SUBCUTANEOUS MYCOSIS

Dr SULAIMAN CONTEH
 Introduction
• These are caused by fungi that grow in
soil and on vegetation.
• They are usually introducted into the
subcutaneous tissue by trauma.
• The common subcutaneous fungi
infections that we will discuss are as
follows:
 Sporotrichosis
 Chromomycosis
 Mycetoma
 Sporotrichosis
• Sporothrix schenckii is a dimorphic fungus
• Sporotrichosis is usually a chronic
infection of the cutaneous or
subcutaneous tissue which tends to
suppurate, ulcerate and drain.
• In recent years, a pulmonary disease has
been seen more frequently.
 Transmission
• The infection is also known as "rose growers
disease."
• The ecologic niche for this organism is rose
thorns, sphagnum moss, timbers and soil.
• A study on the occupational distribution of
sporotrichosis showed that forest employees
accounted for 17% of the cases, gardeners and
florists, 10%; and other soil-related occupations
another 16%. Sporotrichosis occurs worldwide.
 Clinical presentation
• History: Gardener growing thorns or rose
flower and had a thorn prick.
• A pustule develops and ulcerates. It
infects the lymphatic system and then the
disease progresses up the arm with
ulceration (figure 37), abscess formation,
break down of the abscess with large
amounts of pus followed by healing.
Progression usually stops at the axilla.
 Laboratory diagnosis
• Clinical material to be sent to the lab may be
pus, biopsy material, or sputum from pulmonary
patients.
• The yeast form of this fungus in tissue or in
culture, can be round or fusiform. The fusiform
shape is not the usual form but if a cigar-shaped
yeast is observed in tissue, it is usually
diagnostic of sporotrichosis.
• S. schenckii does not stain with the usual
histopathological stains. If sporotrichosis is
suspected, the pathologist must be informed so
he can use special stains.
 Laboratory diagnosis Cont:
• Histologically asteroid bodies, a tissue
reaction (also known as Splendori reaction)
may be seen around the yeast cell. At 25
degrees C, this colony is white-cream and
very membranous (figure 34 and 35), but as it
ages for 2-3 weeks it becomes black and
leathery.
• Microscopically, the mycelium is branching,
septate and very delicate, 2-3 um in diameter.
The pyriform conidia, 2-4 um form a typical
arrangement in groups at the end of a
conidiophore called "daisies".
 Laboratory diagnosis Cont-1:
• Serologic tests are not commercially
available.
 Treatment
• The drug of choice for the cutaneous form
is saturated iodides (e.g., potassium
iodide) administered orally.
• The patient begins with 2-3 drops, 3-
4/days until tolerance to the drug is built
up, then the dose is increased.
• Potassium iodide may interact with the
host immune system.
• For the systemic form the drug of choice is
itraconazole or amphotericin B.
 Chromomycosis
• Chromomycosis is a slowly progressive granulomatous
infection that is caused by several soil fungi when
introduced into the skin by trauma. Several soil fungi
caused tha following diseases Cladosporiosis, Fonseca's
disease, Pedroso's disease, Phaeosporotrichosis, and
Verrucous dermatitis.
• The infection occurs most commonly in tropical or
subtropical climates, often in rural areas.
• It can be caused by many different type of fungi which
become implanted under the skin, often by thorns or
splinters.
• Chromoblastomycosis spreads very slowly; it is rarely
fatal and usually has a good prognosis, but it can be very
difficult to cure.
 Epidemiology
• Chromoblastomycosis occurs around the
world, but is most common in rural areas
between approximately 30° N and 30° S
latitude.
• Madagascar and Japan have the highest
incidence.
• Over two thirds of patients are male, and
usually between the ages of thirty and fifty.
• A correlation with HLA-A29 suggests that
genetic factors may play a role as well.
 Clinical Presentation
• The initial trauma causing the infection is often not noticed or
forgotten.
• The infection builds at the site over a period of years, and a small red
papule (skin elevation) appears. The lesion is usually not painful and
there are few, if any symptoms. Patients rarely seek medical care at
this point.

• Several complications may occur. Usually, the infection slowly

spreads to the surrounding tissue while still remaining localized to the
area around the original wound.
• However, sometimes the fungi may spread through the blood vessels
or lymph vessels, producing metastatic lesions at distant sites.
• Another possibility is secondary infection with bacteria. This may lead
to lymph stasis (obstruction of the lymph vessels) and elephantiasis.
The nodules may become ulcerated, or multiple nodules may grow
and coalesce, affecting a large area of a limb.
 Diagnosis
• The most informative test is to scrape the lesion and add
potassium hydroxide (KOH), then examine under a
microscope.
• The pathognomonic finding is observing Medlar bodies,
sclerotic cells.
• Scrapings from the lesion can also be cultured to identify
the organism involved. Blood tests and imaging studies
are not commonly used.

• On histology, chromoblastomycosis manifests as

pigmented yeasts resembling "copper pennies." Special
stains, such as periodic acid schiff and Gömöri
methenamine silver, can be used to demonstrate the
fungal organisms if needed.
 Treatment
• Chromoblastomycosis is very difficult to cure. There are two primary
treatments of choice.

• Itraconazole, an antifungal azole, is given orally, with or without

flucytosine (5-FC).
• Alternatively, cryosurgery with liquid nitrogen has also been shown
to be effective.
• Other treatment options are the antifungal drug terbinafine, an
experimental drug posaconazole, and heat therapy.

• Antibiotics may be used to treat bacterial superinfections.

• Amphotericin B has also been used.

• Oral flucytosine or Thiabendazole
 Mycetoma
• Mycetoma is a chronic, specific,
granulomatous, fungal disease.
• It mainly affects the foot; and Mycetoma
pedis is also known as Madura foot.
• This infection is endemic in Africa, India,
and Central and South America
 Features
• Eumycetoma usually involves the subcutaneous
tissue after a traumatic inoculation of the
causative organism.
• Swelling and formation of sinus tracts
characterize mycetoma. The sinuses usually
discharge purulent and seropurulent exudate
containing grains.
• It may spread to involve the skin and the deep
structures resulting in destruction, deformity and
loss of function; very occasionally it could be
fatal.
 Treatment
• There are several clinical treatments
available for this disease. They include
surgery, ketoconazole, voriconazole,
itraconazole and amputation of the
affected limb.