Professional Documents
Culture Documents
OUTLINE NEED-TO-KNOW
I. Specimen Collection • Many pathogenic fungi grow slowly, and so any delay in the
II. Samples commonly submitted to mycology laboratory processing decreases the probability of isolating the
A. Hair causative agent, as a result of the overgrowth by
B. Skin contaminants
C. Nails • Cultures of organism suspected of being pathogens should
D. Blood be sealed with tape to prevent lab contamination
E. Bone Marrow ® Should be autoclaved as soon as definitive
F. Cerebrospinal Fluid identification is made
G. Abscess Fluid, Wound Exudates, and Tissue Universal Precaution
H. Respiratory Tract Secretions • “Treat blood and other body fluids as if they contain blood-
I. Corneal Scrapings borne pathogen”
J. Urine Conidia
K. Vagina • Asexual reproductive structure
III. Laboratory Diagnosis of Mycoses
A. Direct Microscopic Examination
• Screw capped tubes are preferred to Petri dishes for
B. Special Tests
recovery of fungi. Petri dishes are not recommended
I. SPECIMEN COLLECTION ® Release of airborne conidia is less likely
• Sterile equipment and aseptic techniques to avoid the ® Reduce dehydration of media
introduction of microorganisms during invasive procedures ® Easy handling and storage; takes up less space for
• Adequate amount of specimen to decrease the chance of false incubation
negative results
• Sample from the area most likely affected by the organism NEED-TO-KNOW
• Proper specimen labelling. • Petri dish is not recommended because the agar in the petri
dish dehydrates/dries easily due to the extended incubation
NEED-TO-KNOW time that is required in fungal cultures. But it still has
• Specimen collection is critical since errors committed cannot advantages:
be corrected and will require collection of a new specimen ® Larger surface area for colony isolation
• The primary criterion for accurate diagnosis of mycotic ® Easier to manipulate when making preparations for
infection is the proper collection of appropriate samples for microscopic examination
testing
• Volume of specimen required for fungal cultures usually II. SAMPLES COMMONLY SUBMITTED TO MYCOLOGY
exceed and is greater than those used in bacteriology LABORATORY FOR CULTURE
® Several types of specimens need to be pre-treated or A. HAIR
concentrated before inoculation(plating) in order to • Samples from the scalp include skin scales and plucked hairs.
maximize the recovery of the fungi • Hairs infected with fungi (e.g. Microsporum audouinii – causes
• Best specimen to be submitted must come from the active Tinea Capitis infection) fluoresce/will give off light using Wood
site of infection lamp
® The choice of the correct specimen in Mycology will
depend on the clinical presentation of the patient and NEED-TO-KNOW
the organ systems affected
• Cut hairs are not suitable for direct examination
• Improper specimen labelling or patient identification is the
• We have to use sterile forceps in pulling/plucking the hair:
most common source of pre-analytical error
® At least 10-12 hairs with the roots attached or with the
• Specimen container must contain the pertinent information
base shaft intact
of the patient
• Wood Lamp – source of ultraviolet light and is used to
® Patient’s name
detect fluorescence in the skin and hair.
® Hospital number
® DOB B. SKIN
® Time and Date of collection • Samples from the outer edge of skin lesions are obtained by
® Type of specimen scraping with scalpel blade or curette
® Test requested • Choose the most recent for scrapings in case of multiple
• Usually, the specimen container is labelled with 2 patient lesions
identifiers (most common)
® Patient’s name and Hospital number / Patient’s name NEED-TO-KNOW
and DOB • Skin is scraped from the outer edge of the skin lesion
® Because it contains the greatest amount of viable
• Transport specimens in leak proof sterile container and fungus
processed as soon as possible. • In cases of multiple lesions, you have to choose the most
• Mold cultures and clinical specimens must be handled recent for scrapings
in class II BSC because we want to provide protection to the
specimen, environment, and laboratory worker from the C. NAILS
dissemination of the conidia which are airborne • Scraping of outermost layer of infected nail with scalpel or
curette
• Deeper scrapings, debris from under the edges of the infected
nails, and nail clippings are also suitable for culture.
NEED-TO-KNOW NEED-TO-KNOW
• May be submitted as scrapings, cuttings, and occasionally, • The use of blood culture provides an accurate method for
as a complete nail. determining the cause of disseminated fungal infection
• Discolored or brittle parts of the nail must also be included ® Blood from septicemic patients can harbor known
in the collection pathogenic and opportunistic fungi, the most common
being is Candida
HAIR, NAILS, AND SKIN
• For dermatophyte culture
• Sites are initially cleaned with 70% alcohol to remove surface
contaminants
• Curette can also be used to collect specimens from young
children and from awkward sites such as interdigital spaces
• Samples should be placed in sterile petri dish and transported
to the lab. Storage at 4c is not recommended since some
dermatophytes are susceptible to cold temperature.
• After samples are received in the lab;
® KOH wet mount is prepared
Figure 1. Automated blood culture system called BACTEC (Left). Biphasic culture
® Samples are inoculated in Saboraud Dextrose Agar (SDA)
bottle (Middle). Isolator tubes (Right).
containing antibiotics:
o Chloramphenicol E. BONE MARROW
o Gentamicin • The specimen from the bone marrow is obtained by means of
o Cycloheximide aspiration
• Mycosel agar can also be used for inoculation (contains • Bone marrow aspirate may be collected in a heparinized
chloramphenicol and syringe or isolator tube
cycloheximide) ® This bone marrow aspirate is then subjected to Giemsa
staining
NEED-TO-KNOW ® Inoculate in Saboraud Dextrose Agar (SDA) with
• Transport should be at room temperature chloramphenicol and gentamicin and Brain Heart Infusion
® Fungi are resilient/flexible but some of them are Agar (BHIA) supplemented with 5% sheep blood.
affected by temperature above 37 degrees and below ® An alternative to this is to place the bone marrow aspirate
10 degrees Celsius in an isolator tube and to process it as a blood culture
• Hair, nails, and skin are particularly sensitive to cold
temperature NEED-TO-KNOW
• SDA – standard culture medium used for the recovery of • These bone marrow samples are used to determine the
fungi cause of disseminated fungal infections
• Cultures should be incubated for a minimum of 21 days at ® Such as fungi that causes septicemia in patients. The
30 degrees Celsius before reporting the results as negative most common being Candida
D. BLOOD F. CEREBROSPINAL FLUID
• 10 ml blood should be collected in SPS tube before they are • Collected by means of lumbar tap or lumbar puncture and
placed in blood culture bottles or can be inoculated directly in should be processed immediately
blood culture bottles • Collected in 3 sterile tubes
® BACTEC, an automated blood culture system, is used for ® The second tube goes to the microbiology section
the recovery of yeasts, except Malassezia spp. • 3-5 ml is adequate for the examination
• Recovery of fungi from blood samples may be enhanced using • If there is a delay in the processing, samples should be kept at
Biphasic culture bottle room temperature or incubated at 30°C.
® Contains slant of Brain Heart Infusion Agar (BHIA) and • Sample should be concentrated by centrifugation before
60-100ml of BHI broth inoculation in a solid culture media
® 1:10 to 1:20 (blood broth ratio) ® The supernatant is reserved for cryptococcal antigen
® Minimum of 5ml of blood is required for each culture bottle testing
® Culture bottles should be incubated at 30 degrees Celsius • Aside from inoculation in a solid culture media, you can also
and maintain for 4 weeks perform:
• SDA with chloramphenicol and gentamicin may be used for ® Cryptococcal antigen testing
primary isolation of fungi in blood samples (Inoculation) ® India Ink preparation
• Giemsa, Gram and Periodic Acid Schiff (PAS) are used for ® Inoculate in SDA and BHIA supplemented with 5% sheep
stained smears, for direct microscopic examinations. blood.
• Aside from culture bottles, we can use Isolator tubes. Isolator
tubes enhance fungal recovery (Histoplasma capsulatum and
NEED-TO-KNOW
other filamentous fungi) from blood and bone marrow
The sediment is processed as follows:
specimens
• For direct microscopy, use a drop of the sediment to make
® Contain agents which lyse WBC and RBC in the blood
an India ink preparation. Resuspend the remaining
which then releases the microorganisms
sediment in 1-2ml of CSF and inoculate in media with no
® Centrifugation of the tube concentrates the organism antibacterial or antifungal agents such as SDA and BHIA
before culturing supplemented with blood. Incubate at 35C and maintain
o The concentrate is inoculated in appropriate culture
cultures for at least 4 weeks
media and incubated at 30 degrees Celsius for 21
days
MV 2 of 6
2.01 Specimen Collection and Transport
G. ABSCESS FLUID, WOUND EXUDATES, AND TISSUE ® Even if only one eye is infected, if possible, obtain two
• Abscess fluid and exudate from wounds are examined for the separate swabs from each eye
presence of granules using dissecting microscope. ® So that the other eye that is not infected will show the
• If no granules are present, the material may be plated directly indigenous microflora and serve as the control
onto the media. • Withdraw the use of antibiotics before taking these corneal
• Tissue should be gently minced before culture/ inoculation scrapings or for any other clinical specimens
® SDA with chloramphenicol and gentamicin ® You have to take the sample before the initiation of
antimicrobial therapy
® BHIA supplemented with 5% sheep blood
® Other wise you will obtain false negative results
® KOH preparation
® Calcofluor white preparation • Store at room temperature if there is any delay in the transport
® Staining (Hematoxylin & Eosin, Methenamine Silver stain,
Periodic Acid Schiff)
• Aside from mincing, grinding of tissue has also been
recommended
® However, this process might destroy some fungal
elements
NEED-TO-KNOW
• In cases of large sections of tissue are submitted to the
laboratory, suspicious areas such as purulent or discolored
sections are selected for mincing and grinding before being Figure 2. Surgical blade (left). Calcium alginate swab (right)
placed in a solid culture J. URINE
• It is essential that the histopathology department also
• First morning urine obtained by midstream clean catch
receives a portion of the tissue in formalin for rapid frozen
method or catheter
section with staining by H&E. Methenamine Silver Stain and
• Refrigerate specimens at 4C for no longer than 12-15 hours if
Periodic Acid Schiff
there is delay in processing (cannot be competed within 2
H. RESPIRATORY TRACT SECRETIONS hours)
• The most common specimens submitted are sputum and ® Urine is a very good medium for the replication of the
transtracheal/tracheal aspirate bacteria and fungi
® Which are lower respiratory tract secretions ® If you leave the specimen at room temperature, this will
allow the growth of contaminant
• Collect early morning sputum
® It is recommended to process the specimen immediately
® The patients should obtain the specimen from a deep
cough shortly after waking up in the morning and before • Centrifuge urine and use the sediment to perform
eating in order to reduce the risk of contaminating the ® KOH preparation
sample with food ® Inoculate in SDA with gentamicin and chloramphenicol
® Ask the patient first to gargle to avoid contaminating the o Used because the urine is often contaminated with
sample with food particles gram negative bacteria
® Should be collected in a sterile container o Used to ensure the recovery of the fungi
• Viscous specimens such as tracheal aspirate can be digested • Centrifuge the urine for 10-15 minutes at 200rpm.
with a use mucolytic agent, which is N-acetyl-L-cysteine and ® KOH preparation
then concentrated before it is inoculated in solid culture media ® Inoculate in SDA with gentamicin and chloramphenicol
• Specimens may be stored at room temperature if processing is and incubate at 35C.
completed within 2 hours K. VAGINA
• If processing is delayed, specimens should be refrigerated at • Vaginal swabs should be transported to the laboratory within 24
4°C. hours of collection using transport swabs which must be kept
• The sample is used to make: moist in sterile tubes.
® KOH preparation ® This method of collection provides specimen suitable for a
® Gram stain wet preparation
® Inoculate in SDA with chloramphenicol and gentamicin • Selective and inhibitory agars should be plated.
and BHIA supplemented with blood. • Vaginal cultures should be screened for yeasts and incubated
o Any bits of blood, pus or necrotic material should be at 30°C for 7 days.
plated directly onto the media
• Fungal cultures will require a long period of incubation, usually
• Incubate culture media at 35C and maintain cultures for 4 3-4 weeks
weeks
® What happens is that the agar, should you use the petri
I. CORNEAL SCRAPINGS dish, will be dehydrated and will allow the growth of
contaminants due to the extended incubation time
• For patients presenting with atypical lesions or ulcers, obtain
corneal scraping using surgical blade or calcium alginate swab ® This solid culture media contains antibiotics to inhibit the
• Collected using surgical blade or calcium alginate swab growth of bacteria and other fungi
® Inoculate directly on SDA at the time of collection and
apply the remaining material to glass slides for staining NEED-TO-KNOW
® Examined under the microscope using smears that are • Recommended temperature for the transport of these
stained with: samples is at room temperature
o Gram stain ® Because some of these fungi are sensitive to cold
o Lactophenol cotton blue (LPCB) temperature
• The swab that is pre-moistened is rolled over the onto the
conjunctiva
MV 3 of 6
2.01 Specimen Collection and Transport
Figure 3. Figure 4.
III. LABORATORY DIAGNOSIS OF MYCOSES 2. CALCOFLUOR WHITE STAIN
A. DIRECT MICROSCOPIC EXAMINATION • Sensitive and reliable method for identifying fungi
The two purposes of direct microscopic examination: ® Because it provides a better contrast from the debris, cells
and tissue fragments which are found in the background
Presumptive diagnosis ® Also give a good definition of the fungal structures
• Traditionally, the KOH preparation has been the recommended
• Provides a rapid or an initial report to the doctor which may
method for direct microscopic examination of specimen
result to early initiation of treatment
however the calcofluor white stain is now believed to be
superior to KOH method
Provides evidence of infection despite negative culture
• The disadvantage of using this stain is that:
results ® it will require the use of fluorescent microscope
• This may happen in specimens from patients receiving anti- ® it is more expensive
fungal therapy. These anti-fungal agents may inhibit the growth ® it will require expertise when it comes to the reporting of
of microorganisms in vitro, even though the infection can still be the result
present in the patient • Slides may be observed using fluorescent microscope
NICE-TO-KNOW
NEED-TO-KNOW
• The types of direct examination used in the identification of
• Using this fluorescent microscope, the fungal elements will
fungal infections include wet preparation such as KOH, India
fluoresce ranging from apple green or white in color
ink, calcofluor white stain, and gram stain depending on the combination of filters used in fluorescent
® Although the gram stain performed in routine microscope
microbiology laboratory often gives the first evidence of
infections with bacteria and yeast, other direct stains 3. GRAM STAIN
give more specific information about mold infections • Fungi are gram-positive
® Histologic stains for tissue may also be useful ® Routinely performed in microbiology because it gives first
1. KOH PREPARATION evidence of infection with bacteria and yeast.
® RECALL Gram Stain Reagent (Mnemonics: VIAS):
• Drop of 10-20% KOH + sample (skin and nail scrapings, hair,
o Primary stain: Crystal Violet
tissue) on a slide is heated
o Mordant: Gram’s Iodine
® 10-20% solution of KOH is useful for detecting fungal
o Decolorizer: Alcohol (Ethyl alcohol)
elements embedded within the skin, hair, nails and tissue
o Counterstain: Safranin
® In this procedure, a drop of the KOH preparation is placed
® Gram positive organism stains purple blue or purple
on a slide. Nail scrapings, hair, skin scales or thin slices of
violet.
tissue is then added to the drop and a coverslip is placed
® Gram negative organism stains pink or red.
® The slide is then gently heated and then allowed to cool for
® Fungi are gram positive, so they are purple, blue or violet
approximately 15 minutes
in color.
• KOH and heat break down/ dissolve/ soften/ digest keratin and
• Used to observe yeast and pseudohyphae present in clinical
skin layers
samples.
® Results to the clearing of the sample and specimen thus
allowing the better visualization of fungal elements 4. INDIA INK PREPARATION
• Modification of KOH test incorporates dimethyl sulfoxide • Used to Examine CSF for the presence of Cryptococcus
(DMSO) and a stain into the KOH solution. neoformans.
® This modification can provide an easier and more reliable ® A drop of India ink is mixed with a drop of sediment from a
result CENTRIFUGED CSF sample. Then it is examined on
® The problem with the non-modified KOH preparation will HPO.
take a longer time and the presence of the artifact remains • Positive (+) yeast cells surrounded by clear area against a black
in the background making the interpretation or reading of background are presumptive evidence of C. neoformans.
the result may prove to be difficult • It is a negative stain.
® Dimethyl sulfoxide will facilitate more rapid breakdown of
the cellular debris without requiring heat
® The stain is taken up by the fungi, making the fungal
elements more visible on microscopic examination
MV 4 of 6
2.01 Specimen Collection and Transport
NEED-TO-KNOW
• Unlike bacteria, fungi do not have same nutritional
requirements and environmental needs as characterized of
bacteria. There are very few types of culture media for the
primary isolation of fungi and SDA and BHIA are very
common already.
Figure 6. Agar which is cut in a small square for slide culture • Gentamicin and chloramphenicol inhibit bacterial growth.
Whereas cycloheximide inhibits bacteria and at the same
NEED-TO-KNOW time many of the environmental fungi are usually considered
• The purpose of lactophenol cotton blue kills, preserves and as contaminants (also serves as antifungal agent).
stains organism. Lactic acid preserves the organism; • Gentamicin, chloramphenicol and cycloheximide are the
Phenol kills the organism; Cotton blue serves as the dye antimicrobial usually included in fungal culture media.
which stains the organism or chitin in the fungal cell wall.
• Major disadvantage is disruption of conidia because of Table 2. Differential test media
teasing because we use teasing needles. CULTURE MEDIA INDICATIONS FOR USE
Birdseed (Nigerseed) agar For growth of Cryptococcus
8. CELLOPHANE TAPE PREPARATION neoformans
• Involves touching the surface of the colony with a piece of clear Trichophyton Agars Identification of the
tape Trichophyton species
• Tape is placed on a slide with Lactophenol cotton blue and Germ tube media (rabbit, To demonstrate germ tube
examined under the microscope. fetal calf, or human serum) production by the yeast Candida
® The procedure is much the same like cellulose tape albicans
method for the detection of the parasite Enterobius Urea agar slant To demonstrate urease
vermicularis which is also called as pinworm or seat worm. production.
(+) pinkish purple within 48
hours after inoculation.
Cornmeal agar with Tween Identification of Candida
80 and trypan blue albicans by chlamydospore
production; identification of C.
MV 5 of 6
2.01 Specimen Collection and Transport
Table 2 NEED-TO-KNOW
• Are culture media used for demonstrating definitive/specific • Cryptococcal antigen test has been considered as a
or particular group of fungi. It also used to demonstrate primary diagnostic tool in the identification of Cryptococcus
certain properties such as production of germ tube urease neoformans. This cryptococcal antigen test replaced India
and pigments. ink preparation in screening the CSF or serum for
*Note: Study both tables since they are included in the unit Cryptococcus neoformans.
test :< • Cross reaction with other fungal antibodies can also be a
problem.
B. SPECIAL TESTS
1. GERM TUBE TEST 3. MOLECULAR METHOD
• The easiest and most important test to identify yeast. It involves • Polymerase Chain Reaction (PCR) aids in the diagnosis of
the use of either serum or plasma. microscopy negative fungal infections in conjunction with other
• Differentiates Candida albicans from other yeasts tests.
® (+) Filamentous outgrowth extending from the yeast cells ® PCR aids in diagnosis of fungal infections which tested
negative using direct microscopic examination.
PROCEDURE ® In research made by Laws et. Al. on the utility of PCR in
the diagnosis of invasive fungal infection, they found out
1. Emulsify a yeast colony in 0.5 ml of sheep or human serum in
that PCR has a sensitivity of 97% and specificity of 57.1%
a small tube. Incubate the tube at 35°C for 3 hours.
for microscopy negative fungal infection.
2. Transfer a drop of the serum to a slide. Place coverslip and
examine under the microscope. ® SENSITIVITY: 97%; SPECIFICITY: 57.1%
NOTE
• For red text
® baliktad yung sinabi ni prof sa discussion and sa
recorded lec posted in canvas. (sensitivity: 57.1%;
specificity: 97%)
Figure 8. differentiates C. albicans which shows true germ tubes from the other
yeasts.
NEED-TO-KNOW
• Test is considered positive or there is a presumptive
identification of Candida albicans if you have a presence of
true germ tube. True germ tube lacks constriction (left
photo; figure 8). There is constriction on the base of the
pseudogerm tube (right). True germ tubes lacks
constriction at their bases where they attach to the mother
cell.
• If constriction is present at the base of the germ tube, it is
called pseudo germ tube which are more characteristic of
Candida tropicalis.
2. SEROLOGIC TESTS
• These are available both for the detection of antigen and
antibodies to selected fungal antigens like (refer to the next
bullet)
• Detection of Cryptococcus, Blastomyces, Aspergillus and
Histoplasma.
® The most important application of serologic test is the
detection of cryptococcal antigen in CSF or serum.
MV 6 of 6
Cellophane Tape & Slide Culture Preparation MYCO&VIRO
Prof. Esmeralda Abling LE 02
31 January 2022 TRANS 02
Step 5 Put the fungally imprinted side of the tape onto the
drop of the dye
Step 4
MV 2 of 3
2.01 Cellophane Tape and Slide Culture Preparation
Step 13 Remove the cover glass from the slide culture and
discard the block of agar.
Step 15 Examine the slide under low power and then HPO of
the microscope and morphological features of agr
can be observed.
MV 3 of 3