MYCOLOGY

CASE SCENARIO – Candida albicans

A 32 year old woman presented to hospital with complaints of vaginal discharge and itching for
past two days. She was a known diabetic patient but not taking medicines regularly. On
examination, a thick, curd like white vaginal discharge was observed. Vaginal discharge was
collected with swab and sent for direct microscopy and fungal culture. Direct microscopy on
KOH preparation showed pseudohyphae. Culture on Sabouraud dextrose agar (SDA) revealed
creamy white pasty colonies.

Questions:

1. What is the clinical diagnosis and causative agent?

Vulvovaginal candidiasis, Candida albicans

2. Identify the culture medium and describe the cultural characteristics and Grams
reaction.
Sabouraud Dextrose Agar (SDA): Creamy white, smooth and pasty with yeasty odor.
Grams reaction: Gram positive budding yeast cells.

3. What are the predisposing factors for this infection?

Ageing, pregnancy, transplantation recipients, malignancy, HIV patients, prolonged
administration of antibiotics etc.

4. What are the other clinical manifestations produced by this pathogen?

Mucosal candidiasis, cutaneous candidiasis, invasive or systemic candidiasis, allergic
candidiasis.

5. What are the other tests to confirm this diagnosis?

Germ tube test (Reynolds-Braude phenomenon), Dalmau plate culture, CHROM agar,
latex agglutination, ELISA, PCR.

6. What is the treatment of choice for this infections?

Cutaneous candidiasis or oral thrush: topical azoles,
Esophageal and Vulvovaginal candidiasis: Oral fluconazole or Caspofungin,
Invasive candidiasis: Amphotericin B or Caspofungin.
 CASE SCENARIO – Cryptococcus neoformans

A 29 year old male with known AIDS presented to the emergency department with headache and
fever for last 3 days. On examination, he was confused and the temperature was 100°F. Neck
rigidity was observed but other vital signs were normal. Clinically, meningitis due to fungal
cause was suspected. A lumbar puncture was performed to collect the cerebrospinal fluid (CSF)
under all aseptic conditions. CSF was sent to the laboratory for direct microscopy, antigen
detection and fungal culture. Gram staining showed gram positive, round budding yeast cells but
no pseudohyhphae. India ink preparation revealed the refractile clear halo (capsule) surrounding
the round budding yeast cells.

Questions:

1. What is the clinical diagnosis and causative agent?

Meningitis caused by Cryptococcus neoformans

2. Identify the culture medium and describe the cultural characteristics and Grams
reaction.
Sabouraud Dextrose Agar (SDA): Smooth, mucoid, cream colored colonies with yeasty
odor.
Grams reaction: Gram positive budding yeast cells.

3. What are the risk factors for this infection?

Patients with advanced HIV infection, hematological malignancies, transplant recipients,
patients on steroid therapy.

4. What are the other clinical manifestations produced by this pathogen?

Pulmonary cryptococcosis, cutaneous cryptococcosis, osteolytic bone lesions.

5. What are the other tests to confirm this diagnosis?

i. Nigrosin capsular staining: Capsule appears as a clear halo around the yeast cells.
ii. Urease test: Positive
iii. Other tests such as latex agglutination reaction for capsular antigen detection.

6. What is the treatment of choice for this infections?

Fluconazole, amphotericin B, flucytosine
 CASE SCENARIO – Aspergillus fumigatus

A 46-year-old lady has complaints of hemoptysis for 2-3 episodes in 2 days and cough for 1
month. She gave past history of pulmonary tuberculosis 10 years back. On chest examination,
bilateral breath sounds were reduced. Chest X-ray revealed fungal ball in previous cavitary
lesion in right upper lobe of lung. Sputum and lung biopsy were sent for fungal culture and
identification.

Questions:

1. What is the clinical diagnosis and causative agent?

Pulmonary Aspergillosis (Aspergilloma), Aspergillus fumigatus

2. Identify the culture medium and describe the cultural characteristics.

Sabouraud Dextrose Agar (SDA): colonies are typically blue-green with a suede-like
surface consisting of a dense felt of conidiophores.

3. What are the predisposing factors for this infection?

Glucocorticoid use, neutropenia, neutrophil dysfunction, COPD, TB etc.

4. What are the other clinical manifestations produced by this pathogen?

Pulmonary aspergillosis, invasive sinusitis, cardiac aspergillosis, cerebral aspergillosis,
ocular aspergillosis, ear infections, cutaneous aspergillosis, onychomycosis.

5. What are the other tests you recommend to confirm this diagnosis?
KOH mount, culture, latex agglutination, G-test, ELISA.

6. What is the treatment of choice for this infections?

Voriconazole, Itraconazole, Posaconazole.
 CASE SCENARIO – Mucor
A 40-year-old female with uncontrolled diabetes mellitus was referred to the Govt. hospital with
severe eye pain and facial rash for 4 days. Facial rash progressed to extensive ulceration of the
midface and bilateral loss of vision. She had nasal bridge collapse, with black eschars on the
nasal mucosa and markedly elevated fasting blood sugar. She had surgical debridement and
tissue was sent for histopathological examination and fungal culture.

Questions:

1. What is the clinical diagnosis and causative agent?

Rhinocerebral mucormycosis, Mucor species

2. Identify the culture medium and describe the cultural characteristics.

Sabouraud Dextrose Agar (SDA): colonies are typically white cottony woolly with tube
filling growth.

3. Draw the diagram of the agent involved.

4. What are the predisposing factors for this infection?

Diabetic ketoacidosis, end stage renal disease, patient with iron therapy, neutropenia.

5. What are the other clinical manifestations produced by this pathogen?

Pulmonary mucormycosis, cutaneous mucormycosis, gastrointestinal mucormycosis,
disseminated mucormycosis.

6. What is the treatment of choice for this infections?

Amphotericin B or Posaconazole.
 CASE SCENARIO –Rhizopus

A 61-year old lady was referred to the local ENT department with an acute history of
photophobia, diplopia and right-sided facial numbness, preceded by rhinorrhoea and right
maxillary sinus pain and swelling. Her past medical history included chronic obstructive
pulmonary disease. On examination, she was noted to have a right-sided facial droop, facial
swelling and numbness. Reduced visual acuity of the right eye were also noted. On initial
flexible nasoendoscopy, pus and crusting of the right nasal cavity with oedema of the maxillary
meatus, but no tissue necrosis, were observed. Exudate is collected and sent for further
microscopic examination and fungal culture.

Questions:

1. What is the clinical diagnosis and causative agent?

Rhinocerebral mucormycosis, Rhizopus species.

2. Identify the culture medium and describe the cultural characteristics.

Sabouraud Dextrose Agar (SDA): Brown to black colored colonies give rise to “Salt and
Pepper” appearance.

3. Draw the diagram of the agent involved.

4. What are the predisposing factors for this infection?

Diabetic ketoacidosis, end stage renal disease, patient with iron therapy, neutropenia.
5. What are the other clinical manifestations produced by this pathogen?
Pulmonary mucormycosis, cutaneous mucormycosis, gastrointestinal mucormycosis,
disseminated mucormycosis.

6. What is the treatment of choice for this infections?

Amphotericin B or Posaconazole.
 CASE SCENARIO - Penicillium

A 55-year-old male visited to ENT OPD with history of left-sided earache and ear discharge
since 10 days. History of chronic infection of ear, use of oil, eardrops, steroids, swimming and
other immuno-compromised conditions were ruled out. Patient had an agricultural background.
On ear examination, yellowish-white sticky thick discharge along with bits of necrotic tissue was
found in the left ear. Radiological examination did not reveal any bony involvement. Routine
laboratory parameters were normal. Tissue material was then sent for mycological examination
and culture.
Questions:

1. What is the clinical diagnosis and causative agent?

Otomycosis, Penicillium species.

2. Identify the culture medium and describe the cultural characteristics.

Sabouraud Dextrose Agar (SDA): rapidly growing, flat with velvety to powdery texture
greenish colonies.

3. Draw the diagram of the agent involved.

4. What are the predisposing factors for this infection?

Hot and humid climate and patients using topical antibiotic in ear, swimmers

5. What are the other clinical manifestations produced by this pathogen?

Endophthalmitis, keratitis, onychomycosis, allergic pneumonitis.

6. What is the treatment of choice for this infections?

Amphotericin B or Itraconazole.
 CASE SCENARIO - Fusarium

A 47-year-old women from an affluent urban background, presented to the Dermatology OPD
with discoloration and disfigurement of all the toenails of the right foot for 11 months. She gave
a history of jogging daily barefoot on grass in the morning. There were no lesions elsewhere in
her body. The patient had no medical co-morbidity and no attendant history of trauma. She
denied any suggestive history of contact in the family or with animals. Examination of the
affected toenails revealed discoloration with thickening and subungual
debris. On microscopic examination, crescent shaped macroconidia were seen and the nail
sample was then sent for culture and future identification.

Questions:

1. What is the clinical diagnosis and causative agent?

Onychomycosis, Fusarium species.

2. Identify the culture medium and describe the cultural characteristics.

Sabouraud Dextrose Agar (SDA): rapidly growing, woolly to cottony, flat, white to
orange colonies.

3. Draw the diagram of the agent involved.

4. What are the predisposing factors for this infection?

Walking barefoot in damp areas such as swimming pools, gyms and shower rooms,
minor skin or nail injury.
5. What are the other clinical manifestation produced by this pathogen?
Keratitis in contact lens wearers.

6. What is the treatment of choice for this infections?

Amphotericin B, Voriconazole, Posaconazole