 are much less common than superficial fungal infections.

 are characterized by a heterogeneous group of infections that

often result from direct penetration of the fungus into the dermis
and subcutaneous tissue through traumatic injury.
 the fungus usually spreads by local deep tissue invasion from
inoculation site.
 the disease usually remain localized and then slowly spreads to
adjacent tissue and eventually to the lymphatics.
 may rarely become systemic or disseminated.
 are confined to the tropical and subtropical regions, but some,
such as sporotrichosis, are also prevalent in temperate regions.
 can occur in healthy individuals, and in immunocompromised
individuals these infections can disseminate widely.
 treatment usually involves use of anti fungal agents and/ or
surgical excision.
A.Sporotrichosis (Rose Gardener's Disease)
1. Causative Agent
- thermally dimorphic Sporothrix shenkii whose natural habitat is living or
dead vegetation.

2. Morphologic and Cultural Characteristics

a. mycelial phase
i. colonies are usually small, moist and white to cream colored which on
further incubation become membranous and coarsely matted, wrinkled, with
the color becoming irregularly dark brown or black and the colony becoming
leathery
ii. microscopically hyphae are delicate, septate, exhibit branching and
bear one-called conidia which are borne bouquet-like, in clusters from the tips
of single conidiophores
b. yeast phase
i. colonies are pasty and grayish
ii. microscopically they are usually spherical, oval, singly or multiply budding
cells but some are fusiform, elongated or cigar-shaped, asteroids may also be seen
iii. mycelial to yeast conversion at 37 degree Celsius in 12-48 hours

3. Transmission
a. through traumatic inoculation with contaminated material (e.g, thorn or
splinter, brushing against a tree bark)
b. inhalation of infectious particles (in pulmonary sporotrichosis)

4. Clinical Manifestation
a. lymphocutaneous sporotrichosis (75% of cases)
i. lesions appear first in the cutaneous and subcutaneous tissue and
progressively involve the draining lymphatics
ii. initially with a small, movable, non-tender, subcutaneous nodule
develops but a small ulcer may also be seen
iii. the subcutaneous nodule becomes discolored and the skin darkens from
red to black which subsequently erupts to form an ulcer or sporotrichotic chancre
iv. after a few weeks, the primary lesion heals and new ones develop
 b. chronic sporotrichosis
i. after the primary lesion, multiple subcutaneous nodules develop along
the lymphatic channels and become hard and cordlike
ii. the course is the same and if untreated, becomes chronic, but may heal
spontaneously
c. fixed sporotrichosis
i. presence of only one lesion without involvement of lymphatics
ii. lesion may be ulcerative or appear as a plaque or rash
d. pulmonary sporotrichosis (rare)

5. Laboratory Diagnosis
Specimens: exudates from unopened subcutaneous nodules or from open
draining lesions; biopsy material
a. KOH or calcoflour white preparations
b. special stains
i. PAS (Periodic Acid-Schiff)
ii. methenamine silver stain
iii. fluorescent antibody stain
c. Culture
i. Inhibitory mold agar or
ii. Sabouraud's agar with antibiotics
iii. Others
 d. Serology
i. yeast cell agglutination test
ii. sporotrichin

6. Treatment
a. oral solution of saturated potassium iodide
- treatment of choice for cutaneous sporotrichosis (can be administered
topically also)
b. amphotericin B, ketoconazole, dihydroxystilbamidine, griseofulvin, and
flucytosine

B. Chromomycosis (Chromoblastomycosis)
- is a chronic fungal infection acquired thru traumatic inoculation of spores,
primarily in the lower extremities.
- characterized by the development of a papule at the site of injury that
spreads to form warty or tumor-like lesions (cauliflower-like).
- secondary and ulceration may ensure.
- rarely, brain abscess may occur.
1. Causative Agents
Chromomycosis is caused by dematiaceous fungi which are imperfect fungi
that produce varying amount of melanin-like pigments found in the conidia
or hyphae or both.
 a. Cladosporium carrionii
b. Phialophora verrucosa
c. Fonsecae pedrosoi and F. Compacta

2. Cultural Characteristics
a. the dematiacous fungi have similar characteristics
b. all are slow-growing and produce heaped-up and slightly folded, darkly
pigmented colonies with a grayish-velvety appearance; the reverse side of the
colonies is jet back
c. yeast species are usually pleomorphic and produced dark, moist colony

3. Microscopic Appearance
a. Cladosporium species
- produce long chains of elliptical conidia (blastoconidia) borne from erect, tall,
branching conidiophores
b. Phialophora species
- produce short, flask-shaped to tubular phialides,usually with a well-
developed collarette, clusters of conidia are produced by the phialides through an
apical pore
c. Fonsecae species
- may exhibit Phialophore-type or Cladosporium-type of sporulation and also
produce lateral or terminal conidia from a lengthening conidiogenous cell
resembling a series of bent knees (conidia are produced sympodially)
 i. F. pedrosoi - produce loose conidial heads
ii. F. compacta - produce more compact conidial heads.

4. Laboratory Diagnosis
Specimens: Scrapings or biopsy from lesions
a. microscopic examination
i. scraping from crusted area added to 10% KOH slow presence of muriform
or sporotic bodies, which appear rounded, brown resembling copper pennies
that exhibit transverse septations.
b. Culture
- Sabouraud's with or without antibiotics
c. extraction and detection of exoantigents

5. Treatment
a. flucytosine - the best
b. amphotericin B and the azoles especially itraconazole

C. Phaeohyphomycosis
- this term refers to infections characterized by presence of darkly pigmented,
septate hyphae in tissue. Clinical forms vary from solitary encapsulated cysts
in the subcutaneous tissue to brain abscess.
1. Causative Agents
a. Exophaila jeanselmei
i. grows early as a black yeast with dark budding yeast forms seen on
microscopy of culture
ii. develops long slender conidiophores with tapered tips and conidia
arising from growth rings (annelides)
b. Phialophora
c. Wangiella dermatitidis
i. early form same as that of Exophiala
ii. produce conidia by phialides that lack collarettes
d. Xylohypha bantiana (Cladosporium bantianum or Cladosporium
trichoides)
i. Cladosporium type of sporulation
ii. infection usually recognized only at autopsy
e. Other normally saprophytic dematiaceous fungi

2. Laboratory Diagnosis
a. microscopic examination (KOH preparation)
- irregular dark,hyphae,as well as yeasts and pseudohyphae are seen in
tissue
b. culture
3. Treatment: Same as in Chromomycosis
D. Mycetoma (Madura foot or Maduromycosis)
- is a chronic, suppurative infection of the subcutaneous tissue and contiguous
bone.
- clinical features are fairly uniform, regardless of the organism involved.
- Feet are the most coomon site for infection and account for at least two-thirds
of cases. Other sites include the lower legs, hands, head, neck, chest, shoulder and
arms.
- Most cases start out as a small hard painless nodule which over time begins
to soften on the surface and ulcerate to discharge a viscous, purulent fluid
containing grains. The infection slowly spreads to adjacent tissue, including bone,
often causing considerable deformity. Sinuses continue to discharge
serosanguinous fluid containing the granules which vary in size, colour and
degree of hardness, depending on the aetiologic species. These grains are the
hallmark of mycetoma.

Two Types of Mycetoma:

 Actinomycotic mycetoma
- Caused by Nocardia, Actinomadura, Streptomyces, and Aerobic actinomyces
 Eumycotic mycetoma
- Caused by a true fungi, most commonly Pseudoallescheria boydii which is
found in soil and sewage; transmitted via traumatic inoculation
1. Clinical Material:
Tissue biopsy or excised sinus, serosanguinous fluid containing the
granules which vary in size, colour and degree of hardness, depending on
the aetiologic species.

2. Direct Microscopy:
Serosanguinous fluid containing the granules should be examined using
either 10% KOH and Parker ink or calcofluor white mounts, and tissue
sections should be stained using H&E, PAS digest, and Grocott's
methenamine silver (GMS).

3. Culture:
Clinical specimens should be inoculated onto primary isolation media, like
Sabouraud's dextrose agar.

4. Serology:
There are currently no commercially available serological procedures for the
diagnosis of mycetoma.

5. Identification:
Characteristic clinical, microscopic and culture features
6. Causative agents:
Acremonium sp., Aspergillus nidulans, Madurella grisea, Madurella mycetomatis,
Scedosporium apiospermum

E. Rhinosporodiosis
A chronic infection characterized by the development of polypoid masses of
the nasal mucosa caused by Rhinosporidium seeberi
1. Laboratory Diagnosis
a. histologic examination of infected tissue
i. reveals epithelial hyperplasia and cellular infiltrate of neutrophils,
lymphocytes, plasma cells and giant cells
ii. large thick-walled sporangia; the cell wall of the spherule is multilayered
and stains with mucicarmine
b. serologic test for rhinosporidial antigen
2. Treatment
a. topically,surgical, and by local injectionof ethylstilbamidine

F. Lobomycosis
A chronic subcutaneous infection of humans and dolphins caused by loboa
loboi (Paracoccidiodes loboi).
1. Laboratory Diagnosis
Specimens: skin skrapings, biopsies or wet preparations of exuditive lesions
a. direct microscopic examination
i. large, spherical or oval yeasts that exhibit multiple budding and form
short chains of three to six or more yeast cells whish are multinucleated and thick-
walled
b. histologic examination
i. granulomtous nodules and occasional asteroid bodies
ii.easts stain with PAS or nethenamine silver and may be seen inside
macrophages

2. Treatment
a. sulfa drugs
b. surgical excision

G. Rhinoentomophthoromycosis (Entomophthoromycosis
conidiobolae)
A rare infection of the nasal mucosa caused by Entomophthora coronata
(Conidiobolus coronatus). Humans suffering from rhinoentomophthoromycosis
get infected by the attachment of conidia of C. coronatus to nasal/sinusoidal
mucosa.
1. Treatment
i. Saturated potassium iodide solution was used in 54% of the cases. Patients
also received amphotericin B, ketoconazole , sulfamethoxazole/trimethoprim,
itraconazole, fluconazole, miconazole, terbinafine, and 5-fluorocytosin.
ii. Surgery was performed in 41% of all cases. Surgical interventions were
excision of infected tissue, reconstructive surgery after antifungal medication,
excision of infected tissue plus reconstructive surgery after antifungal
medication, excision of infected tissue plus orbital decompression, and orbital
decompression alone. Surgery did not correlate with cure.
A. Sporotrichosis

B. Chromomycosis
C. Phaeohyphomycosis

D. Mycetoma
E. Rhinosporodiosis

F. Lobomycosis
G. Rhinoentomophthoromycosis