Systemic mycology

Shimelis Teshome (BSc MLS)

Classification of Human Mycoses and Representative Etiologic Agents

02/23/2021 Shimelis Teshome (BSc MLS) 2

 Causes of Superficial Tineas
• Trichophyton, Microsporum, Epidermophyton
• Anthropophilic fungi: person-to-person (most
common)
• Zoophilic fungi: animal-to-person
• Geophilic fungi: soil-to-person

02/23/2021 Shimelis Teshome (BSc MLS) 3

Pityriasis (tinea) versicolor
• Fungal overgrowth in the stratum corneum
epidermidis, which disrupts melanin synthesis and
manifests as hypopigmented or hyperpigmented skin
patches, usually on the trunk of the body.
• Epidemiology: caused by overgrowth of the lipophilic
fungus, Malassezia furfur, part of the normal flora
• M. furfur also causes fungemia in premature infants
on intravenous (IV) lipid supplements.
• Tinea nigra
• Tinea nigra is a superficial infection of the stratum
corneum epidermidis on the palmar or plantar surfaces
causing benign, flat, dark, melanoma-like lesions.
02/23/2021 Shimelis Teshome (BSc MLS) 4
 Tinea Nigra Epidemiology
• Temperate climates
• Younger patients
• Females
• Palms and soles

02/23/2021 Shimelis Teshome (BSc MLS) 5

 CUTANEOUS MYCOSES
• General aspects of cutaneous mycoses
• Caused by any of the dermatophytes or Candida spp.
• Candida infections are more frequently mucocutaneous
or in skin folds and sometimes disseminate
• Dermatophytes do not disseminate.
• Skin, hair, or nails may be affected; infections are
classified by the area of the body involved.
• Epidemiology
• Diseases acquired from animals (zoophilic) cause lesions
that are significantly inflammatory.
• Two common zoophilic species are Microsporum canis
and Trichophyton rubrum.
02/23/2021 Shimelis Teshome (BSc MLS) 6
 Tinea capitis (ringworm of the scalp skin and hair)
• Anthropophilic tinea capitis (gray patch)
• Occurs in prepubescent children and is epidemic, spread
by head gear, combs, and so forth.
• It is caused by Microsporum audouinii.
• It is usually noninflammatory and produces gray patches
of hair.
• Zoophilic tinea capitis (nonepidemic)
• Is transmitted by pets or farm animals.
• It is most commonly caused by Microsporum canis or by
Trichophyton mentagrophytes

02/23/2021 Shimelis Teshome (BSc MLS) 7

 Manifestations: Tinea Capitis
• Circular patch of scaly skin
• Dry, noninflammatory dermatosis
• Patchy areas of hair loss
• Crown, parietal areas
• “Black dots”: hairs broken off at the scalp
• Kerion or favus: both worse involvement

02/23/2021 Shimelis Teshome (BSc MLS) 8

 T. Capitis Presentation

02/23/2021 Shimelis Teshome (BSc MLS) 9

Favus (tinea favosa)
1. It is a highly contagious and severe form of tinea capitis
with scutula (crust) formation and permanent hair loss
caused by scarring. Prophylaxis of all close contacts is
needed.
2. It is caused by Trichophyton schoenleinii. (Know this
species! Permanent hair loss!)
3. Favus occurs in both children and adults.

02/23/2021 Shimelis Teshome (BSc MLS) 10

Tinea barbae
1. This infection is an acute or chronic folliculitis of the
beard, neck, or face most commonly caused by
Trichophyton verrucosum.
2. It may produce pustular or dry, scaly lesions.

Tinea corporis
1. This dermatophytic infection affects glabrous skin
and is commonly caused by T. rubrum, T.
mentagrophytes, or M. canis.
2. It is characterized by annular lesions with an active
border that may be pustular or vesicular

02/23/2021 Shimelis Teshome (BSc MLS) 11

 Manifestations: Tinea Corporis
• Glabrous skin (smooth and bare)
• Not on scalp, feet, hands, groin, ears, face
• Oval, scaly patch with inflamed border
• Centrally, skin often appears lighter or normal; thus,
the lesion appears to be a ring circling beneath the
skin surface
• 15-20 lesions over the body
• Lesions coalesce: polycyclic appearance

02/23/2021 Shimelis Teshome (BSc MLS) 12

 T. Corporis Presentations

02/23/2021 Shimelis Teshome (BSc MLS) 13

 T. Corporis Presentations

02/23/2021 Shimelis Teshome (BSc MLS) 14

 T. Corporis Presentations

02/23/2021 Shimelis Teshome (BSc MLS) 15

 T. Corporis Presentations

02/23/2021 Shimelis Teshome (BSc MLS) 16

 Tinea cruris
• This acute or chronic fungal infection of the groin is
commonly called jock itch.
• It is often accompanied by athlete’s foot or nail
infections, which also must be treated.
• It is caused by E. floccosum, T. rubrum, T.
mentagrophytes, or yeasts like Candida.

02/23/2021 Shimelis Teshome (BSc MLS) 17

 Manifestations: Tinea Cruris
• Sharply defined lesions
• Inflamed borders, reddish-brown centers
• Begins in groin skinfolds
• Spreads to perineum, thighs, buttocks
• Intense pruritus
• Sweating causes overt pain
• 2˚ bacterial infection possible

02/23/2021 Shimelis Teshome (BSc MLS) 18

 T. Cruris Presentations

02/23/2021 Shimelis Teshome (BSc MLS) 19

 T. Cruris Presentations

02/23/2021 Shimelis Teshome (BSc MLS) 20

 Tinea pedis
• Acute to chronic fungal infection of the feet is commonly
called athlete’s foot.
• It is most commonly caused by T. rubrum, T.
mentagrophytes, or E. floccosum.
• There are three common clinical presentations:
a. Chronic intertriginous tinea pedis (usually white
macerated tissue between the toes)
b. Chronic dry, scaly tinea pedis (hyperkeratotic scales on
the heels, soles, or sides of the feet)
c. Vesicular tinea pedis (vesicles and vesiculopustules)

02/23/2021 Shimelis Teshome (BSc MLS) 21

 Manifestations: Tinea Pedis

• 3 forms
• Intertriginous: macerated, boggy, white, thick, odorous,
pruritic between toes
• Acute vesicular: inflammation, fissuring; 2˚ bacterial
infections; odorous, pruritic; extreme pain in walking
• Moccasin: chronic, nonvesicular, over plantar foot

02/23/2021 Shimelis Teshome (BSc MLS) 22

 T. Pedis

02/23/2021 Shimelis Teshome (BSc MLS) 23

 Manifestation: Tinea Pedis
• Flares in the summer; abates in winter
• May cause tinea manuum: “one-hand, two-
foot disease”; Hands are dry, red, scaly

02/23/2021 Shimelis Teshome (BSc MLS) 24

 Manifestations: Other Tineas
• Unguium: opaque, yellow nails; thickened; brittle,
crumbled; nail lifts and may be lost
• Versicolor: lesions darken in winter, lighten in
summer
• Nigra: black, brown discoloration on palms, lesions
may coalesce; no scaling, nonpruritic, painless

02/23/2021 Shimelis Teshome (BSc MLS) 25

 T. Unguium Presentation

02/23/2021 Shimelis Teshome (BSc MLS) 26

 T. Versicolor Presentations

02/23/2021 Shimelis Teshome (BSc MLS) 27

 Tinea Incognito
• Inappropriate assumption that lesions are
allergenic in etiology
• Treatment of the lesion with steroids
• Steroid decreases inflammatory barriers,
allowing spread to accelerate
• As spread accelerates, patient increases use of
steroids

02/23/2021 Shimelis Teshome (BSc MLS) 28

 Tinea Incognito

02/23/2021 Shimelis Teshome (BSc MLS) 29

 Candida Species
• Are commensal and colonize the skin and mucosal surfaces
of humans
• USA, Spain, Australia, German, France and other countries
BSI due to candida ranked among top ten hospital-acquired
BSIs
• Candida species are increasing and considered as the third or
fourth most common cause of HCAIs in USA
• Sepsis due to Candida species account for 10% to 15% of
health-care associated infections
02/23/2021 Shimelis Teshome (BSc MLS) 30
• More than 150 known species with 15 are the most
frequent
• Only 15 species were isolated as human pathogen
• 95% of infections due to these pathogens were due to
five species
 The Changing Epidemiology of Candida species
• The incidence rates of IC vary in different region of the
world
• Candida species from C. albicans to non albicans
• Reason are not well established
– Patient related factors, study sample size etc

02/23/2021 Shimelis Teshome (BSc MLS) 31

• The knowledge of change in Epidemiology of Candida
species is important for patient management and
required for precautions
– Difference in case fatality
– Susceptibility to antifungal agents

02/23/2021 Shimelis Teshome (BSc MLS) 32

 Table 1: Main characteristics and factors affecting the
emergence of Candida non-albican species

02/23/2021 Shimelis Teshome (BSc MLS) 33

 Pathogenesis
 Morphogenesis
• Phospholipases, by cleaving phospholipids, induce cell
lysis and thereby facilitate tissue invasion
• Candida colonization and biofilm formation play an
important role in the pathogenesis of superficial and
invasive infections because of increased resistance to
antifungal therapy and the ability of yeast cells within
biofilms to withstand host immune defenses

02/23/2021 Shimelis Teshome (BSc MLS) 34

 Clinical Manifestations

 Oropharyngeal Candidiasis
• The transition from commensal to invasive infection of
the oral mucosa is caused by
– local changes in the microflora
– by an inefficient host response system which results in
the overgrowth and invasion of Candida spp.
• Underlying conditions associated with a greater
prevalence of OPC include
• prematurity, ill-fitting dentures, xerostomia, radiation of
the head and neck, uncontrolled diabetes mellitus,
hematologic and solid organ malignancies, oral or
inhaled corticosteroid use, antimicrobial therapy, and
HIV infection
02/23/2021 Shimelis Teshome (BSc MLS) 35
• Candida albicans remains the most common species
responsible for OPC, accounting for 80–90% of cases
– Its adhere to buccal epithelial cells is critical in establishing
oral colonization; C. albicans adheres better to epithelial cells
than non-albicans Candida species.
• Symptoms of oral thrush include a painful mouth,
burning tongue and dysphagia.
• Signs include diffuse erythema with white patches that
appear as discrete lesions on the surfaces of the buccal
mucosa, palate, oropharynx, tongue, and gums.
• With some difficulty, the plaques can be wiped off
revealing a raw, erythematous and sometimes bleeding
base.
02/23/2021 Shimelis Teshome (BSc MLS) 36
• Oropharyngeal candidiasis can impair the quality of life
by reduction in fluid or food intake.
• The most commonly identified form of OPC is termed
acute pseudomembranous candidiasis.
• This form is seen frequently in HIV-positive persons and
presents with a whitish-yellow thick curd–like exudate
on mucosal surfaces
• stomatitis, or denture stomatitis
• cheilitis
02/23/2021 Shimelis Teshome (BSc MLS) 37
Fig. 1 Oropharyngeal candidiasis demonstrating (a) pseudomembranous type, (b)
atrophic erythematous type associated with denture use, and
(c) angular cheilitis
02/23/2021 Shimelis Teshome (BSc MLS) 38
• Esophageal Candidiasis
• Predisposing factors include exposure to local irradiation,
recent cytotoxic chemotherapy, antibiotics, corticosteroids,
and neutropenia
• Esophageal candidiasis in an HIV-positive patient may be
the first manifestation of AIDS, typically occurring at CD4
counts <100 cells/µL
• EC presents with odynophagia, dysphagia, and retrosternal
pain.
• Constitutional findings, such as fever and malaise,
occasionally occur. Rarely, epigastric pain is the dominant
symptom.
• Esophagitis is classified on the basis of endoscopic
appearance
02/23/2021 Shimelis Teshome (BSc MLS) 39
02/23/2021 Shimelis Teshome (BSc MLS) 40
• Cutaneous Candidiasis
• Candida can invade any body surface and cause superficial
infection of the skin, hair, and nails.
• Symptomatic mucocutaneous candidiasis will occur if
dysfunction or local reduction in host resistance promotes an
overgrowth of indigenous flora and there is a breach in the
anatomical barriers.
• Candida albicans and C. tropicalis are the most common
causes of superficial infections of the skin and the nails.
• Generalized cutaneous candidiasis is rare
• Intertrigo is the most common skin infection due to
• Candida, affecting sites in which skin surfaces are in close
proximity providing a warm and moist environment
• Candida folliculitis is predominantly found in the hair
follicles and rarely becomes
02/23/2021 extensive
Shimelis Teshome (BSc MLS) 41
• Chronic Mucocutaneous Candidiasis(CMC)
• Involves multiple superficial sites, primarily the mouth,
facial skin, hair and nails
• Frequently result in a disfiguring form of CMC called
Candida granuloma
• CMC rarely experience visceral or disseminated fungal
infections.
• The most common cause of death is bacterial sepsis.
• CMC is frequently associated with
– endocrinopathies such as hypoparathyroidism (80%),
hypoadrenalism (72%), ovarian failure (60%), growth hormone
deficiency, gonad insufficiency (15%), diabetes mellitus (12%)
– chronic lymphocytic thyroiditis with hypothyroidism (5%)

02/23/2021 Shimelis Teshome (BSc MLS) 42

02/23/2021 Shimelis Teshome (BSc MLS) 43
• Vulvovaginal Candidiasis (VVC)
• During the childbearing years, 75% of women
experience at least one episode of VVC
• Source is from the adjacent perianal area
• Factors pregnancy, oral contraceptives with a high
estrogen content, and uncontrolled diabetes mellitus
• Corticosteroids, antimicrobial therapy, intrauterine
devices, and high frequency of coitus

02/23/2021 Shimelis Teshome (BSc MLS) 44

02/23/2021 Shimelis Teshome (BSc MLS) 45
• Candidemia and Disseminated Candidiasis
• Acute candidemia is indistinguishable from bacterial
sepsis and septic shock.
• Clinical manifestations of fungemia are frequently
superimposed on those of the underlying illnesses and
concomitant bacterial infections, including bacteremia,
are not uncommon.
• There are no specific clinical features of candidemia
associated with individual Candida species.
• Dissemination to multiple organs often involves skin,
kidney, eye, brain, myocardium, liver, spleen, and bone

02/23/2021 Shimelis Teshome (BSc MLS) 46

02/23/2021 Shimelis Teshome (BSc MLS) 47
 Aspergillus
• Contains more than 180 species which are ubiquitous
saprobe
• Occurring mainly in air, soil, water, plants, food, and
inanimate surfaces
• Invasive aspergillosis, chronic pulmonary aspergillosis, and
allergic bronchopulmonary aspergillosis
 Its infection characterized with high mortality
• Common causes of HCAI after construction and renovation
of hospital
02/23/2021 Shimelis Teshome (BSc MLS) 48
 Epidemiology
• The most commonly encountered include A. fumigatus
followed by A. flavus and A. terreus
• Improperly cleaned ventilation systems & contaminated
water systems are sources in the ICU
• Aspergillosis confound with M. tuberculosis
• Construction- related cases of healthcare-associated
pulmonary Aspergellosis is common
• The shift from aspergillus to mucormycetes were reported.
 Due to increasing use
02/23/2021
of voriconazole prophylaxis
Shimelis Teshome (BSc MLS) 49
 Mucorales

• Responsible for mucormycosis, the third commonest

invasive fungal infection
• In the ICU setting related more commonly to massive
injuries/ trauma
• Outbreaks of this mould infections have been increasingly
reported, with contaminated medical supplies
• Immunosuppression and granulocytopenia have become
the most common predisposing factors in hospitals
02/23/2021 Shimelis Teshome (BSc MLS) 50
• Cause of 10% of all invasive fungal infections methods
• Infections in health care due to Mucorales were
increasingly reported with high mortality rate
• Increasingly reported gastrointestinal mucormycosis of
neonates incidence currently

• Adult case nosocomial mucormycosis was also reported

02/23/2021 Shimelis Teshome (BSc MLS) 51

02/23/2021 Shimelis Teshome (BSc MLS) 52