Opportunistic

Mycoses
Zygomycosis & Aspergillosis

Mohamed Ansar CK
MSc MLT Microbiology
Zygomycosis
• Zygomycosis represents group of life-threatening infections caused by
aseptate fungi belonging to the phylum Zygomycota.

• Agents of zygomycosis fall into two orders:

1. Order Mucorales
2. Order entomophthorales
1. Order mucorales (causes mucormycosis)
• Rhizopus(R. oryzae and R. microsporus)
• Mucor racemosus
• Rhizomucor pusillus
• Absidia corymbifera
• Apophysomyces elegans

2. Order entomophthorales (causes entomophthoromycosis)

• Basidiobolus ranarum
• Conidiobolus coronatus
Mucormycosis - Pathogenesis
• Spores of fungi causing mucormycosis are found ubiquitously in the
environment .
• Transmission occurs via inhalation, inoculation or rarely ingestion of
spores.
• Spores develop into mycelial form containing wide aseptate hyphae
which are angioinvasive in nature resulting in spread of infection.
Predisposing factors:
• Agents of mucormycosis require iron as growth factor. Hence
conditions with increased iron load are at higher risk of developing
invasive mucormycosis.

Diabetic ketoacidosis (OKA)

End stage renal disease.
Patients taking iron therapy or deferoxamine (iron chelator).
Defects in phagocytic functions (e.g. neutropenia or steroid therapy).
Clinical Manifestations
• Mucormycosis has six types of clinical presentations.
1. Rhinocerebral mucormycosis:
• It occurs commonly in patients with diabetic ketoacidosis.
• It is the most common form; starts as eye and facial pain, may
progress to cause orbital cellulitis, proptosis and vision loss.
2. Pulmonary mucormycosis :
• It is the second most common form,
• It occurs in patients with leukemia.
3. Cutaneous mucormycosis.
4. Gastrointestinal mucormycosis :
• It is seen commonly in premature neonates.
5. Disseminated mucormycosis:
• Brain is the most common site of dissemination, but can affect any
organ.
6. Miscellaneous forms:
• Any body site may be randomly affected such as bones, trachea and
kidneys, etc.
laboratory Diagnosis
• Histopathological staining of tissue biopsies shows broad aseptate
hyaline hyphae with wide angle branching ·
• Culture on SDA at 25°C: Reveals characteristic white cottony woolly
colonies with tube filling growth (hence called lid lifters). In some
species, e.g. Rhizopus the colonies become brown black later, due to
sporulation giving rise to salt and pepper appearance .
• Microscopic appearance: LPCB mount of the colonies reveals broad
aseptate hyaline hyphae, from which sporangiophore arises and then
ending at sporangium which contains numerous sporangiospores.
• Rhizoid: Some species bear a unique root Like growth arising from
hyphae called rhizoid which provides initial clue for identification of
the fungus.
• Species can be differentiated depending on the position of the rhizoid
with respect to sporangiophore .
 Rhizopus bears nodal rhizoid
 Absidia bears internodal rhizoid
 Mucor - rhizoid is absent.
Treatment
• Amphotericin B deoxycholate remains the drug of choice for all forms
of mucormycosis except the mild localized skin lesions in
immunocompetent patients.
• which can be removed surgically.
Entomophthoromycosis
• This includes the subcutaneous lesions produced by members of
order Entomophthorales, i.e. Conidiobolus and Basidiobolus; the
latter is also associated with visceral involvement.
Aspergillosis
• Aspergillosis refers to the invasive and allergic diseases caused by a
hyaline mold named Aspergillus.
• There are nearly 35 pathogenic and allergenic species of Aspergillus,
important ones being- A. fumigatus, A. flavus and A. niger.
Pathogenesis
• Aspergillus species are widely distributed in nature, most commonly
growing on decaying plants, producing chains of conidia.
• Transmission occurs by inhalation of airborne conidia.
Risk factors
• Risk factors for invasive aspergillosis are:
 Glucocorticoid use (the most important risk factor)
 Profound neutropenia
 Neutrophil dysfunction
 Underlying pneumonia, chronic obstructive pulmonary disease,
tuberculosis or sarcoidosis
 Anti-tumor necrosis factor therapy.
Clinical Manifestations
• The incubation period varies from 2 to 90 days.
• Depending up on the site of involvement, Aspergillus produces
various clinical manifestations such as:
Pulmonary aspergillosis
Other forms of aspergillosis
• Pulmonary aspergillosis:
• It is the most common form of aspergillosis
• It includes various manifestations such as:
 Allergic bronchopulmonary aspergillosis (ABPA)
 Severe bronchial asthma
 Extrinsic allergic alveolitis
 Aspergilloma (fungal ball)
 Chronic cavitary pulmonary aspergillosis
• Other forms of aspergillosis include:
 Invasive sinusitis (acute and chronic from)
 Cardiac aspergillosis
 Cerebral aspergillosis
 Ocular aspergillosis
 Ear infection
 Cutaneous aspergillosis
 Nail bed infection
 Mycotoxicosis
• A. fumigatus accounts for most of the cases of acute pulmonary and
allergic aspergillosis.
• A. flavus is more common in hospitals and causes more sinus, skin
and ocular infections than A. fumigatus.
• A. niger can cause invasive infection but more commonly colonizes
the respiratory tract and causes otitis externa.
Laboratory Diagnosis
• Specimens such as sputum and tissue biopsies may be collected.

• Direct Examination KOH (10%) mount or histopathological staining

of specimens reveals characteristic narrow septate hyaline hyphae
with acute angle branching;
Culture
• Specimens are inoculated onto SDA and incubated al 25°C.
• Species identification is done based on macroscopic and microscopic
(LPCB mount) appearance of the colonies.
• Colonies consist of hyaline septate hyphae from which conidiophores
arise which end at vesicles.
• Vesicles are either tubular or globular in shape.
• From the vesicle, finger-Like projections of conidia producing cells
arise called phialides or sterigmata.
• Phialides are arranged either in one or two rows, the first row is called
metulae.
• Conidia arise from the vesicles either on their entire surface or only
on the upper half.
Antigen Detection
• ELISA detecting Aspergillus specific galactomannan antigen in
patient's sera or urine is useful for establishing early diagnosis.
Antibody Detection
• Detection of serum antibodies is very useful for chronic invasive
aspergillosis and aspergilloma, where the culture is usually negative.
• Titer falls rapidly following clinical improvement.
• In allergic syndromes such as ABPA and severe asthma, specific serum
IgE levels are elevated.
Detection of Metabolites
• Detection of alpha 1-3 glucan (by G test) or mannitol (by gas liquid
chromatography) is useful alternative for establishing the diagnosis,
particularly when the culture is negative.

Skin Test
• Positive skin test to various antigen extracts of Aspergillus indicates
hypersensitivity response and is usually positive for various allergic
type of aspergillosis.
Treatment
• For invasive aspergillosis- voriconazole is the drug of choice.
• For ABPA - itraconazole is the drug of choice.
• For single aspergilloma- surgery is indicated
• For chronic pulmonary aspergillosis- itraconazole or voriconazole is
the drug of choice.
QUESTIONS
• Zygomycosis/ mucormycosis is usually caused by which of the
following fungi?
• Select all the correct answers:
a) Plasmodium spp
b) Rhizopus spp
c) Mucor spp
d) Histoplasma spp
e) both b&c

Ans : e
• Black fungal spores are found in the environment and pose a significant
health threat as they are identified as a lethal fungal infection, especially
in COVID-19 patients, particularly those with diabetes or those who
have spent extended periods in intensive care units.
• Identify the potential fungal infection documented during the
second surge of COVID-19 pandemic in India.
• a) Candidiasis
b) Aspergillosis
c) Mucormycosis
d) Penicilliosis

• Ans : C
• 'Aflatoxin' is usually present in moldy foods such as nuts and corn
which can be poisonous for animals as well as humans.
• Name the possible pathogen which produces this toxin?
a) Aspergillus flavus
b) Clostridium botulinum
c) Bacillus anthracis
d) Aspergillus niger

• Ans : A
• A 62 year old woman is diagnosed with rhinocerebral mucormycosis.
Name the possible fungus responsible for the infection?

a) Pneumocystis jeroveci
b) Rhizopus oryzae
c) Coccidioides immitis
d) Aspergillus flavus

Ans : B
• Which of the following are Not the common characteristics of A.
fumigatus and A. flavus?
a. Both of the organisms secrete aflatoxins
b. Present in the environment
c. A. flavus is also a common plant pathogen
d. Both fungi are types of molds

• Ans : A