MYCOSES

Fungi are eukaryotic protista that differ from bacteria and

other prokaryotes in many ways.
They possess rigid cell walls containing chitin, mannan
and other polysaccharides.
The cytoplasmic membrane contains sterols.
They possess true nuclei with nuclear membrane and
paired chromosomes.
 They divide asexually, sexually or by both processes.
 They may be unicellular or multicellular.
The cells show various degrees of specialisation
Fungi may be classified depending on cell morphology
into four groups :
• Yeast • Yeast-like fungi • Moulds • Dimorphic fungi
Yeasts:
Cryptococcus neoformans
 Unicellular fungi
Reproduce by budding
Macroscopic appearance-pasty colonies (resembling bacterial
colonies) in culture .
Microscopic appearance-oval to round; occur as spherical or oval
forms in tissues and in culture; filamentous (hyphae-like)
structures are not seen in tissues or in culture. 
Yeast-like fungi
Eg: Candida albicans.
Unicellular fungi Reproduce by budding and by fission
Macroscopic appearance-pasty colonies (resembling bacterial
colonies) in culture
Microscopic appearance-spherical or oval forms in tissues and in
culture; filamentous structures may be seen.
 Filamentous fungi or moulds
Eg: Aspergillus fumigatus
Composed of hyphae which may have cross-walls or
septa (multicellular) or may be devoid of septa
(coenocytic).
Reproduce by asexual means (spore formation); some
exhibit sexual reproduction
 Macroscopic appearance-surface texture may be
cottony/woolly/velvety/granular; pigmentation may be
observed from the reverse.
Microscopic appearance-thread-like filamentous hyphae
seen in tissues and in culture.
Dimorphic fungi
Dimorphic fungi  that can exist in the form of both mold
and yeast.
 This is usually brought about by change in temperature.
The fungi are also described as thermally dimorphic
fungi.
Human pathogenic dimorphic fungi grows as a mold
at room temperature, and as a yeast at human body
temperature or in a lab at 37ᵒC.
Eg: Histoplasma capsulatum.
Human fungal infections are called mycoses.

Divided into :

1. Superficial
2. Subcutaneous
3. Systemic
4. Opportunistic
 Superficial mycoses
There are 2 types of superficisl mycoses: Surface infections
and cutaneous infections.
Surface infections: The fungi live on dead layers of the skin
and its appendages.
No contact with living tissues and hence no inflammatory
response.
Eg: Tinea (pityriasis) versicolor, Tinea nigra and piedra.
Cutaneous infections: The most important cutaneous
infection is dermatophytosis caused by a group of related
fungi called the dermatophytes.
Infection is generally confined to the cornified layer of the
skin and its appendages.
Allergic and inflammatory responses are induced in the
host.
Candida albicans may also cause infections of the skin
and mucosa as well as systemic diseases.
1. Surface Mycoses
Pityriasis Versicolor
Previously known as Tinea versicolor.
This is a chronic, usually asymptomatic, involvement of
the stratum corneum.
It occurs mainly in young adults.
Causative agent: The lipophilic, yeast-like fungus
Malassezia furfur (formerly Pityrosporum orbiculare)
Clinical features: Characteristic discrete or confluent macular
areas of discolouration or depigmentation occur on the skin of
the chest, abdomen, upper limbs and back.
Diagnosis: Examination of skin scrapings shows an abundance
of yeast-like cells and short, branched filaments. The fungus
can be grown on sabouraud agar covered with a layer of olive
oil.
Tinea nigra
Localised infection of skin, particularly of the palms producing
black or brownish macular lesions.
Caused by Exophiala werneckii ( formerly known as Hortaea
werneckii) and Exophiala castellanii.
Skin scrapings show brownish branched septate hyphae and
budding cells.
Colonies on Sabouraud’s dextrose agar – grey or black colour.
Piedra
Fungal infection of hair – appearance of firm, irregular
nodules along the hair shaft.
Nodules are composed of fungal elements cemented
together on hair.
Two varieties Black piedra caused by Piedraia hortae and
white piedra caused by Trichosporon beigelii.
2. Cutaneous Mycoses
Dermatophytosis
Dermatophytosis commonly known as ringworm.
Fungal products responsible for local inflammation.
Dermatophytes identified by colony morphology and
type of spore which they produce.
Produce 2 types of spores – Microconidia or small spores
and macroconidia or large spores – have many
compartments.
Trichophyton
Colonies are variable depending upon species.
Microconidia may be round or tear shaped.
Macroconidia relatively scanty – elongated with blunt
ends.
Infects skin, hair and nails.
T.rubrum most common species infecting humans and
causes chronic infections.
Microsporum
Colonies are cotton like velvetty or powdery with white,
yellow or brown pigmentation.
Microconidia relatively scanty.
Macroconidia are predominant – large, multicellular, boat
shaped structures, borne singly on the ends of hyphae.
Infects hair and skin but not usually nails.
Imp sps – M.canis
Epidermophyton
Colonies are waxy and folded with greenish yellow
colour.
Microconidia absent.
Macroconidia are multicellular, club shaped and typically
arranged in clusters.
Infects skin and nails but not hair.
Only one sps – E. floccosum
Clinical features
Lesions in the skin tend to be circular, dry, erythematous,
scaly and itchy.
Favus: A chronic type of ringworm in which dense crusts
(scutula) develop in the hair follicles, leading to alopecia
and scarring.
Kerion: Severe boggy lesions with marked inflammatory
reaction that sometimes develops in scalp infection due
to dermatophytes.
Nails infected by dermatophytes are deformed, friable
and discoloured, and there is accumulation of debris
under the nails. In lesions, dermatophytes appear as
hyphae and arthrospores.
 Pathogenicity:
Dermatophytes grow only on the keratinised layers of
the skin and its appendages and do not ordinarily
penetrate living tissues.
Mechanisms of pathogenesis are unclear. Fungal
products may be responsible for inciting local
inflammation.
 Hypersensitivity to fungal antigens may play a role
and may be responsible for the sterile vesicular
lesions.
Diagnosis: Diagnosis is established by clinical
features, use of Wood's lamp where applicable and
by laboratory investigations.
Laboratory investigations:
 1. Specimens: Scrapings of the skin and nail, as well as
short lengths of hair plucked from the scalp. Scrapings are
taken from the edges of ringworm lesions.
 2. Direct microscopic examination: A wet preparation of
the specimen is made by placing the scrapings in a drop
of 10-20% potassium hydroxide (KOH) on a slide, which is
then covered by a coverslip and left for 10-20 minutes (to
digest the keratin).
Additional time may be required to digest nails. Digestion
of keratin ('clearing') is helped by gently warming the
slide. The presence of branching hyaline septate (non-
pigmented) hyphae is considered positive for fungi;
spores may also be seen.
In suspected Tinea capitis, fungal elements are looked for in
plucked hair. Selection of infected hair for examination is
facilitated by exposure to UV light (Wood's lamp). Infected
hair will be fluorescent.
Two types of hair infection may be distinguished in wet
mounts: ectothrix, in which arthrospores are seen as a
sheath surrounding the hair, and endothrix, in which the
spores are inside the hair shaft.
Demonstration of the fungus in nails may be difficult and
may be possible only after clearing with KOH for a day or
two. 
3. Culture: Species identification is possible only by culture
examination. It is necessary to identify the causitive fungus.
For this, the specimen is inoculated onto Sabouraud glucose
neopeptone agar containing chloramphenicol (this antibiotic
suppresses the growth of contaminating bacteria)
Sabouraud agar containing chloramphenicol and
cycloheximide (to suppress bacteria and non-der-
matophytic filamentous fungi)
 The plates are incubated aerobically at 25-30°C for to 21
days, and are checked daily for the appearance of fungal
colonies.
 Identification of dermatophytes in the laboratory is by
examining the: Macroscopic characteristics of the fungal
colonies (rate of growth, texture, colour on the observe
and reverse).
Hypersensitivity can be demonstrated by skin testing with
the fungal antigen, trichophytin.
 Subcutaneous Mycoses
Affects subcutaneous tissues.
Different types:
1. Mycetoma
2. Chromoblastomycosis
3. Sporotrichosis
4. Rhinospodiosis
5. Subcutaneous zygomycosis.
 Mycetoma
Chronic, slowly progressive infections of subcutaneous tissues
especially of the foot and rarely of other parts.
Disease was reported from Madurai and is therefore known as
maduramycosis or madura foot.
Caused by actinomycetes and filamentous fungi.
Causative agent enters through minor trauma.
Disease usually begins as small subcutaneous swelling of the
foot, which enlarges, burrowing into the deeper tissues and
tracking to the surface as multiple sinuses discharging fluid
containing granules.
These granules or grains are microcolonies of the causative
agents and their demonstration is done in diagnosis.
Colour and consistency of granules vary between different
agents causing disease.
 Chromoblastomycosis
Watery cutaneous nodules which resembles the florets of
cauliflower. Usually confined to subcutaneous tissues of
feet and lower legs.
Most common fungi responsible : Fonsecaea sps,
Phialophora sps, Cladosporium sps.
Fungi inhabits soil and enter skin through traumatic
implantation.
Lesions show fungus as round or irregular dark brown
yeast like bodies with septae called sclerotic cells.
  Sporotrichosis
Caused by Sporothrix schenckii.
Disease occurs on skin, subcutaneous tissues and lymph
nodes, characterized by formation of nodules which
become soften and breakdown to form ulcers.
Fungus is a saprophyte which is found widely on plants,
thorns and timber.
Infection acquired through thorn pricks or other minor
injuries.
Fungi spreads from primary site through lymphatics but
does not extends beyond lymph nodes.
Most cases occurs in upper limb.
In infected tissues fungus is seen as cigar shaped yeast
cells without mycelia.
Asteroid bodies seen – Lesions composed of a central
fungal cell with eosinophilic material radiating from it.
Rhinosporidiosis
Chronic granulomatous disease characterised by
development of polyps usually confined to nose, mouth,
eyes but rarely seen on genital or other mucous
membranes.
Causative agent – Rhinosporidium seeberi.
Mode of infection not known, but believed to originate
from stagnant water or aquatic life.
 Subcutaneous zygomycosis
Caused by 2 organisms: Basidiobolus ranarum which
causes basidiobolomycosis and Conidiobolus coronatus
which causes conidiobolomycosis.
Basidiobolomycosis – painless subcutaneous nodule
which develops and enlarges to involve a whole limb or
large areas of body. Infection through insect bites.
Conidiobolomycosis – Swelling and disfigurement and
mainly affects the tissues of face.
 Systemic Mycoses
Affect any organ of the body and usually spreads via
bloodstream.
Two groups of systemic mycoses
1. Caused by true pathogens
2. Caused by opportunistic pathogens.
True pathogens are fungi able to cause infections in healthy
individuals.
Eg: Histoplasma, Blastomyces, Coccidioides.
Opportunistic occurs in severely ill or immunocompromised
individuals.
Eg: Candida, Aspergillus, Penicillium marneffei, Zygomycetes
fungi.
Cryptococcus neoformans doesnot fit in both group, they can
cause infections in healthy and immunocompromised individuals.
 Histoplasmosis
Caused by the dimorphic fungus Histoplasma capsulatum –
grows as mould in nature but as yeast in tissues.
Seen in moist soil and in birds faeces.
Infection – inhalation.
Asymptomatic, but some may develop lung infections and in
small cases spreads to other organs.
Inhaled conidia produce primary pulmonary infection that may
progress to systemic involvement of a variety of organs and
chronic lung disease.
Diagnosis
 Histology and culture
 Skin test for histoplasmin [the major hyphal antigen] is not
useful, because most people are positive in endemic area.
 Blastomycosis
Chronic infection caused by inhalation of dimorphic
fungus Blastomyces dermatitidis
Granulomatous mycotic infection that predominantly
involves lungs and skin; but can spread to other organs.
Rarely seen in India.
 Coccidioidomycosis
Infection caused by inhalation of dust containing spores
of Coccidioides immitis.
Lives in alkaline soils, hot climates and is endemic to
southwestern U.S.
Normally a benign, sub-clinical upper respiratory
infection.
In a small percentage of cases, organism disseminates
from the lungs to a variety of organs, particularly the CNS,
meninges, skin, soft tissues, and bone .
Rarely seen in India.
Opportunistic Systemic infections
Opportunistic mycoses are fungal infections that do not
normally cause disease in healthy people, but do cause
disease in people with weakened immune defenses
(immunocompromised people).
The most common infections are:
1. Candidiasis
2. Aspergillosis
3. Zygomycosis
4. Infections with Penicillium marneffei
Aspergillosis
These 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.
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 invade the membranes of
the nose, eyes, heart, and brain of people with diabetes and
malnutrition, with severe consequences.
Infections with Penicillium marneffei
Very rarely cause human infections.
But P.marneffei reported as an important pathogen in HIV
infected patients.
 Candidiasis
Candidiasis may be of 2 types:
1. superficial disease affecting skin and mucosa
2. Systemic disease.
Causative agent: Candida albicans
Widespread yeast
Normal flora of oral cavity, genitalia, large intestine or
skin of humans
Account for 80% of nosocomial fungal infections
Account for 30% of deaths from nosocomial infections
Cutaneous candidosis: may be intertriginous or paronychial.
 Intertriginous is an erythematous, scaling or moist lesion
with sharply demarcated borders, where papular lesions are
most prominent. The sites affected are those where the skin
is macerated by perspiration: the groin, perineum, axillae
and inframammary folds.
 Paronychia and onychomycosis are seen in occupations that
lead to frequent immersion of the hands in water.
Mucosal lesions :
Vaginitis, characterised by an acidic discharge and found
frequently in pregnancy.
Oral thrush, found commonly in bottle-fed infants and the
aged and debilitated. creamy- white patches appear on the
tongue or buccal mucosa; following removal, these leave a
red oozing surface.
Intestinal candidosis : is a frequent sequel to excessive
oral antibiotic therapy and may present as diarrhea not
responding to antibacterial treatment.
Bronchopulmonary candidosis is seen as a rare
complication of pre-existing pulmonary or systemic
disease.
Systemic infections such as septicemia, endocarditis and
meningitis may occur as terminal complications in severe
generalised diseases such as leukemia and in persons on
prolonged immunosuppression.
Lab Diagnosis:
This can be established by microscopy and culture.
Wet films or Gram-stained smears from lesions or
exudates show budding Gram-positive cells.
Cultures can be obtained readily on Sabourauds dextrose
agar and on ordinary bacteriological culture media.
Colonies are creamy white, smooth and with a yeasty
odour.
 Candida albicans can be differentiated from other
Candida species by growth characteristics, sugar
assimilation and fermentation tests.
A rapid method for identifying Candida albicans is based
on its ability to form germ tubes within 2 hours when
incubated in human serum at 37ᵒC( Reynolds-Braude
phenomenon)
 Cryotococcosis
Infection caused by yeast – Cryptococcus neoformans.
Cryptococcus neoformans have a polysaccharide capsule.
Found in environment- particularly in faeces of pigeons and
other birds.
Acquired by inhalation. Occasionally through skin or mucosa.
Most infections are assymptomatic.
Primary infection in lungs.
Pulmonary cryptococcosis may lead to mild pneumonitis.
Cryptococcal meningitis is most common disseminated
manifestation and Can spread to skin, bone and prostate.
Cutaneous cryptococcosis occurs as small ulcers or may form
large granulomas.
Viseceral cryptococcosis may stimulate tuberculosis and cancer.
Lumbar puncture and microscopic examination of
cerebrospinal fluid is diagnostic.
Negative stain demonstrating encapsulated budding
yeast.
Culturing and biochemical identification: Fungus
grow readily on SDA forming smooth, mucoid, cream
coloured colonies.
 Cyrptococcal antigens in CSF and serum.