Cutaneous infections and AIDS

The pathogens involved and their detection

Pathogens involved:
Viruses Fungi Bacteria Parasites Arthropod

HIV/AIDS mucocutaneous infections

Oral Hairy leukoplakia Oral Candidiasis Seborrheic dermatitis Dermatophytes Staph infections Herpes genitalis Herpes Zoster Pyoderma

H.Schoefer 1998 (%) N=330 45.0 15.8 (Candidiasis 40.3 30.6 30.3 (folliculitis) 25.8 21.2 18.2

Kumarasamy 2000 (%) N=833 2.3 45.0 ---------8.0 2.9 7.7 11.2

--------26.0 0.5

Molluscum contagiosum 1.3 Scabies ---------------

Viruses
Herpes Zoster infection - HZV Herpes labialis, anogenital Herpes - HSV Molluscum contagiosum - Pox virus (DNA) Warts - HPV

Diagnosis Clinical appearance:

Molluscum contagiosum Warts

HSV or HZV Lab diagnosis;

Viral

culture most sensitive clinical method

Culture sensitivity is higher when the herpetic vesicular lesions first appear and before they ulcerate Later ulcerative lesions may have no detectable virus.

Antigen detection less sensitive.

Serologic testing (antibodies)for detection of past infection not acute infection, Immunocompromised patients unlikely to mount a significant (fourfold or greater) rise in anti-HSV titre between acute and convalescent samples.

Herpes viruses - electron micrograph

Viruses typically appear as geometric arrays of spherical particles

Bacteria:
Staphylococcus infections Folliculitis Boils (Furuniculosis) Pyoderma

Diagnosis of Staphylococcus aureus infections

Specimen - swab in transport medium Gram stain - Gram positive cocci Culture Sheeps blood agar Identification: Gram + coagulase test +DNase

Parasite

Scabies: Sarcoptes scabei

Diagnosis:
Look for - presence of burrows or rash at site of infection - mites, eggs, mite faecal matter in Skin scraping Egg Mite

Superficial Fungal infections

Dermatophyte infections Candidiasis ?Seborrheic dermatitis Superficial manifestations of systemic infection: Histoplasmosis Cryptococcosis

Candida infections appropriate specimen

Onychomycosis Specimen: Scraping or Clipping

Interdigital Candidiasis Specimen: Scraping

Oral Candidiasis Specimen: Swab

Lab Diagnosis of Candidiasis

Microscopy
Candida species Swab Smear Gram stain /PAS

Skin scrape 10% KOH Preparation Pseudohyphae +blastospores

Lab Diagnosis of Candidiasis

Culture on Sabouraud dextrose agar +chloramphenicol. Incubate at 37C

Gram stain, germ tube test, chlamdospore production, Carbohydrate assimilation

Lab Diagnosis of Dermatophyte infections

Tinea pedis

Tinea capitis Tinea corporis

Tinea unguium

Lab Diagnosis of Dermatophyte infections Specimen Clippings or scrapings

Nail scrapings and clippings on black paper

Lab Diagnosis of Dermatophyte infections

Hair invasion

Microscopy:
10or 30% KOH preparation Skin Fungal hyphae + arthrospores

Ectothrix

Endothrix

Lab Diagnosis of Dermatophyte infections

Culture on Sabouraud dextrose agar + chloramphenicol +cycloheximide Incubate at 25C

Trichophyton rubrum

Cryptococcosis
Cryptococcus neoformans (Filobasidiella neoformans)
Varieties neoformans gattii grubii Serotypes D B,C* A* Main geographic distribution Northern Europe Tropical + sub tropical World-wide

Source: pigeon droppings (A,D), gum trees (B,C)

Cryptococcus neoformans in india ink preparation shows important identification features

Carbohydrate capsule Cell wall Cell contents

AIDS associated cryptococcal infection

May present with severe progressive pneumonia + acute dyspnoea Disseminated cutaneous lesions pustular + papular, nodular, ulcerated lesions Meningitis

Specimens to diagnose cryptococcal infection

Sputum Bronchoalveolar lavage Transbronchial biopsy Blood culture Biopsy C. neoformans is a Urine Class 2 Pathogen

Detection methods
Microscopy 10%KOH + india ink preparations Culture Chocolate agar Sabouraud dextrose agar chloramphenicol Niger seed agar Serology to detect Ab and capsular antigen

Cryptococcus neoformans in india ink

Culture characteristics

Latex particle agglutination test

Latex particles coated with Ab to carbohydrate capsule Agglutinates in presence of Antibody Specimens: Serum, CSF, urine, BAL, aspirate Sensitivity 75-100% Specificity 90-100% False positives: Rheumatoid factor Klebsiella Syneresis fluid Some soaps, disinfectants

Summary C.neoformans lab diagnosis - ve

India ink +ve +ve

Culture + antigen test

Culture

Histoplasmosis
Histoplasma capsulatum (Ajellomyces capsulatus) Dimorphic fungus 37C Yeast phase Infection 25C Filamentous phase + Macroconidia Microconidia

Histoplasma capsulatum

Clinical Features
1. Primary lung infection Sub-acute/acute (caves disease) Flu-like illness usually self-limiting Acute pneumonia 2. Chronic cavities 3. Disseminated from lung RES Wt. Loss Fever Liver,spleen Ulcers mouth Skin lesions

Severe acute pneumonia

Specimens
Sputum BAL Lymph nodes Liver biopsy Blood Bone marrow Urine Biopsy from skin lesions
H.capsulatum is a Class 3 pathogen

Tests available
Microscopy Culture Serology PCR

H.capsulatum - PAS stain

Small intracellular yeast cells

H. capsulatum

Cultures

H. capsulatum

Yeast phase - 37C

H.capsulatum

Macro and micro-conidia - 25C

Comparison of sensitivities of different diagnostic test for disseminated histoplasmosis in patients with AIDS

J.Wheat Clin.Microbiol Rev 1995

Diagnostic tests are available in Zimbabwe? Microscopy Gram. India ink, KOH Culture Cryptococcal antigen test