Superficial and Cutaneous Mycoses MYCO&VIRO

Prof. Marlyn Vicerra LE 03

07 February 2022 TRANS 01

OUTLINE 2. DISEASE CHARACTERISTICS

I. Laboratory Diagnosis of Fungal Infections • Clinically, infection caused by this organism usually has
A. Microscopy minimal invasion of the cornified skin
B. Culture → Usually discrete, serpentine, hyper- or hypopigmented
C. Serological (Systemic fungi) macular/macules patches that may enlarge and coalesce
II. Superficial Mycoses
→ Usually on the chest, upper back, arms or abdomen
A. Pityriasis versicolor
B. Tinea nigra
C. Piedra 3. LABORATORY DIAGNOSIS
III. Cutaneous Mycoses • Diagnosed by direct microscopic examination of scrapings of
A. Dermatophytes infected skin treated with 10- 20% KOH
B. Epidemiology → Pityriasis versicolor can be diagnosed by direct
C. Clinical Findings visualization of fungal elements under the microscope of
D. Diagnosis epidermal scales collected by skin scrapings treated with
I. LABORATORY DIAGNOSIS OF FUNGAL INFECTIONS 10% KOH with or without calcofluor white
A. MICROSCOPY • Lesions fluoresce under Wood’s lamp
→ Yellow or yellowish color
• KOH (10% or 20%) – fresh specimen
• Special stains - (Periodic Acid Schiff, Giemsa, etc.)
NEED-TO-KNOW
B. CULTURE • Microscopically, the colonies are comprised of budding
• Incubate at room temperature 4-6 weeks. yeast-like cells with occasional short unbranched hyphae
Table 1. and spherical cells
Sabouraud Dextrose Agar • The organisms are usually numerous and may be visualized
(SDA) with hematoxylin and eosin (h&e) or periodic acid schiff (pas)
Mycosel (SDA+ Antibiotic) Non sterile specimen stains
Brain Heart Infusion Agars Sterile specimen • The appearance of the organism under the microscope
within the lesions typically have a so-called “spaghetti and
C. SEROLOGICAL (SYSTEMIC FUNGI) meatball” appearance (di ko macomprehend yung sinabi
• To evaluate the status of the disease niya after 4:06 – 4:09)
• Complement Fixation
• Latex Agglutination
o e.g., Cryptococcosis 4. TREATMENT
• Skin Test • Treated with daily applications with selenium sulfide
o e.g., Histoplasmosis → This infection can be treated by using topical azoles or with
selenium sulfide shampoo
II. SUPERFICIAL MYCOSES
NEED-TO-KNOW
• One category of fungal infection that affects the outer most layer
of the skin, hair, nails and specifically colonizing the keratinized
outer layers
• Infections brought about by these organisms show little or no
host immune response or asymptomatic and non-destructive,
therefore easy to diagnose and treat
Figure 1. Photomicrograph of skin surface biopsy stained with periodic acid schiff
reagent to show pseudo mycelium and clusters of spores from lesion of pityriasis
A. PITYRIASIS VERSICOLOR versicolour (x50).
• Or Tinea versicolor
→ Common superficial infection observed worldwide B. TINEA NIGRA
• The common agents for this infection are the lipophilic yeast • Or tinea nigra palmaris
species of: • Superficial and chronic infection of the stratum corneum
→ Malassezia furfur complex • Caused by dematiaceous fungus: hortaea (exophiala)
→ M. Furfur werneckii
→ M. Globose → Sometimes called cladosporium werneckii
→ M. Restricta → A black fungus
→ M. Dermatitis (dermatis sabi niya per M. Dermatitis lang
lumalabas sa net) 1. EPIDEMIOLOGY
• Saprobic fungus living alone in the following environments: soil,
1. EPIDEMIOLOGY plants, beach sand, air, decomposing fish and normal skin
• In tropical environment, may affect 30 – 35% of the population (scalp and interdigital spaces).
• Young adults are most commonly affected → Living in highly polluted environment
• Human infection is thought to result from the direct or indirect • Affects individuals of both sexes and may involve any age
transfer of infected keratinous material from one person or → But most cases refer to females aged 20 years and under
individual to another • Cases frequently appear in coastal regions, indicating the
• Usually of a cosmetic problem/ concern possibility of acquiring a fungal infection on the seaside

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 3.01 Superficial and Cutaneous Mycoses
2. DISEASE CHARACTERISTICS
• Dark (brown to black) discoloration, often on the palm
→ Tinea nigra appears as a solitary, irregular dark pigment.
Brown to black macule usually on the palms and soles
• There is no scaling or invasion of the hair follicles and the
infection is not contagious
3. LABORATORY DIAGNOSIS
• To be able to diagnose such infection, microscopic examination
of skin scrapings treated with 10-20% KOH
• The appearance usually branched, septate hyphae and
budding yeast cells with melanized cell walls
• This organism appears as dermatiatious
NEED-TO-KNOW
• Under the microscope it is frequently branched septate
hyphae
• The arthroconidia and elongate budding cells is also present
• Grows in culture on standard medium: SDA at 25 oC
4. TREATMENT
• The infection responds well to topical therapy such as
keratolytic agents, like 2 to 4% salicylic acid, and with antifungal
azole creams:
→ Ketoconazole cream,
→ Imidazole derives,
→ Ciclopirox olamine
Figure 2. Hortaea (Exophiala) werneckii. Left. Micromorphology of the colony:
septated brown filaments, blastospores and artbrospores
C. PIEDRA
• Axillary, pubic, beard and scalp hair may be infected
• Treatment: remove hair and apply antifungal agent
1. BLACK PIEDRA
• Another infection affecting the hair, primarily the scalp
• Caused by Piedraia hortai
• will form a cream colored, dry, wrinkled colonies
a. LABORATORY DIAGNOSIS
• Grows as pigmented mold from brown to reddish black
• As the culture or the organism grows or ages, it appears to be
having spindle-shaped ascus spores which are formed within a
specialized structures called asci
• Using the sda, it grows very slow at 25oc and
→ May start as yeast-like colony and
→ Later becoming velvety as the hyphae developed
• As may be seen microscopically containing ascus spores up to
8 •
NEED-TO-KNOW
• The asci and the ascus spores are also produced within the
rock-hard, hyphal mass that surround the hair shaft
• The hyphal mass is held together by a cement-like substance
and contains the asci and the ascus spores which is the
sexual phase of the fungus
• Under the microscope, the nodule reveals branched,
pigmented hyphae
MV
b. Epidemiology
• This is uncommon and has been reported from tropical areas
and is thought to be a condition of poor hygiene
• It is asymptomatic and generally involves the scalp
c. Disease Characteristics
• Clinically it presents as a small dark nodule that surround the
hair shafts
• Nodular infection of the hair shaft
d. Treatment
• Can be treated by haircut and proper regular washing
Figure 3.
2. WHITE PIEDRA
• A superficial infection of hair caused by yeast-like fungi of the
genus Trichosporon
• Caused by Trichosporon spp.
→ The species causing scalp hair white Piedra is
Trichosporon ovoides
→ Pubic hair white Piedra is Trichosporon inkin
a. EPIDEMIOLOGY
• This condition occurs in both tropical and sub-tropical regions
and is related to poor hygiene
• These fungi or organisms affect the hair of the groin and axilla
b. DISEASE CHARACTERISTICS
• Usually surrounding the hair shaft and forms a white to brown
swelling along the hair strand
• Also cause soft, and pasty swelling along the hair strand but
causes no damage to the hair shaft
• Larger, softer, yellowish nodules on hairs
c. LABORATORY DIAGNOSIS
• The infected hair showing hyphal elements and arthroconidia
and/or budding yeast cells must be placed on culture media
without antibiotic which is the cycloheximide
→ As this will inhibit the species of trichosporon
→ After 48 – 72 hours of incubation at room temperature, it
• The trichosporon can be identified using the following test
→ Sugar assimilations
→ Potassium nitrate
→ Urease production
→ Morphology on cornmeal agar
d. TREATMENT
• This infection can be treated using topical azoles and improved
hygiene
Shaving of the infected area are also effective and negate the
necessity of medical treatment
Figure 4. Left. Many yellowish-white nodules, of soft texture, attached to and
surrounding the hair sheath, mostly in its distal portion (Red arrow heads)
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III. CUTANEOUS MYCOSES C. CLINICAL FINDINGS

• The second category of fungal infection or mycoses is 1. TINEA PEDIS (ATHLETE’S FOOT)
cutaneous mycoses • Trichophyton rubrum, Trichophytom mentagrophytes,
• Include infections caused by dermatophytic fungi/ Epidermophyton floccosum
dermatophytes • Most prevalent of all dermatophytes
→ the disease is called dermatophytosis • Chronic infection of toe webs
• Caused by fungi that infect only the keratinized tissue (skin, hair
and nails) NEED-TO-KNOW
• Caused by any of the several species related to filamentous • Various sites on the foot may be involved but Tinea
fungi in the genera: pedis usually affects the soles and toe webs.
a. Microsporum/ mycosporon • Various forms of dermatophytosis are referred to as
b. Trichophyton Tineas or Ringworms.
c. Epidermophyton • Clinically, the Tineas are classified according to the
• Various forms of dermatophytosis are referred to as “tineas” or anatomic site of the structure affected such as Tinea
“ring worms” pedis in the foot.

A. DERMATOPHYTES 2. TINEA UNGUIUM (ONYCHOMYCOSIS)

NEED-TO-KNOW • Trichophyton rubrum, Trichophyton mentagrophytes,
Epidermophyton floccosum
• Each genus of dermatophytic mold is characterized by
specific pattern or growth in culture by the production of • Nail infection may follow prolonged Tinea pedis
microconidia and macroconidia • Hyphal invasion of nails usually appear discolored or yellow,
brittle, thickened and crumbly
Table 1. • Nail scrapping is treated with 10-20% KOH
Microsporum Multicellular macroconidia with echinulate • For laboratory diagnosis, observe branching hyphae or chains
spp. walls of arthroconidia
Identified by observation of its macroconidia • Difficult to treat – takes several days or months of oral
Trichophyton Cylindric smooth walled macroconidia and itraconazole; relapses are common
spp. characteristic microconidia
Microconidia are characteristic structures of 3. TINEA CORPORIS AND TINEA MANUS
Trichophyton • Tinea Corporis and Tinea Manus is caused by Trichophyton
Epidermophyton Produces only club-shaped macroconidia, rubrum and Epidermophyton floccosum
spp. smooth walled, 2 or 4-celled and formed in • Tinea Corporis
clusters → The ringworm of the body is a rash caused by fungal
Does not produce microconidia but its infection known as tinea corporis.
smooth-walled macroconidia born in → Usually, itchy circular rash with clearer skin in the middle.
clusters of 2-3 are quite distinctive Remember ringworm gets its name because of its
appearance.
• Tinea Cruris
→ Trichophyton rubrum, Trichophyton mentagrophytes,
Epidermophyton floccosum
→ Also called as the jack itch.
→ Causes red itchy rash in warm and moist areas of the body
and the rash often affects the groin and the inner thighs and
maybe shaped like a ring.
Figure 5. Left: Microsporum spp. Middle: Trichophyton spp. Right: → Pruritic circular patches with advancing red, vesiculated
Epidermophyton spp. border and central scaling.
• Tinea Manus
B. EPIDEMIOLOGY → A fungal infection of the hands
• Dermatophytes can be classified in 3 categories based on their → Tinea aka ringworms, and manus refers to it being on the
natural habitat hands so the Tinea causes red scaly rash and has a border
→ Geophilic – from the soil, and are occasional pathogen of that is slightly raised.
both animals and humans • Itraconazole and terbinafine
→ Zoophilic – from animals, normally parasitized the hair
and skin of animals but can be transmitted to humans.
→ Anthropophilic – from humans, may be transmitted
directly or indirectly from one person to another.
• Infection begins in the skin after trauma and contact
• Host susceptibility enhanced by moisture, warmth, specific skin
Figure 6. Trichophyton rubrum (Left). Trichophytom mentagrophytes (Middle).
chemistry, composition of sebum and perspiration, youth,
Epidermophyton floccosum (Right).
heavy exposure, and genetic predisposition
• Incidence is higher in hot, humid climates and under crowded
NEED-TO-KNOW
living conditions
Tinea Corporis, Tinea Manus and Tinea Cruris
• Source of infection is soil or infected animal if geophilic or
• Grows only within dead keratinized tissues
zoophilic.
• Metabolites, enzymes and antigens diffuse through
• Anthrophilic – direct contact or through fomites such as
viable layers of the epidermis
contaminated towels, clothing, shared shower stalls.
• to cause erythema, vesicle formation and pruritus

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 3.01 Superficial and Cutaneous Mycoses
• Lesions expand centrifugally and active hyphal growth
is at the periphery – obtain material for diagnosis
• Itraconzole and terbinafine
4. TINEA CAPITIS AND TINEA BARBAE
• Trichophyton mentagrophytes and Microsporum canis
• Tinea Capitis
→ Ringworm of the scalp and is a rash caused by fungal
infection usually causes itchy, scaly, bald patches on the
head.
• Tinea Barbae
→ Trichophyton mentagrophytes
→ Beard ringworm or known as Barber’s Itch.
→ Fungal infection of skin, hair, hair follicles of the beard
and mustache area. The beard ringworm may be
passed to other person by direct contact with infected
people or animals with contaminated objects or from
the soil.
NEED-TO-KNOW
Tinea Capitis and Tinea Barbae
• Infection begins with hyphal invasion of the skin of the
scalp with subsequent spread down the keratinized wall
of the hair follicle
• Infection of the hair takes place just above the hair root.
• Infection produces dull, gray, circular patches of alopecia,
scaling and itching.
• Microsporum canis
→ Produce a chain of spores that form a sheath around
the hair shaft (known as ectothrix); spores impart a
greenish to silvery fluorescence when examined under
Wood’s light.
• Trichophyton tonsurans
→ Chief cause of “black dot”, tinea capitis produces
spores within the hair shaft (known as endothrix); hairs
do not fluoresce; hairs are weak and typically break
easily at the follicular opening.
Figure 7. Microsporum canis
Figure 8. Trichophyton tonsurans
NEED-TO-KNOW
Tinea capitis
→ zoophilic species may induce a severe inflammatory
and hypersensitivity reaction called kerion
→ Favus – another clinical manifestation of tinea capitis:
caused by trichophyton schoenleinii, which leads to the
formation of scutula (crusts) around the follicle.
D. DIAGNOSIS OF DERMATOPHYTOSIS
• Dermatophyte infections diagnosis detect lesions using Wood’s
lamp
• Wood's lamp (black light) emits UV-A radiation (ranging 315-
400 nm) with a peak at 365 nm and almost no visible light.
MV
• Two criteria are helpful in diagnoses
→ Enhancement: due to the loss of epidermal pigment and
the limited penetration depth of UV-A, Wood's lamp
accentuates the contrast between vitiliginous and
uninvolved skin.
→ Fluorescence: a distinctive bluish fluorescence
• Specimens:
→ Collected by scrapings from skin and the nails, and hairs
plucked from involved areas
→ Then treated on slide with a drop of 10-20% koh
o For soft specimen, it is treated with 10% koh and for
the hard one is treated with 20% koh.
→ In skin and nails: examine for branching hyphae, or chains
of arthroconidia
→ In hairs: dense sheaths of spores around /inside the hair.
Figure 9. Skin/Nails (left). Hairs (Right).
ADDITIONAL NOTES:
I. Microscopy
• To be able to properly diagnose infection caused by
fungi, we can perform direct microscopic examination
after the specimen has been collected and treated
either with:
→ KOH (10-20-%)- fresh specimen
→ Can be treated with Special stains – (Periodic Acid
Schiff, Giemsa, H&E etc.)
II. Culture
• To diagnose fungal infection, specimens collected
maybe placed in a routine culture medium such as:
→ Saboraud Dextrose Agar (SDA) incubate at room
temperature for 4-6 weeks.
→ Mycosel (SDA + Antibiotic) – for Non-sterile
specimen
→ Brain Heart Infusion Agar – for Sterile Specimen
III. Serological Examination (Systemic Fungi)
• To evaluate the status of the disease
→ Complement fixation
→ Latex agglutination (Cryptococcosis)
→ Skin Test (e.g. Histoplasmosis)
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