MEDICAL MYCOLOGY

CODE: MLC 411

FUNGAL INFECTIONS
 SUPERFICIAL MYCOSES
• These are superficial cosmetic fungal infections of the hair,
dead skin and lipids secretions. Fungi which cause this kind
of infection are living as saprophytes.
• They don’t provoke any immune response from the host.
• No living tissue is invaded.
• Essentially no pathological changes are elicited.
• These infections are often so harmless that patients are often
unaware of their condition.

Four infections have been described:

o Malassezia infections
o Tinea nigra
o Piedra - Black piedra
- White piedra
1. Malassezia infections
• The fungal genus Malassezia comprises lipid-dependent
and lipophilic yeast species that are part of the normal skin
microbiota. The 14 species are classified in class
Malasseziomycetes of Basidiomycota.

• The density of skin colonization with Malassezia depends

on age, body site, and comorbid skin conditions, as well as
the geographic area.

• Malassezia are found in the highest density in sebaceous

areas such as the scalp, face, and upper trunk. It is seen
in higher densities in young adults, who tend to have
relatively oily skin.
Factors responsible for overgrowth of Malassezia

• Geographical: It is seen more commonly in the warm and

humid tropical and subtropical climates which is more suited
for its growth. Reports show the growth of M. globosa tends
to increase in summer when temperatures are high and due
to sweat.

• Age: The age group that commonly gets affected with

pityriasis versicolor (PV) is that from 20 to 40 years.

• Hormonal factors: Patients who are on corticosteroid

therapy, malnutrition and increased plasma cortisol levels.
Clinical Manifestations
a) Pityriasis versicolor:
This is a chronic, superficial fungal disease of the skin
characterised by well-demarcated white, pink, fawn, or
brownish lesions, often coalescing, and covered with thin
furfuraceous scales.

Lesions occur on the trunk, shoulders and arms, rarely on

the neck and face, and fluoresce a pale greenish color
under Wood's ultra-violet light. Young adults are affected
most often, but the disease may occur in childhood and old
age.

Aetiology: The main species isolated in pityriasis versicolor are

Malassezia furfur, Malassezia globosa, Malassezia sympodialis.
Tinea versicolor
b) Pityriasis folliculitis:
Characterized by follicular papules and pustules localized
to the back, chest and upper arms, sometimes the neck,
and more seldom the face. These are itchy and often
appear after sun exposure. Scrapings or biopsy specimens
show numerous yeasts occluding the mouths of the
infected follicules.
c) Seborrhoeic dermatitis and dandruff
Current evidence suggests Malassezia, combined with
multifactorial host factors is also the direct cause of
seborrhoeic dermatitis, with dandruff being the mildest
manifestation.

Host factors include genetic predisposition, changes in quantity

and composition of sebum (increase in wax esters and a shift
from triglycerides to shorter fatty acid chains), increase in
alkalinity of skin (due to eccrine sweating) and external local
factors such as occlusion.

Patients with neurological diseases such as Parkinson's

disease and those with AIDS are commonly affected.
Clinical manifestations are characterized by erythema and
scaling in areas with a rich supply of sebaceous glands i.e the
scalp, face, eyebrows, ears and upper trunk. Lesions are red
and covered with greasy scales and itching is common in the
scalp.

The clinical features are typical and skin scrapings for a

laboratory diagnosis are unnecessary.

d) Fungemia
Malassezia has also been reported as causing catheter
acquired fungaemia in neonate and adult patients undergoing
lipid replacement therapy. Such patients may also develop
small embolic lesions in the lungs or other organs.
In literature, only two species namely M. furfur and M.
pachydermatis are proven agents in systemic disease.
Pathogenesis in Malassezia infections
Malassezia is a lipid-dependent, dimorphic fungus that is a
component of normal skin flora. Transformation of Malassezia
from yeast cells to a pathogenic mycelial form is associated
with the development of clinical disease.

External factors suspected of contributing to this conversion

include exposure to hot and humid weather, hyperhidrosis, and
the use of topical skin oils. Tinea versicolor is not related to
poor hygiene.
Laboratory Diagnosis:
1. Clinical Material:
Skin scrapings from patients with superficial lesions, blood
and indwelling catheter tips from patients with suspected
fungemia.

2. Direct Microscopy:
Skin scrapings taken from patients with Pityriasis
versicolor stain rapidly when mounted in 10% KOH,
glycerol and Parker ink solution and show characteristic
clusters of thick-walled round, budding yeast-like cells and
short angular hyphal forms up to 8um in diameter (ave.
4um diam.). These microscopic features are diagnostic for
Malassezia furfur and culture preparations are usually not
necessary.
Malassezia furfur microscopic appearance
3. Culture:
Culture is only necessary in cases of suspected fungemia. M.
furfur is a lipophilic yeast, therefore in vitro growth must be
stimulated by natural oils or other fatty substances. The most
common method used is to overlay Sabouraud's dextrose agar
containing cycloheximide (actidione) with olive oil or alternatively to
use a more specialized media like Dixon's agar which contains
glycerol mono-oleate (a suitable substrate for growth).

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

5. Identification:
Microscopic evidence of unipolar, broad base budding yeast
cells and special lipid requirements for growth in culture are usually
diagnostic. Their cells contain a collarette at the end, giving
them a unique bottle-necked shape.
Management:
The most appropriate antifungal treatment for pityriasis
versicolor is to use a topical imidazole in a solution or lathering
preparation. Ketoconazole shampoo has proven to be very
effective.

Alternative treatments include zinc pyrithione shampoo or

selenium sulfide lotion applied daily for 10-14 days or the use
of propylene glycol 50% in water twice daily for 14 days.

In severe cases with extensive lesions, or in cases with lesions

resistant to topical treatment or in cases of frequent relapse
oral therapy with itraconazole [200 mg/day for 5-7 days] is
usually effective.
Mycologically, yeast cells may still be seen in skin scrapings
for up to 30 days following treatment, thus patients should be
monitored on clinical grounds.

Patients also need to be warned that it may take many

months for their skin pigmentation to return to normal, even
after the infection has been successfully treated. Relapse is
a regular occurrence and prophylactic treatment with a
topical agent once or twice a week is often necessary to
avoid recurrence.
2. Tinea nigra
A superficial fungal infection of skin characterized by brown
to black macules which usually occur on the palmar
aspects of hands and occasionally the plantar and other
surfaces of the skin. World-wide distribution, but more
common in tropical regions of Central and South America,
Africa, South-East Asia and Australia.

Aetiology agent: Hortaea werneckii

• Hortaea werneckii is the only species classified in the
genus Hortaea. It is a dematiaceous yeast that inhabits
the soil. It is halophilic and has also been isolated from
saltwater fish. Hortaea werneckii is an occasional cause
of human infections.
Pathogenicity and Clinical Significance
The infection is mostly acquired via direct inoculation of the
fungus onto the skin due to contact with soil, wood, and
decaying vegetation.

The lesions of tinea nigra are usually located on palms but

may occasionally involve other parts of the body, such as soles
of the feet. These lesions are typically brown to black, flat, not
scaly, non-inflammatory and with irregular contours. They
resemble and must be differentiated from those of malignant
melanoma and junctional nevus. Familial spread of infection
has also been reported.

While most of the patients do not have any symptoms related

to these lesions, some may have itching.
Laboratory Diagnosis:
1. Clinical Material:
Skin scrapings.
2. Direct Microscopy:
Skin scrapings should be examined using 10% KOH and Parker
ink or calcofluor white mounts.
3. Culture:
Clinical specimens should be inoculated onto primary isolation
media, like Sabouraud's dextrose agar
4. Serology:
Not required for diagnosis.
5. Identification:
Characteristic clinical, microscopic and culture features.
Macroscopic Features
• The colonies of Hortaea werneckii grow slowly and mature
within 21 days. From the front, they are initially pale in color,
moist, shiny, and yeast-like.

• In time, these colonies become velvety, olive black, and are

covered with a thin layer of mycelium. From the reverse, the
color is black.

Microscopic Features
• Septate hyphae, (bicellular) yeast-like conidia, and
chlamydospores are observed. The yeast-like conidia (2-5 x
5-10 µm) are the initial structures observed in the early
phase of the colony development. These cells have a round
end and a tapered and elongated annelidic neck part.
• They are hyaline initially and become pale olivaceous in
time. They function as annellides and produce new
annelloconidia.

• Annelloconidia are 1 to 2 celled and the internal cell wall or

septum is usually deeply pigmented. They may gradually be
converted to chlamydospore-like cells. Septate, thick-walled,
and brown hyphae (up to 6 µm wide) are formed as the
colony ages. The annelloconidia are formed at intercalary
and lateral annellidic points along the hyphae

Management
• Usually, topical treatment with Whitfield's ointment (benzoic
acid compound) or an imidazole agent twice a day for 3-4
weeks is effective.
Hortaea werneckii -Pigmented, septate hyphae with lateral
annellides.
The broadly ellipsoidal, two-celled annelloconidia. Mature conidia have the
brown pigmentation while younger cells stain more intensely with the
Lactophenol Cotton Blue (LPCB). One end of the annelloconidia usually
stains darker indicating the location of the annellated ring or the point where it
was previously attached to the conidogenous annellide.
3. White piedra
• White piedra is a superficial cosmetic fungal infection of the
hair shaft caused by Trichosporon. It is also known as tinea
nodosa, trichosporonosis nodosa, and trichomycosis
nodularis. Infected hairs develop soft greyish-white nodules
along the shaft.

• White piedra is found worldwide, but is most common in

tropical or subtropical regions. Found in soil and on plant
material as well as humans and animals. It may be present
as normal flora on the skin, on nails and in the mouth of
humans.

• They are regularly associated with the soft nodules of white

piedra, and have been involved in a variety of opportunistic
infections in the immunosuppressed patient.
• Aetiology: Trichosporon spp. Six species are of clinical
significance: T. asahii, T. asteroides, T. cutaneum, T. inkin,
T. mucoides and T. ovoides.

Clinical Manifestations
• Infections are usually localised to the axilla or scalp but
may also be seen on facial hairs and sometimes pubic
hair. White piedra is common in young adults. The
presence of irregular, soft, white or light brown nodules,
1.0-1.5 mm in length, firmly adhering to the hairs is
characteristic of white piedra.

Laboratory Diagnosis
1. Clinical Material
Epilated hairs with white soft nodules present on the shaft.
2. Direct Microscopy
Hairs should be examined using 10% KOH and Parker ink or
calcofluor white mounts. Look for irregular, soft, white or light
brown nodules, 1.0-1.5 mm in length, firmly adhering to the
hairs.

3. Culture
Hair fragments should be implanted onto primary isolation
media, like Sabouraud's dextrose agar. Colonies of
Trichosporon spp. are white or yellowish to deep cream
colored, smooth, wrinkled, velvety, dull colonies with a
mycelial fringe.
4. Serology
Not required for diagnosis.

5. Identification
Characteristic clinical, microscopic and culture features.

Management
Shaving the hairs is the simplest method of treatment.
Topical application of an imidazole agent may be used to
prevent reinfection.
4. Black piedra
• Black piedra is a superficial fungal infection of the hair shaft
characterized by formation of hard black nodules on the shafts of
the scalp, beard, moustache and pubic hair. It is common in
Central and South America and South-East Asia. The source of
the infection is usually in soils, poor hygiene, long hair,
cultural use of veils and the application of plant oils to wet hair
favours the growth of the infection.

Aetiology: Piedra hortae

Pathogenicity and Clinical Significance

This disease is characterized by formation of brown to black nodules
that are very firmly attached to the hair shaft. The nodules are
composed of ascostromata. Scalp hair is the most frequently infected
area. Most of the cases are asymptomatic and may remain so for
years. However, breaks due to weakness of the hair shaft may occur
eventually in severe cases which can lead to hair loss and baldness.
Laboratory Diagnosis
1. Clinical Material
Epilated hairs with hard black nodules present on the shaft.

2. Direct Microscopy
Hairs should be examined using 10% KOH and Parker ink or
calcofluor white. Look for darkly pigmented nodules that may
partially or completely surround the hair shaft. Nodules are
made up of a mass of pigmented stroma-like ascostromata
containing asci.

3. Culture
Hair fragments should be implanted onto primary isolation
media, like Sabouraud's dextrose agar at 250C. Colonies of
Piedra hortae are dark, brown-black and take about 2-3
weeks to appear.
4. Serology
Not required for diagnosis.

5. Identification:
Characteristic clinical, microscopic and culture features.

Macroscopic Features
• Colonies of Piedraia hortae are slow growing, small, folded,
velvety and dark brown to black in color. They may remain
glabrous or covered with short aerial hyphae. Piedraia
hortae may produce a reddish brown diffusable pigment.
From the reverse, the colony is black in color.
Microscopic Features
• Septate hyphae, ascostromata, asci, and ascospores are
visualized.
• Hyphae are darkly pigmented and contain numerous
intercalary chlamydoconidium-like cells.
• Ascostromata are sub-globose to irregular in shape and
black in color. Each usually contains a single ascus.
• Asci are ellipsoid, solitary or in clusters and contain 8
ascospores. Ascus walls dissolve readily.
• Ascospores are hyaline to darkly pigmented. They are
one-celled, fusoid, curved, and taper towards both ends
to form the typical whip-like appendages
Management:
The usual treatment is to shave or cut the hairs short.

Topical antifungal agents in the form of cream or

shampoos are effective; 2% ketoconazole or 2%
miconazole shampoo applied once a week for three weeks
is effective. Non-surfactant based leave-on lotions are also
an option. Ciclopirox (0.77%) lotion or 1 to 1.5% shampoo
have also been used successfully.

Oral antifungals such as terbinafine and itraconazole have

been used successfully in cases resistant to topical
medications. Oral terbinafine 250 mg once daily for 6
weeks was also found to be effective in the treatment of
black piedra.