Superficial Fungal Infections

Dr.T.V.Rao MD

11/24/2012

Dr.T.V.Rao MD

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SUPERFICIAL MYCOSES
The superficial mycoses are usually confined to the outermost layer of skin, hair and do not invade living tissues.

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SUPERFICIAL MYCOSES
Pityriasis versicolor Tinea nigra Black piedra White piedra
Keratomycosis
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• Superficial chronic infection of Stratum corneum • Etio: Malassezia furfur (Pityrosporum orbiculare) (Lipophilic yeast) • Clinical findings: Hyperpigmented or depigmented maculae on chest, back, arms, abdomen
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PITYRIASIS VERSICOLOR (Tinea versicolor)

Superficial
• Do not elicit immune response • No discomfort • Cosmetic problems • Limited to stratum conium
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Pityrisis versicolor

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Ring worm Infections
• Infection of the Stratum corium. • Called as Dermatophytosis or Tinea. • Called as per the site of Infection. • Tinea pedis – feet are involved. • Tinea captis – Scalp.
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RING WORM LESIONS

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Tinea lesions on Scalp

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Ring worm lesions on Face

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Severe nail infection with Trichophyton rubrum in a 37-year-old male AIDS patient. 11/24/2012 Source: Intern. J. Dr.T.V.Rao MD 31(1992): 453. Dermatol.

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Dermatophytes,
• There are 20 species of Dermatophytes infect humans. • Classed under broad category. 1 Trichophyton, 2 Microsporum, 3 Epidermophyton Infective particles -, a fragment of keratin,
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Common spp of Dermatophytes Infecting Humans
• • • • • • T.rubrum T.mentagrophytes T.tonsurans T.verucosom Epidermophyton floccosum Microsporum cannis
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Identification of Genus
• Identified on the Basis of Macro conidia. • Identification of species depends on the disposition of Microcondia • Majority of Dermatophytes produce 1 Macro conidia and 2 Micro conidia. In Epidermophyton Micro conidia are absent
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FUNGAL DISEASES
. Cutaneous mycoses: Fungal infections of the skin, hair, and nails.

 Secrete keratinase, an enzyme that degrades keratin.
 Infection is transmitted by direct contact or contact with infected hair (hair salon) or cells (nail files, shower floors).  Examples:

Ringworm (Tinea capitis and T. corporis)

– Athlete’s foot (Tinea pedis)
– Jock itch (Tinea cruris)
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Cutaneous mycoses involves
• • • • Skin Hair Nails Evoke cellular immune response • Dermatophytes • Clinical manifestations ringworm or tinea
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Cutaneous mycoses

Etiology
• Microsporum Trichophyton
Epidermophyton

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Cutaneous mycoses
• Classifications:
Anatomic location Tinea pedis Tinea capitis Tinea corporis Tinea cruris

Ecologic location
Geophilic Zoophilic Anthrophilic
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Basic types of Dermatophytic infection:
1. The acute or inflammatory type of

infection, which is associated with CMI to the fungus, generally heals spontaneously or responds nicely to treatment. 2. The chronic or non-inflammatory types of infection, which is associated with a failure to express CMI to the fungus at the site of infection, is relapsing and responds poorly to treatment.
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Classification of Dermatophytes

• Trichophyton • Microsporoum • Epidermophyton Differentiated on the Basis of Macrocondia,By Microscopy
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Cutaneous Mycosis

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Macroconida

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Macroconida

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Micro conidia

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Spread of Dermatophytes,
• Spread of infection occurs through direct or indirect contact. • Other ways of spread, From – Floors of swimming pools. Brushes,Combs,Towels, Predisposing factors Peeling of skin or minor trauma Genetic predisposition ? T Cell immunity is important, Phagocytes play a role. Invade Keratin ,Enzymatic, or Mechanical causes.
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Trichophyton
• • • • • • Colonies are powdery ,velvety, Micro conidia are abundant, Arranged in clusters, Hyphae are borne on conidiophores Special hyphal structures. Infects Skin, Hair, Nails,
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Microsporum
• • • • Colonies are cotton like, Velvety or powdery, Macroconida are scanty, Macrocode are large ,Multicellular spindle shaped, • Infects Hair, and Skin, Nails are not infected.
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Epidermophyton
• Colonies are powdery , greenish yellow, • Macroconida are multicellular, pear shaped, typically arranged in clusters. • Infects - Skin, Nails But not Hair.

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General characteristics of Macroconida and Microconidia of Dermatophytes
Genus Microsporum Epidermophyton
Trichophyton

Macroconidia Numerous, thick walled,rough Numerous, smooth walled
Rare,thin walled, smooth
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Microconidia Rare Absent
Abundant

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Macroconida

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Pathogenesis
• • • • • • Depends on – site – species, Only dry scaling Hyperkeratosis, Irritation, Erythema of skin, Weeping pustules, Ulceration,
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Clinical Presentation
• Can produce Lesions on Body,face,scalp • Annular lesions ,raised,inflamatory borders, • Groin lesions spread outwards from flexor areas, • Toe clefts, sole • Nails get discolored, thickening, and become friable.
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On scalp
• • • • • Scaling Hair loss, Hyphal break up to chains. Endothrix –T.tonsurans,T.violaceum Ectothrix - Microsporum,T.verucosum. In Endothrix breaks at the mouth of follicle, Black dot, • In Ectothrix breaks hair 2-3 mm from mouth of the follicle. • Mixed infections do occur.
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The Hair may show Endothrix or Exothrix

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Cutaneous mycoses
• THE IDENTIFICATION REACTION(ID)
• Patients infected with a dermatophytes may show a lesion, often on the hands, from which no fungi can be recovered or demonstrated. • It is believed that these lesions, which often occur on the dominant hand (i.e. right-handed or left-handed), are secondary to immunological sensitization to a primary (and often unnoticed) infection located somewhere else (e.g. feet). • These secondary lesions will not respond to topical treatment but will resolve if the primary infection is successfully treated.
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Clinical Manifestations
• Appear as scaly lesion • Upper trunk, neck • May be Hypo pigmented and Hyper pigmented • Spread to other sites of the body
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Laboratory Diagnosis
• Direct Microscopy, • Demonstration of clusters of round yeast cells • Short and stout hyphae,
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Id reaction
• Inflammation associated with infection with fungi • An immunological reaction to fungal infection
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Laboratory Diagnosis
• • • • • • • Collection of samples, Specimens of skin, hair, nails Collected in folded black paper, Stored up to 12 months, Nails by clippings, Skin by scrapping with blunt scalpel, Hair by plucking
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Microscopy,
• Direct Microscopy with wet mount preparation with 15-20% Potassium hydroxide (Koh) preparation • Examination under fluorescent Microscope with Calcoflour • Examination under Woods lamp
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Examination under Wood’ Lamp

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Culturing of Dermatophytes
• Small fragments of Keratinous material used for culturing on • Sabouraud's agar, • 4 % Malt extract agar, • Colony morphology and color pigmentation observed. • Microscopic observation
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Treatment and Prevention,
• Topical therapy • Application of Topical Azoles ,compound Terbinafin,oral Grisofulvin,
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Treatment
• Pityriasis responds to Topical therapy, • 1% Seliniumsulphide, • Azoles – Ketoconazole. • Oral Azoles,
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Treatment
• Skin – azoles,inhibits cytochrome 450 dependent enzyme systems at the demethylation step from lanosterol to ergosterol • Hair- Griseofulvin, oral , affects micro tubular system
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Other Fungal Infections of Skin
• Pityriasis Versicolor ,Belong to Genus Malassezia • Infection of stratum corneum • Manifest as patches of discoloration of skin, • Caused by lipophilic yeast • Depends on Host and Environments, • Tropical countries- Young adults,
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Morphology
• Produce round yeast cells, • Short hyphae • Appear as Gram Positive
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Candidiasis can Present as Skin Lesions
• Candidiasis , Monoliasis, • Can infect Skin, Mucosa, or Internal Organs,, • Called as Yeast Like fungus
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Candida and other species,
• Candida albicans, • Others spp C.tropicalis, C.Krusei, C.glabrata, C.parapsilosis,

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Candida
• Common flora Exist in Mouth, Gastrointestinal tract. Vagina, skin in 20 % of normal Individuals. Colonization increases with age, in pregnancy Hospitalization Immunity Depends on T lymphocytes, and Europhiles
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Morphology and Culturing
• Ovoid shape or spherical budding cells and produces pseudo mycelium • Routine cultures are done Sabroud’s Glucose agar, • Grow predominantly in yeast phase • A mixture of yeast cells and pseudo mycelium and true mycelium are seen in Vivo and Nutritionally poor media.
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Pseudohypal structures in
Candida

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Pathogenesis and Pathology
• Mucosal infection superficially –Discrete white patches on mucosal surface. • Can affect tongue • Infants and old persons are affected • Immune compromised /AIDS. Oral Candidiasis is commonly seen • Vaginal Candidiasis causes itching soreness white discharge, White colored lesions, • Pregnancy with advance, • One episode through life time
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Other lesions
• Esophageal infection common in HIV / AIDS • Skin – Nail infections • Axilla Groin • Toe clefts, • Napkin dermatitis, • Nails frequent immersion in water House wives, Washer man Nurses,
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Predisposing factors.
• Infancy, old age, Pregnancy, • Change of flora. • Moisture, occlusion Trauma • T Lymphocyte disease. Neutropenia. • Diabetes mellitus

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Location of Infections
• Localized and Disseminated. • Multi organ involvement. • Kidney,Liver,Splee n, Brain.GIT.Eye, • Catheter related infections,
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Other lesions
• Chronic muco coetaneous Candidiasis • In childhood – suspect defects of Lymphocytes and Neutrophils,
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Laboratory Diagnosis
• • • • • Skin scrapings, Mucosal scrapping, Vaginal secretion Culturing Blood and other body fluids, Observations Microscopic observation after Gram staining. Gram + yeast cells.
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Cutaneous mycoses
• Laboratory diagnosis: scrapings from clinical specimens • Hair – endothrix (spores inside the hair shaft -ectothrix -exception: T.schoenleinii Disease-favus-waxy mass of hyphal elements (scutulum) microscopic – degenerated hyphal elements
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Cutaneous mycoses
• Cultures

• Selective media – containing
Cyclohexamide and chlorampenicolincubate at 25 C.

• Identification based on the conidia
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Diagnosis
• Diagnosis is based upon:
1. Anatomical site infected 2. Type of lesion 3. Examination with a Woods lamp (366 A°) 4. Examination of KOH-treated skin scales from the infected area 5. Culture of the organism (not too important)
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Diagnosis of Deep seated infections
• Difficult to culture, • Alternative methods • Antibody titers, • ELISA testing • CIE
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Culturing
• Sabouraud's Medium or Blood agar • Yeast colonies appear within 1-2 days • Germ tube test - Incubation of colonies in serum at 37 c from 1.5 to 2 hours produce • Short hyphae known as germ tube • Candida albicans are Germ tube producers • Other tests are – Sugar assimilation and fermentation tests.
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Germ Tube Test C.albicans

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Germ Tube Test C.albicans

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Treatment
• Skin removal of the organism by: 1.Selenium sulfide 2.Thiosulfate 3.Salicylic acid 4.Hyposulfite inhibition of ergosterol by: 1.miconazole
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Treatment with Modern Drugs
• • • • • Nystatin, Amphotericin B Miconazole, Topical Imidazole application Systemic infection needs Intravenous – Amphotericin B Intravenous or Fluconazole.
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Differential diagnosis
• In a differential diagnosis you must consider:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
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Leprosy Secondary syphilis Pityriasis rosea Psoriasis Nummular eczema Lichen planus Alopecia areata Trichotillomania Dyshidrosis Contact dermatitis.
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