Diploma In Biomedical Sciences

Medical Microbiology II

Mycology
Medical Mycology
Mycoses
 Mycoses
• Mycoses are diseases caused by fungi
• Mode of infection
• Inhalation
• Trauma
• Ingestion
• Rarely from person to person
• Most mycoses are not contagious
3
 Fungal Diseases (Mycoses)
1. Superficial Mycoses: Localised, e.g., hair
shafts
2. Cutaneous Mycoses: Affect hair, skin, and
nails
3. Subcutaneous Mycoses: Beneath the skin
4. Systemic Mycoses: Deep within body
5. Opportunistic Mycoses: Caused by normal
microbiota or environmental fungi
4
Superficial Mycoses

5
 Superficial Fungal Infections

• Skin infections
• Limited to stratum corneum
• Do not penetrate deeper tissues
• No inflammation

6
 Superficial Mycoses

Identification of
Disease Aetiological Agent Symptoms
organism
Hypopigmented “Spaghetti and
Pityriasis macules meatballs" appearance
Malassezia furfur
versicolor (lesions in skin of organism in skin
rashes) scrapings
Black, 2-celled oval
Tinea nigra Exophiala werneckii Black macules
yeast in skin scrapings
Black nodule on hair
Black nodule on
Black piedra Piedraia hortai shaft composed of spore
hair shaft
sacs and spores
White nodule on hair
Cream-coloured
shaft composed of
White piedra Trichosporum beigelii nodules on hair
mycelia that fragment
shaft
into arthrospores
7
 Pityriasis versicolor

• aka tinea versicolor

• Caused by the fungus Malassezia furfur
• Malassezia species are commensal yeasts
• They occur most frequently in hot and
humid tropical climates
• They are also prevalent in temperate
climates
8
 Pityriasis versicolor
• Malassezia has an oil requirement for growth
• It has increased incidence in adolescents
• It has predilection for sebum-rich areas of the
skin e.g. scalp, forehead etc
• The use of bath oils and skin lubricants may
enhance disease development
• Malassezia species are not considered to be
contagious
• Infection is not due to poor hygiene
9
 Pityriasis versicolor
• Inhabit the skin of about 90% of adults
without causing harm
• It suppresses the expected immune response
to it in some people allowing it to proliferate
and cause a skin disorder often without any
inflammatory response
10
 Pityriasis versicolor

• Pityriasis versicolor occurs when the

budding yeast form transforms to the
mycelial form
• Various factors implicated e.g. hot and
humid environment, oily skin, and excessive
sweating
11
 Clinical Presentation

• Multiple white, pink to brown, oval to round

coalescing (merging) macules and patches
• They are mild and fine scaling mainly found on
the seborrheic (oily) areas especially the upper
trunk and shoulders
• They are also found on the face, scalp,
antecubital fossae, sub-mammary regions and
groins often confluent and quite extensive
12
 Clinical Presentation

• Associated scales may be shown by

scratching of the skin surface
• They produce chemicals that reduce the
pigment in the skin, causing whitish
patches, azelaic acid, pityriacitrin, and
malassezin
13
Tinea versicolor caused by Malassezia furfur

• Fungal infections confined to the stratum corneum

without tissue invasion

14
 Laboratory Diagnosis

• In Wood's light a yellow-green

fluorescence may be observed in
affected areas due to pityrialactone
• Skin scrapings microscopy using KOH
• Clusters of yeast cells and long hyphae like
“spaghetti and meatballs”
15
 Laboratory Diagnosis

• Malassezia species are difficult to grow

in the laboratory
• Scrapings may be reported as "culture
negative“
• Grows best if a lipid such as olive oil is
added to Littman agar culture medium
16
Laboratory diagnosis
 Treatment

• Topical selenium sulphide

• Oral ketaconazole
• Oral itraconazole

18
 Tinea nigra

• Superficial chronic infection of stratum corneum

• Aetiological agent: Hortae (Exophiala) werneckii
(pigmented)
• It tolerates low pH
• Frequent in tropical areas
• Clinical findings: Brownish maculae on palms,
fingers, face
19
 Symptoms

• Tinea nigra is largely painless and harmless,

but it does produce a few symptoms
• A brown or black patch resembling a stain
that usually occurs on the palm of the hand or,
more rarely, on the sole of the foot
• The patch is generally flat, with defined
borders
20
 Symptoms

• The darkest area of the patch is at the edges

• Shading gets lighter as it extends inward
• This darker outside area may look like a
halo
• The lesion is slow-growing and usually
appears on only one hand or foot
21
Symptoms

22
Laboratory diagnosis of Tinea nigra

• Microscopy
• Septate hyphae and yeast cells (brown in colour)
• Culture
• Black colonies
• Treatment
• Topical salicylic acid, tincture of iodine, urea, or
benzoic acid
23
Laboratory diagnosis of Tinea nigra
 Piedra
• A superficial infection that forms nodules
on hair shafts
• Infections are normally associated with the
scalp, but facial and pubic hairs can also be
infected
• Transmission is via shared hair brushes and
combs, and several members of a family are
typically infected at the same time
25
 Black piedra
• Kingdom: Fungi
• Phylum: Ascomycota
• Class: Dothideomycetes
• Order: Capnodiales
• Family: Piedraiaceae
• Genus: Piedraia
• Species: Piedraia hortae
26
 Black piedra

• Fungal infection of the scalp hair

• Aetiological agent: Piedraia hortae
• Frequent in tropical areas
• Clinical findings: Discrete, hard, dark
brown to black nodules on the hair

27
 Black piedra

Black piedra nodules on hair

28
Laboratory diagnosis of Black piedra

• Microscopy: Septate pigmented hyphae,

unicellular and fusiform ascospores
with polar filament(s)
• Culture: Brown to black colonies
• Treatment: Topical salicylic acid, azol
creams

29
 White piedra

• Fungal infection of facial, axillary or

genital hair
• Aetiological agent: Caused by
Trichosporon beigelii (yeast)
• Frequent in tropical and temperate
zones
30
 White piedra

• Clinical findings: soft, white to yellowish

nodules loosely attached to the hair
• Laboratory findings
• Microscopy: Intertwined septate hyphae, blasto-
and arthroconidia
• Culture: Soft, creamy colonies
• Treatment: shaving, azoles
31
White Piedra Infestation

32
Cutaneous Mycoses (Dermatophytoses)

• Dermatophytoses are infections strictly

confined to keratinised epidermis (skin, hair,
nails)
• They are called ringworm and tinea
• 39 species in the genera Trichophyton,
Microsporum, Epidermophyton
• They are closely related and morphologically
similar
33
Cutaneous Mycoses (Dermatophytoses)

• Causative agent of ring worm varies from

case to case
• Natural reservoirs - humans, animals, and soil
• Infection is facilitated by moist, chafed
(scratched) skin
• Long infection period is followed by localised
inflammation and allergic reactions to fungal
proteins
34
35
Cutaneous Mycoses (Dermatophytoses)

• Ringworm of scalp (tinea capitis)

• Affects scalp and hair-bearing regions of
the head
• Hair may be lost
• Ringworm of beard (tinea barbae)
• Affects the chin and beard of adult males
• Contracted mainly from animals 36
Cutaneous Mycoses (Dermatophytoses)

• Ringworm of body (tinea corporis)

• Occurs as inflamed, red ring lesions
anywhere on smooth skin
• Ringworm of groin (tinea cruris)
• “Jock itch”
• Affects groin and scrotal regions

37
Cutaneous Mycoses (Dermatophytoses)

• Ringworm of foot and hand (tinea pedis

and tinea manuum) “Athlete’s foot”
• Is spread by exposure to public surfaces
• Occurs between digits and on soles
• Ringworm of nails (tinea unguium)
• Is a persistent colonisation of the nails of the
hands and feet that distorts the nail bed
38
 Clinical Significance

Dermatophyte Skin Hair Nails

Microsporum X X
Epidermophyton X X

Trichophyton X X X

39
Cutaneous Mycoses (Dermatophytoses)

Tinea pedis: Athlete’s Foot Ring Worm

40
Cutaneous Mycoses (Dermatophytoses)

41
Cutaneous Mycoses (Dermatophytoses)

Tinea corporis
42
 Cutaneous Mycoses
• Fungal infections that involve keratinised tissues as
skin, hair, nail
• Example: Tinea caused by dermatophytes

43
 Cutaneous Infections

• Trichophyton
rubrum
• Chronic infections
of the toe nails

44
 Cutaneous Mycoses
• Microsporum spp
• In hair, skin, rarely nails; frequently in children,
rarely in adults; often spontaneous remission occurs
(ringworm)
• Trichophyton spp
• Hair, skin, and nails; in both children and adults
(athlete’s foot)
• Epidermophyton spp
• Skin, nails, rarely hair; in adults, rarely in children
(ringworm)
45
 Microsporum spp

• Macroconidia are
attached singly
• Thick walled
• Mature forms are
echinulate (spiny)

46
Trichophyton spp

• Macroconidia are
attached singly
• Have smooth walls

47
 Epidermophyton spp.

• Macroconidia are
attached in
multiples
• Smooth walls
(beaver tails)
• Grows slowly
48
 Laboratory Diagnosis of Tinea

• Specimen collection
• Direct examination
• Culture
• Identification

49
 Specimen Collection

• Hair
• Plucked, not cut, from edge of lesion
• Skin
• Wash, scrape from margin of lesion
• Nails
• Scrapings from nail bed or infected area
• Transport the specimens in sterile petri dish
50
 Direct Examination
• Examine hair for fluorescence
• Wood’s lamp

• Yellow green
fluorescence = positive
51
 Direct Examination

• Examine specimen for

fungal elements
• 10% KOH preparation
• The KOH dissolves the
tissue and debris leaving
just the fungal elements

• Calcofluor white stain

• This is a fluorescent stain
that aids in the detection of
fungal elements by taking
up the fluorescent stain
The picture shows a positive
Calcofluor white stain showing
arthroconidia and hyphae
52
 Specimen Processing

• Hair
• Cut into short segments before setting up a
culture

• Nails
• Mince into small pieces before culturing
53
 Culture Media

• Select two media types

• General purpose – Sabouraud’s agar
• Selective for fungal pathogens – Mycosel
agar
• Antibiotics
• Gentamicin: inhibits normal bacterial flora
• Cycloheximide: inhibits saprophytic fungi
54
 Culture Growth Requirements

• Place specimen pieces on culture media

• Streak for isolation
• Incubate at 30°C in ambient (room) air
• Growth at 3 days to 3 weeks
• Examine plates frequently for 4 weeks
55
 Identification

• Colony morphology
• Microscopic morphology
• Scotch tape preparation
• Tease preparation
• Slide culture

56
 Identification
• Physiological tests
• Urea hydrolysis • Rice grain media
• Hair perforation • Vitamin requirements

57
 Treatment of dermatophytes

• Treatment of dermatophytes includes

topical antifungal agents – tolnaftate,
miconazole applied for several weeks
• Lamisil or griseofulvin 1-2 years

58
Subcutaneous (Sub-superficial) Mycoses

• Fungal infections beneath the skin

• Caused by saprophytic fungi that live in soil
or on vegetation
• Infection occurs by implantation of spores
or mycelial fragments into a skin wound
• Can spread to lymph vessels
59
Subcutaneous (Sub-superficial) Mycoses

• Mycetoma
• Actinomycotic mycetoma
• Eumycotic mycetoma

60
 Subcutaneous Infections

• Fungi normally saprobic

• Introduced through wounds
• Adapt to the human animal by
changes in
• Morphology
• Physiology
61
 Mycetoma
• Localised, tumorous lesions in cutaneous and
subcutaneous tissues usually the foot
• Nodules are formed, and a collection of pus
and formation of sinuses results
• Actinomycotic mycetomas must be
differentiated from Eumycotic (true fungi)
mycetomas and as they have greatly differing
treatments
62
 Actinomycotic mycetoma
• “Lumpy-jaw”
• The initial nodules formed are firm and
described as "woody" or "lumpy"
• Sulphur granules – Bread crumb-like aggregates
of microorganisms and cellular debris which
take on the appearance of a sulphur particle
• Caused by Nocardia spp. and Streptomyces spp.
• Advanced cases often require amputation due to
physical impairment
63
 Eumycotic Mycetoma

• Clinical picture similar to actinomycotic

mycetomas
• Disease is slowly progressive, with patients
frequently dying of secondary infections
• Treatment consists of excising early,
localised lesions (amputation may be
required for advanced infections)
64
 Eumycotic Mycetoma

• Anti-fungal drugs have little effect

• Body tries to wall off the offending fungus
• Invasion of deeper tissue may follow, with
bone involvement, draining sinus tracts, or
progression through the lymphatics

65
66
 Fungal Diseases (Mycoses)
• Superficial mycoses: Localised, e.g., hair
shafts
• Cutaneous mycoses: Affect hair, skin, and
nails
• Subcutaneous mycoses: Beneath the skin
• Systemic mycoses: Deep within body
• Opportunistic mycoses: Caused by normal
microbiota or environmental fungi
67
 Systemic Mycoses
• True pathogens that cause Systemic
Mycoses belong to the class Ascomycota
• Histoplasma capsulatum
• Coccidioides immitis
• Blastomyces dermatitidis
• Paracoccidioidomycosis brasiliensis (South
America)
68
 Systemic Mycoses
• Also called endemic mycoses
• Begin as primary pulmonary lesions that
may disseminate to any organ
• Caused by dimorphic fungi
• Can spread throughout the body
• Fungi that cause systemic infections have
predilection for specific organs
69
 Systemic Mycoses

• Systemic infections are usually caused

by fungi in soil by inhalation of spores
• Infection begins in the lungs and
spreads to the rest of the body
• Not contagious from person to person

70
 Systemic Mycoses
• Unlike most other fungi, the five systemic mycotic
agents are inherently virulent
• Each species has biochemical and structural
features that enable it to evade host defences
• The primary focus of infection is the lung but
secondary infection may occur elsewhere in the
body
• The five aetiological agents are identified by their
morphology on agar plates (saprobic phase) and in
tissue (parasitic phase)
71
 Histoplasmosis
(Histoplasma capsulatum)

72
 Histoplasmosis
• Also called cave disease
• Caused by Histoplasma capsulatum
• The organism is dimorphic (being a mold that can
convert to a yeast form)
• H. capsulatum is endemic in many parts of the
world including North and South America
• It is found in the soil and growth is enhanced by the
presence of bird and bat excreta
• Environments containing such material are often
implicated as sources of human infection
73
 Histoplasmosis

• The lungs are the main site of infection but

dissemination to the liver, heart, and CNS can occur
• Pulmonary infection can resemble symptoms seen
in tuberculosis
• Inhalation of conidia from the environment is the
source of infection
• Histoplasmosis is characterised by intracellular
growth of the pathogen in macrophages and a
granulomatous reaction in tissue
74
Epidemiology

75
 Immunology

• Immune response
• Cell-mediated responses are of primary
importance
• Activated macrophage can kill yeast cells
• Evasion of defences
• Survival in macrophages elevates pH of
phagosomes (specialised membrane-bound
organelles generated in phagocytic cells)
• Alteration of cell surface
76
Transmission and pathogenesis of Histoplasma capsulatum

Areas with
large amounts
of bird
droppings are
especially
dangerous

77
 Transmission and pathogenesis of
Histoplasma capsulatum

• Inhalation of spores released by environmental

mold form initiates pulmonary infection
• Inhaled spores transform into yeast cells within
alveolar spaces with infection of alveolar
macrophages
• Primary infection is asymptomatic or mild, and
infection with H. capsulatum becomes latent
78
 Transmission and pathogenesis of
Histoplasma capsulatum

• Decrement in CD4+ T cell function (AIDS, age

especially in older men with chronic obstructive
pulmonary disease and/or Diabetes Mellitus
induces reactivation of latent infection with chronic
cavitary histoplasmosis of the lung
• This causes haemoptysis, or disseminated
histoplasmosis with fever, weight loss,
hepatosplenomegaly, adrenal insufficiency, and/or
meningitis
79
 Symptoms

• The mildest forms of histoplasmosis cause no signs or

symptoms
• Nonetheless, severe infections can be life-threatening
• When signs and symptoms occur, they usually appear 3 to 17
days after exposure and can include:
• Fever
• Chills
• Headache
• Muscle aches
• Dry cough
• Chest discomfort
• Fatigue
80
 Laboratory Diagnosis
• The gold standard for the diagnosis of
histoplasmosis:
• Recovery in culture of H. capsulatum from a
clinical specimen
• Histopathological demonstration of the
characteristic intracellular forms of H.
capsulatum in infected tissues
• Antigen detection has become increasingly important
• It allows for a rapid diagnosis of probable
histoplasmosis
81
 Laboratory Diagnosis

• Diagnosis is based on the identification of the

distinctive budding yeast in KOH or Gomori
Methenamine Stain (GMS) prepared samples of skin
scrapings, sputum, CSF, or various tissues
• Direct histology and culture of blood or bone marrow
• Serological testing for antibody and histoplama
antigen in blood and urine
• In HIV-infected patients with disseminated
histoplasmosis, histoplasma antigen detection in urine
is at least 90% sensitive
82
 Laboratory Diagnosis

• Presence of small (2-4 m) intracellular yeast

cells surrounded by a clear halo in macrophages
(Giemsa stain)
• Growth of mold in culture at 30oC with
presence of large tuberculate macroconidia
(conidia are spores) and numerous microconidia
• Conversion of mold to small yeast cells at 37oC
83
 Histoplasma capsulatum

Intracellular yeast at 370C Tuberculated macroconidia, grown at 250C

Tuberculate macroconidium (with typical thick walls and radial, finger like
projections) is a diagnostic structure of Histoplasma capsulatum
84
 Histoplasma capsulatum

Blood smear stained with Wright’s stain of a patient with disseminated

histoplasmosis showing a neutrophil containing two yeast-like structures
typical of H. capsulatum (arrow)
85
Histoplasma capsulatum

86
Histoplasma capsulatum

87
 Histoplasma capsulatum

H&E stain (left) shows macrophages filled with organisms giving the cytoplasm a
slightly vacuolated appearance
A GMS (Gomori Methenamine Stain) (right) shows clustered organisms in
cytoplasm
88
 Histoplasma capsulatum

Giemsa stain: intracellular oval bodies surrounded by an artefactual “capsule”

89
 Treatment

• Amphotericin B still mainstay of therapy for

disseminated and severe pulmonary
histoplasmosis
• Ketoconazole or itraconazole is effective as
therapy for self-limited disease (used in
AIDS)

90
Coccidioidomycosis
(Coccidioides immitis)

91
 Coccidioidomycosis

• Caused by Coccidioides immitis

• C. immitis is considered to be the most
virulent of fungal pathogens
• It is a dimorphic fungus
• Lives in alkaline soils in semi-arid, hot
climates
92
 Coccidioidomycosis

• Grows in the soil, but inhalation of a single

spore can initiate infection
• Spores inhaled from dust lead to primary
pulmonary infection which can progress to
system body-wide disease

93
 Risk Factors

• Age: Extremes more susceptible

• Sex: Males more susceptible
• Pregnancy: 3rd trimester
• Ethnicity
• Immunosuppression
94
Transmission and pathogenesis of Coccidioidomycosis

95
Transmission of Coccidioidomycosis

• Mycelia of Coccidioides immitis are found in

dry, dusty soil
• Contact is by inhalation of arthroconidia
• Most commonly an asymptomatic self
limited pulmonary disease
• Nevertheless, the disease may spread via the
blood to skin, soft tissues, bones, joints and
meninges
96
 Immunology

• Immune Response: T-cell mediated (Th-1):

IL-2, IFN-γ
• Evasion of Defences: Resistant to killing by
phagocytes due to;
• Protein rich, hydrophobic outer wall
• Alkaline halo associated with urease
• Damage: secreted proteinases break down
collagen, elastin, haemoglobin, IgG, and IgA
97
 Clinical Manifestation

• Most primary pulmonary infections clinically

inapparent, or present with mild flu-like symptoms
• Fever
• Arthralgia – joint pain
• Invasion of the CNS may result in meningitis,
headache, nausea, and emotional disturbance
• Degrees of cough and sputum production
• Erythema nodosum – a painful disorder of the
subcutaneous fat
98
Clinical Manifestation

Disseminated
coccidiomycosis

99
 Diagnosis

• Examination: Suppurative or
granulatomatous inflammation
• Histopathology: spherules or endospores
seen in sputum, exudates or tissue
• Skin biopsy with Gridley or Gomori
methenamine silver stain
100
 Diagnosis

• Culture: danger, highly infectious

• Serology: Complement fixation assay (in
cerebrospinal fluid), particle agglutination
assay
• DNA probe assay

101
 Coccidioidomycosis

Spherules
Conidia
In infected tissues, C. immitis
appears as a mixture of
endospores and spherules

102
 Coccidio “endospores” PAS+

Surrounded by infectious granulomatous pattern,

i.e. neutrophils, plasma cells, epithelioid, and
giant cells
103
 Treatment

• Fluconazole 400 to 800 mg/day

• If meningeal, need itraconazole or
amphotericin B intrathecally (injection into
spinal canal)

104
 Blastomycosis
(Blastomyces dermatitidis)

105
 Blastomycosis

• Caused by Blastomyces dermatitidis

• It is a dimorphic fungus (yeast form in
tissue at 37oC and mold form in culture at
30oC)
• Natural habitat:
• Soil containing decayed vegetation
• Decomposed wood along waterways or next to
lakes
106
 Blastomycosis

• The disease is produced primarily by extra-

pulmonary dissemination, especially to the skin
but also to the genitourinary tract (prostate,
epididymis), and bone
• Air-borne spores are released by environmental
mold form and inhaled into the lungs with
clinically inapparent (generally) pulmonary
infection
107
 Blastomycosis

• Blastomycosis is usually not opportunistic

infection and occurs in normal host
• Risk Factors
• Occupational contact with soil
• Owning a dog
• Living in endemic area
108
 Immunology

• Evasion of defences
• Escapes phagocytosis by neutrophils and
monocytes by shedding its surface antigen after
infection
• Damage
• Consequence of the immune response to the
organism – skin lesions respiratory infiltrates

109
Mode of infection

110
 Mode of infection

• Dimorphic organism originates in the soil

and infection ensues by inhalation of spores
• Inhalation of dust disturbed from the
environmental sources carries fungal spores
and pieces of hyphae into the lungs
• Inhaled 10-100 conidia convert to yeasts
and multiply in lungs
111
 Mode of infection

• The pulmonary infection is either self-

limiting or progressive
• Dissemination often occurs to the skin and to
the bone
• 80% of patients have large skin lesions
• A large number also have granulomatous
pulmonary lesions
112
 Pulmonary Blastomycosis

• Pulmonary blastomycosis is the most

common manifestation of blastomyces
infection in humans
• Initial pulmonary lesions are asymptomatic
• If symptoms do develop, they are vague and
include cough, fever, malaise, and weight
loss
113
 Cutaneous blastomycosis

• Consists of generally painless lesions on

the face and upper body
• Can be raised and wartlike, or craterlike
(sunken) due to the death of tissue

114
Blastomyces dermatitidis

Cutaneous blastomycosis

115
 Osteoarticular blastomycosis

• A condition where fungus spreads

to the spine, pelvis, cranium, ribs,
long bones, or subcutaneous
tissues surrounding joints

116
 Laboratory Diagnosis

• Direct examination
• Culture
• Specimens
• Sputum
• Bronchial washings
• Biopsies
• Cerebrospinal fluid
• Skin scrapings
• Visualisation of broad-based budding yeast forms by
Gomori Methenamine Silver and PAS stain
117
 Laboratory Diagnosis

• Growth of mold in culture at 30oC with oval

microconidia at the tips of conidiophores
(lollipops)
• Conversion to yeast forms at 37oC

118
Blastomyces dermatitidis

Hyphal state

Yeast state

119
 Blastomyces dermatitidis

• Blasto culture is
difficult, requires
Sabouraud’s dextrose
agar, Mycosel and a
brain-heart infusion
agar to which blood
has been added

120
 Blastomyces dermatitidis

Broad based budding yeast KOH will show single or

singly budding spherical
cells with refractile walls

121
 North American Blastomyces
Blasto means “broad based buds”

122
 Treatment
• Amphotericin B is the drug of
choice for rapidly progressive
blastomycosis
• Itraconazole or Fluconazole for
less severe cases

123
Paracoccidioidomycosis

124
 Paracoccidioidomycosis

• Aka South American Blastomycosis

• Causative fungus is Paracoccidioides
brasiliensis
• It is an infection of the lung or skin
• Most infections are self-limiting, systemic
disease is not common
125
 Paracoccidioidomycosis
• It is a chronic granulomatous disease that
characteristically produces a primary
pulmonary infection
• It then disseminates to form ulcerative
granulomata of the buccal, nasal, and
occasionally the gastrointestinal mucosa

126
 Epidemiology

• Distributed in Central and South

America
• Lung infection occurs through
inhalation or inoculation of spores
• Systemic disease is not common

127
 Clinical Manifestation

• Subacute Juvenile Form

• Affects children and adolescents of both
sexes
• It probably results from rapid dissemination
of a primary infection due to severe
immunological failure
128
 Clinical Manifestation

• Subacute Juvenile Form 2

• Its course is subacute with marked deterioration of
the overall general condition, with;
• Fever
• Anorexia
• Loss of body weight
• Subcutaneous abscesses
• Generalised lymphadenopathy
• Hepatosplenomegaly
129
 Clinical Manifestation

• Chronic Adult Form

• The chronic adult form affects adults above
30 years of age, mainly men
• The infection is chronic with a
predominance of respiratory symptoms

130
Paracoccidiomycosis patients –
ulcerative granulomata of
the buccal, nasal mucosa…

131
 Diagnosis and Treatment
• Diagnosis - KOH or
Gomori Methenamine
Silver preparations of
tissue samples revealing
yeast cells with multiple
buds in a “steering wheel”
formation
• Treatment
• Amphotericin B,
Steering wheel apperance
Ketoconazole, sulfa drugs
132
133
Opportunistic Mycoses

134
 Opportunistic Mycoses
• Opportunistic mycoses are fungal infections that do not
normally cause disease in healthy people
• But do cause disease in people with weakened immune
defences (immunocompromised people)
• Causes of weakened immune function
• Inherited immunodeficiency diseases
• Drugs that suppress the immune system (cancer chemotherapy, corticosteroids,
drugs to prevent organ transplant rejection)
• Radiation therapy
• Infections (e.g., HIV)
• Cancer
• Diabetes Mellitus
• Advanced age
• Malnutrition
135
 Opportunistic Mycoses
• The most common opportunistic mycoses
1. Cryptococcosis caused by Cryptococcus
neoformans
2. Candidiasis caused by Candida albicans
3. Pneumocystis pneumonia caused by
Pneumocystis jiroveci (formerly Pneumocystis
carinii)in AIDS patients
4. Aspergillosis caused by aspergillus fungus
5. Zygomycosis cauaed by fungi in the Genera
Rhizopus, Absidia, and Mucor
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Cryptococcosis

138
 Cryptococcosis
• Cryptococcosis is causes by Cryptococcus
neoformans
• It is a widespread encapsulated yeast that
inhabits soil around pigeon roosts
• Cryptococcosis is a common infection of AIDS,
cancer or Diabetes Mellitus patients
• It is a primary infection of lungs but can
disseminate to meninges and brain and can
cause severe neurological disturbance and death
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 Immunology
• Evasion of defences
• Yeast cells are resistant to phagocytosis because of the
capsule
• Melanin protects against oxidative injury
• Immune response
• Activated neutrophils have an increased capacity to
phagocytose C. neoformans
• Cell mediated immunity is our primary defence
• About 30% of cryptococcus infections occur in patients
with lymphoma (CNS)
• Major oportunistic infection in patients with AIDS
140
Transmission

141
 Transmission
• Cryptococcus neoformans is ubiquitous and
infections occur worldwide
• Transmission is from inhalation of soil, dust, pigeon
droppings
• Does not cause disease in birds
• Primary site of human infection is the lungs
• Cryptococcal meningitis is the most common
disseminated manifestation
• Can spread to skin, bone and prostate

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 Pathogenesis
• Cryptococcus neoformans is neurotropic
with dissemination to the brain causing
meningoencephalitis
• Cryptococcal disease occurs primarily in
immunocompromised conditions including
AIDS, lymphoreticular malignancies, and
corticosteroid therapy

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 Cryptococcus neoformans forms of the disease
CATEGORIES NOTES

Pulmonary form

Acute Infection Rarely diagnosed except in AIDS patients who may present with severe acute respiratory distress (ARDS)

Chronic May produce nodules or masses (usually in the upper lobes), cavities, segmental pneumonia, pleural
Pulmonary effusion, or lymphadenopathy

Disseminated forms

Central Nervous Meningitis that follows a subacute course is typical. Complications include papilledema, cranial nerve
system involvement, visual loss, and hydrocephalus. Single or multiple intracerebral fungal masses may also occur,
but are rare

Cutaneous Painless lesions that may appear as papules, pustules, plaques, ulcers, subcutaneous masses, or cellulitis

Others Endophthalmitis, chorioretinitis, conjunctivitis, sinusitis, otitis, sinusitis, myocarditis, pericarditis,

endocarditis, gastroduodenitis, hepatitis, cholecystitis, peritonitis, renal abscesses, adrenal involvement,
arthritis, osteomyelitis, lymphadenitis, breast masses.

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 Signs and symptoms
• The presentation in cryptococcosis varies with the
site of infection and the patient’s immune status
• Signs and symptoms of pulmonary cryptococcosis
in immunocompetent patients
• Cough
• Cough with the production of scant mucoid sputum
• Pleuritic chest pain
• Low-grade fever, dyspnoea, weight loss, and malaise
(less common)
145
 Signs and symptoms

• HIV-infected patients with pulmonary

cryptococcosis may present with the
following:
• Fever
• Cough
• Dyspnoea
• Headache
• Weight loss
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Cryptococcus neoformans

147
 Diagnosis

• Lumbar puncture
• Microscopic examination of cerebrospinal
fluid
• India ink staining
• Cyrptococcal antigens in CSF and serum
• Culture of organisms from blood or CSF

148
Gram Stain of tissue infected with C. neoformans

149
 India ink (colloidal carbon) stain
• This is used to detect mainly
Cryptococcus neoformans and
other encapsulated fungi in a cell
suspension e.g., CSF sediment
• The background field, rather than
the organism itself, is stained,
which makes any capsule around
the organism visible as a halo
• In CSF, the test is not as sensitive
as cryptococcal antigen
• Specificity is also limited;
leukocytes may appear
encapsulated

150
151
 Biochemical Tests

• Urease production
• Inability to reduce
nitrate
• Production of melanin
from caffeic acid (3,4-
dihydrocinnamic acid)
on Niger Seed Agar
• Carbohydrate
assimilation patterns
152
 Serological Diagnosis
• Based on detection of capsular polysaccharide
(glucuronoxylomannan) antigen
• No antibody tests performed
• Several tests
• Latex agglutination
• PREMIER Cryptococcal antigen assay
• Enzyme Immunoassay
• Pastorex Crypto Plus
• IMMY Latex-Cryptococcus antigen assay
153
 Treatment

• Treatment for disseminated cryptococcosis

is Amphotericin B
• It is followed by Fluconazole orally
• Meningeal disease gets Amphotericin B plus
Flucytosine, then Fluconazole orally

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Candidiasis

155
 Candidiasis
• Candidiasis is caused by Candida albicans
• Normal flora of oral cavity, genitalia, large intestine or skin of 20%
of humans
1. Found in the gastrointestinal tract, upper respiratory tract,
buccal cavity, and vaginal tract
2. Growth is normally suppressed by other microorganisms found
in these areas
3. Alterations of gastrointestinal flora by broad spectrum
antibiotics or mucosal injury can lead to gastrointestinal tract
invasion
4. Skin and mucus membranes are normally an effective barrier
but damage by introduction of catheters or intravascular
devices can permit Candida albicans to enter the bloodstream
156
 Candidiasis
• In vitro (25o C):
mostly yeast
• In vivo (37o C):
Yeast, hyphae, and
pseudohyphae

157
 Risk factors for candidiasis

• Post-operative status
• Cytotoxic cancer chemotherapy
• Antibiotic therapy
• Burns
• Drug abuse
• Gastrointestinal damage

158
 Candidiasis
• Vaginal candidiasis is the most common
clinical infection
• Local factors such as pH and glucose
concentration (under hormonal control) are
of prime importance in the occurrence of
vaginal candidiasis
• In mouth: normal saliva reduces adhesion
(lactoferrin is also protective)
159
Clinical manifestations of Candidiasis

Thrush

Candidal diaper rash

160
 Diagnosis
• Presumptive diagnosis is made if budding yeast
cells and pseudohyphae are found
• Growth on selective, differential media
differentiates Candida species
• Based on detection of:
• Antigen
• β-glucan (Fungitec-G – enzymatic assay)
• Mannan (Pastorex, Platelia - ELISA)
• Antibody (?) (IgA, IgG – ELISA, Immunodiffusion
161
Diagnosis

162
 Treatment

• Topical antifungals for superficial infections,

Amphotericin B, and fluconazole for systemics

163
Pneumocystis Pneumonia

164
 Pneumocystis Pneumonia

• Pathogen: Pneumocystis jiroveci

• Originally considered a protozoan but has
been reclassified as a fungus
• An obligate unicellular parasite and cannot
survive on its own
• Transmission occurs through inhalation of
droplet nuclei containing fungus

165
 Geographic Distribution
• Worldwide
• Most children exposed by the age of 3-4
years
• Commonly found in the interstitial
tissue of lungs of healthy individuals,
but no disease occurs
• Widespread in mammals
166
 Pneumocystis jiroveci

• A small, unicellular fungus that causes

pneumonia [Pneumocystis Pneumonia (PCP)]
• Pneumonia is the most prominent
opportunistic infection in AIDS patients
• This pneumonia forms secretions in the lungs
that block breathing and can be rapidly fatal if
not controlled with medication
167
 Transmission
• Aerosol droplets
• Direct contact
• Congenital infection
• Household pets
• Interspecies transmission?
• Reactivation of latent infection when
immunocompromised

168
Life Cycle

169
 Life Cycle
• Life cycle is not fully known
• Asexual and sexual reproduction
• Four general morphological forms in mammals
• Trophozoite (has amoeboid trophozoite form)
• Precysts
• Cysts
• Sporozoites (intracystic bodies)
• Cyst (diagnostic form)
• Chitinous membrane and 8 intracystic bodies
• Pore in cyst wall used for releasing sporozoites
• Can be spherical or collapsed
170
 Clinical Presentation

• Lung epithelium becomes desquamated due to pneumonia

• Alveoli fill with foamy exudate containing parasites
• Fever, non productive cough, breathing difficulty,
respiratory failure, cyanosis
• Death occurs by asphyxia
• Rapid progression of the disease occurs in patients without
HIV/AIDS
• Patients with HIV/AIDS have a slower progression of the
symptoms
• 100% mortality if untreated
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 Diagnosis

• Clinical symptoms
• Sputum or bronchial lavage
• Special staining with toluidine blue,
methenamine silver
• Gram-Weigert stain for cysts
• ELISA, immunofluorescence assay, DNA
amplification being developed
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 Treatments

• Trimethoprim-sulphamethoxazole (TMP-SMZ)
• Pentamidine isethionate inhalant
• Treatments can be toxic and patient must be
monitored closely
• Prophylactic treatment if CD4 count is low (<200)
• Highly Active Antiretroviral Therapy (HAART)
regimen to boost immune system function,
corticosteroids
• The pneumonia vaccine currently in use does not
prevent against PCP
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Aspergillosis

174
 Aspergillus
• Aspergillus is a very common airborne
soil fungus
• 600 species, 8 involved in human
disease
• Inhalation of spores causes fungus balls
in lungs and invasive disease in the eyes,
heart, and brain
175
 Aspergillosis
• Agent: Aspergillus fumigatus, A. flavus
• Aspergillosis is the most common fatal infection
seen in patients with chronic granulomatous disease
of childhood
• Patients with this condition are unable to form toxic
oxygen radicals after phagocytosis
• Progressive and disseminated disease can
complicate neoplastic diseases, especially acute
leukemia, bone marrow and organ transplantation
(not necessarily AIDS)
176
 Aspergillosis
• In immunosuppressed hosts: invasive pulmonary
infection, usually with fever, cough, and chest pain
• May disseminate to other organs, including brain,
skin, and bone
• In immunocompetent hosts: localised pulmonary
infection in persons with underlying lung disease
• Also causes allergic sinusitis and allergic
bronchopulmonary disease
177
Aspergillus

178
 Transmission
• Aspergillus species constitute the most commonly
found fungi in any environment
• Major portal of entry is the respiratory tract
• Dissemination can occur from the lungs and involve
other areas of the lung, the brain, GI tract, and
kidney
• CNS and nasal-orbital cavities can also occur
without lung involvement
• Risk factors for invasive disease are neutropenia and
high doses of adrenal corticosteroids
179
 Clinical Manifestations

Invasive eye
infection

Conjunctival infection Brain abscesses (darkened areas)

180
 Serological Diagnosis

• Diagnosis of invasive disease

• Based on the detection of Aspergillus antigens
• ELISA kits to detect Galactomannan and -Glucan
• Diagnosis of allergic disease
• Based on the detection of IgE by ELISA
• May also use complement fixation or
Immunodiffusion

181
 Diagnosis and Treatment

• Amphotericin B and
Nystatin

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Zygomycosis
 Zygomycosis

• Zygomycota are extremely abundant saprobic fungi found in

soil, water, organic debris, and food
• Genera most often involved are Rhizopus, Absidia, and
Mucor
• Usually harmless air contaminants
• Commonly seen in patients with uncontrolled Diabetes
Mellitus, people who inject illegal drugs, in some cancer
patients, and in some patients receiving antimicrobial agents
• They invade the membranes of the nose, eyes, heart, and
brain of people with Diabetes Mellitus, malnutrition with
severe consequences
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 Diagnosis and Treatment

• Clinically based on patient history

• Microscopic findings in fungus
• Physical removal of infected tissues and
management of predisposing factors
• Drug of choice - Amphotericin B
administered intravenously for 8-10 weeks

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