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Rikka Mae M. Donasco Date: 06/21/2022

LESSON 3: SUBCUTANEOUS MYCOSIS

Subcutaneous mycosis

The fungi that cause subcutaneous mycoses normally reside in soil or

on vegetation. They enter the skin or subcutaneous tissue by traumatic
inoculation with contaminated material.
For example, a superficial cut or abrasion may introduce an
environmental mold with the ability to infect the exposed dermis.
In general, the lesions become granulomatous and expand slowly from
the area of implantation. Extension via the lymphatics draining the
lesion is slow except in sporotrichosis.

These mycoses are usually confined to the subcutaneous tissues, but in

rare cases they become systemic and produce life-threatening disease.
Subcutaneous mycoses to consider:
1. Sporotrichosis
2. Chromoblastomycosis
3. Phaeohyphomycosis
4. Mycetoma

SPOROTRICHOSIS
Caused by: SPOROTHRIX SCHENCKII
A dimorphic fungus
@ RT – hyphae with pyriform conidia in “flowerette arrangement”
@ 37 – ellipsoid, budding cigar shaped yeast, singly or multiple
budding
lives on vegetation. It is associated with a variety of plants—
grasses, trees, sphagnum moss, rose bushes, and other horticultural
plants.
At ambient temperatures, it grows as a mold, producing branching,
septate hyphae and conidia, and in tissue or in vitro at 35–37°C as a
small budding yeast.

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Following traumatic introduction into the skin, S. schenckii causes

sporotrichosis, a chronic granulomatous infection. The initial episode
is typically followed by secondary spread with involvement of the
draining lymphatics and lymph nodes.
SPOROTRICHOSIS: Rose gardener’s disease, occupational hazard for
gardeners.

Conidia

Petals

Yeast (left) and Mold (Right) form of S. scheneckii

DIAGNOSTIC LABORATORY TESTS
Specimens, like biopsy material or exudate from granulomatous or
ulcerative lesions, are examined directly with KOH or calcofluor white
stain, the yeast are rarely found.
The use of specials stains like Gomori methanamine silver (stains the
cell walls black), Periodic Acid-Schiff stain (imparts a red color to
the cell walls), and fluorescent antibody are used to enhance the
sensitivity of the test.
Another structure termed an asteroid body is often seen in tissues of
individuals infected with S. schenckii.

In hematoxylin and eosin-stained tissue, the asteroid body consists of

a central basophilic yeast cell surrounded by radiating extensions of
eosinophilic material, which are depositions of antigen-body complexes
and complement.
The most reliable method of diagnosis is culture. Specimens are
streaked on Inhibitory Mold Agar or Sabouraud Dextrose Agar containing
antibacterial antibiotics and incubated at 25–30°C. The identification
is confirmed by growth at 35°C and conversion to the yeast form.

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Asteroid
Yeast cells

TREATMENT, PREVENTION AND CONTROL

In some cases, the infection is self-limited. Although the oral
administration of saturated solution of potassium iodide in milk is
quite effective, it is difficult for many patients to tolerate.
The treatment of choice is oral itraconazole or another azole. For
systemic disease, amphotericin B is given.
Prevention includes measures to minimize accidental inoculation and
the use of fungicides, where appropriate, to treat wood.

CHROMOBLASTOMYCOSIS (CHROMOMYCOSIS)
Chromoblastomycosis (chromomycosis) is a subcutaneous mycotic
infection that is usually caused by traumatic inoculation of any of
the recognized fungal agents, which reside in soil and vegetation.
caused by a variety of copper colored soil saprophytes, non-healing
tumor like lesions resembling cauliflower
caused by dematiaceous fungi –dark slow growing fungi
All are dematiaceous fungi, having melanized cell walls: Phialophora
verrucosa, Fonsecaea pedrosoi, Fonsecaea compacta, Rhinocladiella
aquaspersa, and Cladophialophora carrionii.

The infection is chronic and characterized by the slow development of

progressive granulomatous lesions that in time induce hyperplasia of
the epidermal tissue.

• PHIALOPHORA VERRUCOSA

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short septate hyphae with short conidiosphores that give rise to flask
or cup shaped phialides with collarettes

• CLADOSPORIUM CARRIONII

dark long branching conidiosphores that give rise to chains of

blastoconidia, septate hyphae

MORPHOLOGY OF DEMATIACEOUS FUNGI

The dematiaceous fungi are similar in their pigmentation, antigenic
structure, morphology, and physiologic properties. The colonies are
compact, deep brown to black, and develop a velvety, often wrinkled
surface.
The agents of chromoblastomycosis are identified by their modes of
conidiation. In tissue they appear the same, producing spherical brown
cells termed muriform or sclerotic bodies that divide by transverse
septation.
Septation in different planes with delayed separation may give rise to
a cluster of flour to eight cells

SCLEROTIC BODIES

DIAGNOSTIC LABORATORY TESTS

Specimens of scrapings or biopsies from lesions are examined
microscopically in KOH for dark spherical cells. Specimens should be
cultured on IMA or SDA with antibiotics.
The dematiaceous species is identified by its characteristic conidial
structures.

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There are many similar saprophytic dematiaceous molds, but they differ
from the pathogenic species in being unable to grow at 37°C and being
able to digest gelatin.

TREATMENT, PREVENTION & CONTROL

Surgical excision with wide margins is the therapy of choice for small
lesions. Chemotherapy with flucytosine or itraconazole may be
efficacious for larger lesions. The application of local heat is also
beneficial. Relapse is common.
The disease occurs chiefly on the legs of barefoot agrarian workers
following traumatic introduction of the fungus. Chromoblastomycosis is
not communicable. Wearing shoes and protecting the legs probably would
prevent infection

PHAEOHYPHOMYCOSIS

Phaeohyphomycosis is a term applied to infections characterized by the

presence of darkly pigmented septate hyphae in tissue. Both cutaneous
and systemic infections have been described.

Subcutaenous Phaeohyphomycosis

• Exophiala jeanselmei
• Phialophora richardsiae
• Bipolaris spicifera
• Wangiella dermatitidis

Systemic Phaeohyphomycosis

• Exophiala jeanselmei
• Phialophora richardsiae
Both
• Bipolaris spicifera
• Wangiella dermatitidis
• Exserohilum rostratum
• Alternaria species
• Curvularia species

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In tissue, the hyphae are large (5–10 μm in diameter), often distorted

and may be accompanied by yeast cells, but these structures can be
differentiated from other fungi by the melanin in their cell walls.
Specimens are cultured on routine fungal media to identify the
etiologic agent. In general, itraconazole or flucytosine is the drug
of choice for subcutaneous Phaeohyphomycosis.
Brain abscesses are usually fatal, but when recognized, they are
managed with amphotericin B and surgery. The leading cause of cerebral
Phaeohyphomycosis is C. bantiana.

EXOPHIALA JEANSELMI

• pale brown conidiosphores forming cylindrical annelids, conidia

gather at tip of annelids

MYCETOMA

Mycetoma is a chronic subcutaneous infection induced by traumatic

inoculation with any of several saprophytic species of fungi or
actinomycetous bacteria that are normally found in soil. The infection
is characterized by local swelling of the infected tissue and
interconnecting, often draining, sinuses or fistulae that contain
granules, which are microcolonies of the agent embedded in tissue
material.
An actinomycetoma is a mycetoma caused by an actinomycete; a
eumycetoma (maduromycosis, Madura foot) is a mycetoma caused by a
fungus.
The fungal agents of mycetoma include, among others, Pseudallescheria
boydii, Madurella mycetomatis, Madurella grisea, Exophiala jeanslmei.

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E. jeanselmei and the Madurella species are dematiaceous molds. These

molds are identified primarily by their mode of conidiation.
In tissue, the mycetoma granules may range up to 2 mm in size. The
color of the granule may provide information about the agent.
For example, the granules of mycetoma caused by P. boydii and A.
falciforme are white; those of M. grisea and E. jeanselmei are black;
and M. mycetomatis produces a dark red to black granule. These
granules are hard and contain intertwined, septate hyphae (3–5 μm in
width). The hyphae are typically distorted and enlarged at the
periphery of the granule

• PSEUDOALLESHERIA BOYDII
most common cause of mycetoma

• ACTINOMYCES /NOCARDIA
do not stain with fungal stains

DIAGNOSTIC LABORATORY TEST

Granules can be dissected out from the pus or biopsy material for
examination and culture on appropriate media. The granule color,
texture, and size and the presence of hyaline or pigmented hyphae (or
bacteria) are helpful in determining the causative agent.

TREATMENT, PREVENTION AND CONTROL

• The management of eumycetoma is difficult, involving surgical

debridement or excision and chemotherapy. P. boydii is treated
with topical nystatin or miconazole. Itraconazole, ketoconazole,
and even amphotericin B can be recommended for Madurella
infections and flucytosine for E. jeanselmei. Chemotherapeutic
agents must be given for long periods to adequately penetrate
these lesions.

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• The organisms producing mycetoma occur in soil and on vegetation.

Barefoot farm laborers are therefore commonly exposed. Properly
cleaning and wearing shoes are reasonable control measures

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