→ Because they literally lift the lid of the petri dish because of commonly involving the paranasal sinuses and can extend to
the rapid growth within 24 to 96 hours the central nervous system (rhinocerebral manifestation).
b. MICROSCOPIC APPEARANCE • Some can also produce toxins that can cause gastrointestinal
disturbances.
• Hyphae are sparsely septate/occationally septate and are • Among the three genera discussed here, the most common
ribbon-like and thin walled; cause of human disease is Rhizopus spp. Typically involving
• Typically form rootlike hyphae called rhizoids, which function patients with Diabetes mellitus (this is a risk factor). Also for
in attachment and nutrient absorption Aspergillosis, DM is also considered as a risk factor.
• There are many species or genera of Zygomycetes, but the
most notable are Rhizopus spp., Mucor spp., and Absidia spp. C. FUSARIUM SPP.
Table 2. • Are hyaline, septate, monomorphic mold.
Rhizopus spp. Sporangiophores are unbranched that arise • Colonies may initially appear yeast-like.
opposite the rhizoids 1. IDENTIFYING CHARACTERISTICS
→ The rhizoids are at the point where the
sporangiospores and stolons meet a. COLONY MORPHOLOGY
→ Take a look at the general structure for • Produces white, cottony colonies that quickly develop pink or
better explanation. (Figure 12.) violet centers.
Mucor spp. Sporangiophores are single or branching. NEED-TO-KNOW
Another important characteristic is there are • Take note that it is a mold that’s why we use the term yeast-
no rhizoids. like when referring to the colonies.
Lichtheimia Sporangiophores are just like Mucor-- • The colonies initially resemble those of the yeast isolates but
spp. (Absidia branching but the difference is there are remember that it is monomorphic and it means that it does
spp.) rhizoids. not have a yeast phase and it is consistently in the mold
In Figure 13., the Sporangiophore of Absidia form.
is between two rhizoids
Slight swelling below the columella at the b. MICROSCOPIC APPEARANCE
base of the sporangia • Form septate hyphae and two forms of conidiation
**Refer to Figure 13 for better illustration of Rhizopus, Mucor, and Absidia spp.
→ One, conidiophores with phialides producing large
Structures.
macroconidia that are described as sickle shape or
banana shape or boat shape or canoe shape; and
→ Simple conidiophores, with small, oval conidia singularly or
in clusters.

Figure 12. General Structure

• Refer for Figure 12. We refer to the stalk as sporangiophore
and the tip is a sporangium.
• For Rhizopus spp. There are no branches (the sporangiophre
is unbranched) and found opposite of it are the rhizoids
• Rhizoids are rootlike projections that anchor the growing cells
to the substratum primarily for attachment and nutrient
absorption
• Stolon may be occasionally septate. These are filaments that
join clusters of sporangiophores and terminate at the rhizoids in
the case of Rhizopus.
Figure 14. Fusarium spp. illustration
• Refer to figure 14. Picture b. These are the typical macroconidia
that are sickle shape and Picture c. are the conidiophores that
have oval conidia/blastoconidia that are best identified or
recovered in cornmeal agar.
• If you use cornmeal agar and grow it, then chlamydoconidia
may be demonstrated.

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c. PATHOGENESIS
• Associated with a variety of clinical presentations, including
mycetomas, keratitis, and systemic infections.
• The primary cause of eumycetoma Pseudalleschria boydii,
Scedosporium apiospermum, and Madurella spp.
• In addition, Fusarium spp. may also cause mycetomas. It
presents as skin lesions with necrotic centers resembling the
lesions associated with Aspergillus.
• Systemic infections particularly among bone marrow
transplant recipients are prone to developing Fusariosis
which presents with very high fever and some cases fungemia
meaning it may be isolated in the blood.
NEED-TO-KNOW
• In bacteriology, there’s an actinomycetoma caused by
Nocardia, Actinomyces, and Streptomyces spp. But when
we talk about mycetomas caused by fungi, eumycetoma is
the more appropriate term to distinguish it from the
actinomycetomas caused by fungi-like bacteria.
D. CANDIDA ALBICANS
• Most commonly yeast isolate; normal flora of the mucous
membranes lining the respiratory, gastrointestinal, and female
genital tracts.
• It may be isolated from almost all clinical specimens.
1. IDENTIFYING CHARACTERISTICS
• Produces chlamydospores on cornmeal agar with Tween 80
(recommended culture medium if you want to demonstrate
chlamydospores).
• Presumptive identification is a positive germ tube.
→ Its demonstration will presumptively identify the isolate as
C. albicans but you have to rule out Candida dubliniensis
which also produces a positive germ tube and C. tropicalis
which produces a pseudogerm tube.
→ When we say pseudogerm tube, there is a constriction
at the base which is typical of Candida tropicalis.
→ Refer to figure 15. Chlamydosphore can be seen when the
isolate is grown in the cornmeal agar.
o The typical finding is budding yeast cells and you may
also see/demonstrate pseudohyphae.
o All of those in the structure can be demonstrated
when the isolate is grown in corn meal agar.
Figure 15. C. albicans illustrations (a.) pseudohyphae and budding yeast, (b)
chlamydosphore and pseudohyphae, (c) germ tube
a. PATHOGENESIS
• Causes thrush, vulvovagintis, diaper rash, onychomycosis,
paronychomycosis, as well as systemic infections, including
meningitis, UTIs, and heart and lung infections.
E. CRYPTOCOCCUS NEOFORMANS
• Common fungal isolate from CSF of patients with HIV/AIDS or
immunocompromised patients.
• It is the causative agent of fungal meningitis (cryptococcal
meningitis).
1. IDENTIFYING CHARACTERISTICS
• Gram stain – yeasts appear in spherical form and are not of
uniform size; form the so-called starburst pattern.
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• thick polysaccharide capsule demonstrated by using Negative
staining with India ink or Nigrosin.
→ India ink is not as sensitive as antigen test.
• direct antigen test for cryptococcal antigen performed on CSF
and serum specimens
→ Between the two, the more sensitive technique is direct
antigen test or latex agglutination assay for cryptococcal
antigen than negative staining.
• only forms blastoconidia in culture
• brown to black colonies on Birdseed/ Nigerseed/ Caffeic acid
agars
• To identify C. neoformans, we need to perform biochemical
testing
→ The organism should produce positive biochemical tests
for urease, phenol oxidase, and inositol utilization test.
a. PATHOGENESIS
• causes cryptococcosis, which can produce a mild to moderate
pulmonary infection and can lead to systemic infections and
meningitis in immunocompromised patients; acquired by
contact with bat, pigeon, or other bird droppings, in addition to
contaminated vegetables, fruit, and milk.
→ It may also be isolated from respiratory specimens
F. PNEUMOCYSTIS JIROVECII (P. CARINII)
• Non-filamentous fungus previously classified as protozoans
and was initially known as Pneumocystis carinii.
NEED-TO-KNOW
• P. carinii is not the human species or human specific. It is
jirovecii that is actually isolated from humans because
carinii is from monkeys and rats.
1. IDENTIFYING CHARACTERISTIC
• demonstrated in respiratory specimens in bronchoalveolar
lavage (BAL) and induced sputum. e.g. open lung biopsy,
transbronchial aspirate, and nasopharyngeal aspirates.
→ BAL is more informative compared to induced sputum
because it represents the lower respiratory tract, and it is
preferred especially when you are investigating
immunocompromised patients from a possible P. jirovecii
infection.
• nonfilamentous fungus
• Stains used for identification if microscopic examination is
performed:
→ Methenamine silver
→ Periodic Acid Schiff
→ Giemsa and
→ the all-around stain for fungi is fluorescence stain
Calcofluor white.
• Cup-shaped cysts contain several intracystic bodies,
trophozoites with dark staining nuclei
→ Cysts and Trophozoites is the evidence that it is used to
be a protozoan which were retained even after it was
reclassified as true fungus spp. These terms referring to
the stages referring to its life cycle were retained.
• Nucleic acid probes and amplification assays (PCR) to
definitively identify P. jirovecii.
→ Morphologic/Microscopic examination is not that sensitive.
a. PATHOGENESIS
• generally asymptomatic in healthy individuals but can result in
a serious or fatal pneumonia among immunocompromised
patients. (HIV patients or other with compromised immunity)
ADDITIONAL NOTES:
→ Refer to Figure 16 and 17 on Page 7 and 8.
→ The tables are the summary but take note of the
characteristics of Aspergillus spp. In the table including
A. fumigatus, A. flavus, A. niger, and A. terreus.
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→ Take note of the growth rate column in the figure for the
dimorphic fungi (slow growers) and Aspergillus spp. are
rapid growers (3-5 days) and Zygomycetes are
extremely rapid growers (1-3 days).
→ Diagnostic techniques (last column; right) or the
confirmatory tests for identification; for dimorphic fungi,
one of the important tests is the conversion of yeast
form using cottonseed conversion agar.
→ For zygomycetes, Identification is based on
characteristic morphologic features. One important
distinguishing characteristic is the presence or absence
of Rhizoids and their position with respect to
sporangiophore.
→ Mucor spp. do not have rhizoids.
→ For Aspergillus spp., identification is based on
microscopic morphologic features and colonial
morphology; Particular is the use of Czapeks medium
for Aspergillus.
→ For dimorphic fungi, take note of the Microscopic
Morphologic Features Column especially those under
of the Non-blood Enriched medium.
→ BASAHIN ANG TABLES. They are not there for nothing
^__^

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 Systemic and Opportunistic Mycoses (Tables) MYCO&VIRO
Prof. Roderick Balce LE 05
21 February 2022 TRANS 02

Figure 16. Summary of the characteristic features of fungi known to be common causes of selected fungal infection in humans

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Figure 17. Continuation; Summary of the characteristic features of fungi known to be common causes of selected fungal infection in humans

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