Microbial World

 Prokaryotes:
1. Bacteria
2. Archae
 Eukaryotes
1. Algae
2. Fungi
3. Protozoa
4. Parasites
 Fungi
 Features:
 Cell wall: Chitin
 Cell membrane:
 Ergosterol
 Zymosterol
 Aerobic/ facultatively anaerobic
 Mostly microscopic
 Moisture essential for growth
 Types of Fungi
 Yeasts:
 Single celled
 Reproduction: Budding
 Molds:
 Long filaments
(hyphae)
 Form mycelium
 Septate/ Non septate
 Dimorphic
 Importance
 Biologic recycling of organic matter
 Preparation of foods:
 Beer
 Cheese
 Bread
 Wine
 Mushrooms
 Economic impact: Plant diseases
 Source of biologically active compounds:
•Hallucinogens •Carcinogens
•Adrenergic alkaloids •Antibiotics
•Vitamins •Immunosuppressive agents
•Mutagens •Potential anticancer substances
 Groups
1. Zygomycetes: 3. Ascomycetes:
 Bread moulds  Aspergillus
(Rhizopus)  Histoplasma
 Food spoilage  Coccidioides
organisms  Candida
 Rhizomucor  Pneumocystis
 Sporothrix
 Dermatophytes

2. Basidiomycetes: 4. Deuteromycetes
 Common mushrooms (Fungi Imperfectii):
 Cryptococcus  Medically &
 Malassezia economically imp fungi
 Penicillin producing
Types of Fungal
Diseases

1. Fungal allergies
2. Mycotoxicoses
3. Mycoses
 Fungal Allergies
 Strong hypersensitivity reactions against:
 Fungal spores
 Fungal components
 Do not require:
 Growth
 Viability
 Depending upon the site of deposition of allergens:
 Rhinitis
 Sinusitis
 Bronchial asthma
 Alveolitis
 Generalized pneumonitis
Mycotoxicoses
 Mycetismus
 Mycotoxins:
 Amatoxins
 Phallotoxins
 Aflatoxin
 Ochratoxin
 Sporidesmin
 Zearalenone
 Sterigmatocystin
 Target organ: Liver
 Mycoses
 Actual growth of a fungus on a human or
animal host
 Establishment of mycoses depends upon:
 Host defenses
 Size of innoculum
 Route of exposure
 Virulence of the fungus
 Clinical Classification of
Mycotic Infections

 Superficial:  Subcutaneous:
 Pityriasis versicolor  Rhinosporidiosis
 Tinea nigra  Rhinoentomophthoromycosis

 Cutaneous:  Systemic:
 Candidiasis  Histoplasmosis
 Dermatophytosis  Paracoccidioidomycosis
 Candidiasis
 Cryptococcosis
 Aspergillosis
 Mucormycosis
 Specimen Collection,
Handling & Transport
 Sample Collection:
 Primary criterion for diagnosis of mycotic infections
 Transportation & processing done ASAP
 Tissue from site of active disease- ideal
 Most common specimens:
 Respiratory secretions
 Hair
 Skin
 Nail
 Tissue
 Blood
 Bone marrow
 CSF
 Respiratory Specimen

 Viscous material (Tracheal aspirate):

 Cotton Swab
 Specimen digested with trypsin & concentrated
 Sputum:
 Deep cough early in the morning
 Nebulizer to induce sputum
 Collected into a sterile screw top container
 Media:
 Non selective
 Media with antibiotics
 KOH preparation
 Mucin Collection

 Nasal decongestant spray

 Flush with 20ml N/S
 Forceful exhalation through nose
 Return collected in sterile pan
 Skin:
 70% isopropyl alcohol before sampling
 Scraped from outer edge of a surface lesion
 Blood:
 Transport medium required
 Exudates/ Pus:
 Sterile sealed container
 Diagnosis

 Direct microscopic examination

 Culture
 Serology
 Direct Microscopic
Examination
 Wet preparations:
 KOH mount
 India Ink
 Calcofluor white

 Histologic stains:
 Periodic- Acid Schiff (PAS ) stain
 Grocott- Gomori methenamine silver nitrate (GMS) stain
 H&E stain
 Giemsa stain
 Masson- Fontana stain
 Culture
 Culture Media:
 Saboraud’s Dextrose Agar
 SDA with antibiotics
 Brain Heart Infusion (BHI) agar enriched with blood
& antibiotics
 Incubation:
 Temp: 25-30°C (37°C for dimorphic fungi)
 Duration: 4-6 weeks
 Candida
 Candida: Part of normal flora of skin, mucus membranes & GIT
 Candidiasis: Most common systemic mycoses
 Pathogenic strains:
 C. albicans
 C. tropicalis
 C. glabrata
 C. krusei
 Clinical Classification of Candidiasis:
 Cutaneous & Mucosal candidiasis:
 Thrush
 Stomatitis
 Esophagitis
 Systemic Candidiasis
 Esophagitis
 Chronic Mucocutaneous Candidiasis
 Predisposing factors:
 Cutaneous & mucosal candidiasis:
 Physiologic:
 Pregnancy
 Old age
 Infancy
 Traumatic
 Hematologic: AIDS
 DM
 Iatrogenic:
 Antibiotics
 Steroids
 Systemic Candidiasis:
 Immunosuppression
 Surgery
 Steroids
 Malignancies
 Cytoxic drugs
 Morphology
 Dimorphism:
 Yeast cells
 True hyphae
 Pseudohyphae
 Germ tubes
 Microscopy:
 Spherical/ ellipsoidal budding yeasts
 Size: 3-6 μm
 Cornmeal agar: Chlamydiospores
 Culture:
 Species cannot be differenciated
 Within 24-48hrs
 Raised
 Cream coloured
 Opaque
 1-2mm
 Hyphae penetrating the agar medium
 Aspergillus
 Ubiquitous molds
 Numerous species
 Approx 20 cause human infection
 Pathogenic species:
 A. fumigatus
 A. flavus: Nose & PNS
 A. niger: systemic disease in immunocompromised

 Clinical diseases:
 Otomycosis
 Fungal rhinosinusitis
 Morphology
 Microscopy:
 Conidiophores
 Expand into large vesicles at the end
 Covered with phialides
 Culture:
 Powdery
 Pigmented
 A. fumigatus: Gray, green
 A. flavus: Yellow- green
 A. niger: Black
Aspergillus niger & flavus
 Mucormycosis
 Phycomycosis, zygomycosis
 Molds
 Class: Zygomycetes
 Order: Mucorales
 Fungi:
 Ubiquitous
 Thermotolerant
 Saprophytes
 At risk patients:
 Acidosis
 Leukemia
 Immunocompromise
 Etiologic agents:
 Rhizopus oryzae
 R. rhizopodiformis
 Absidia corymbifera
 R. pusillus
 Rhizomucor spss.
 Mucor spss.
 Clinical manifestations:
 Rhinocerebral mucormycosis
 Thoracic mucormycosis
 Cutaneous infections
 Morphology
 Microscopy:
 Broad
 Sparsely septate hyphae (10μm)
 Twisted & ribbonlike
 Branching at rt. angles
 Culture:
 Rapid growth
 Abundant, cottony aerial mycelia
 Paracoccidioidomycosis
 C/A: Paracoccidioides brasiliensis
 Chronic granulomatous disease:
 Mucous membranes
 Skin
 Respiratory system

 Most cases from Brazil

 Invade mucous memb of mouth→ teeth fall out
 White plaques in buccal mucosa
 Histologically: Captain’s wheel
 Cryptococcosis
 C. neoformans
 Distinctive yeast
 Diseases:
 Meningitis
 Pulmonary disease
 Found in pigeon & chicken droppings
 Diagnosis:
 India ink test
 Latex agglutination test for cryptococcal antigen
India Ink staining of CSF
 Polyenes
 Azoles
 Imidazoles
 Triazoles
 Echinocandins
 Allylamines
 Flucytosine
 Griseofulvin
 Polyenes
 Eg.:
 Amphotericin B
 Nystatin
 MOA:
 Bind to sterols of eukaryotic cell memb→ leakage of cell
contents
 Amphotericin B:
 Active against all fungi
 Leishmania
 Given parenterally
 Poor CSF penetration
 ADRs:
 Fever
 Rigor
 Nephrotoxicity
 Hyperkalemia
 Headache
 Azoles
 Inhibit cyt p450 14α-demethylase →inhibit
fungal cell wall synthesis
 Active against:
 Candida
 Dermatophytes
 Aspergillus
 Imidazole:
 Topical: Clotrimazole
 Systemic: Ketoconazole
 Triazoles:
 Fluconazole: Inactive against invasive moulds
 Itraconazole: Inactive against zygomycetes
 Echinocandins
 Capsofungin
 Inhibit cell wall glucan synthesis →cell wall
lysis
 Active against:
 Candida
 Aspergillus
 Inactive against:
 Other moulds
 Cryptococcus
 Allylamines

 Terbinafine
 Reduce ergosterol synthesis
 Active against dermatophytes
 Uses:
 Skin dermatophyte infection
 Nail dermatophyte infection
 Flucytoscine:
 Incorporates into fungal mRNA instead of uracil →
disruption to protein & DNA synthesis
 Activity:
 Cryptococcus
 Candida
 Resistance: Common
 ADRs:
 Bone marrow toxicity
 Hepatotoxicity

 Griseofulvin:
 MOA unclear
 Use: Nail infections
Mycotic Diseases of the
External Ear

 Otomycosis
 Dermatophytosis
 Chromoblastomycosis
 Sporotrichosis
 Otomycosis

 Defn: Superficial, diffuse, fungal infection of

the ear canal
 Predisposing condition usually present
 Aetiological agents:
 Aspergillus: (Tropical & Subtropical regions)
 Niger
 Flavus
 Fumigatus
 Candida: (Temperate regions)
 Albicans
 Parapsilosis
 Tropicalis
 Penicillium
 Rhizopus
 Mixed
 Epidemiology
 Environment:
 Warm
 Humid
 Children less commonly affected
 Not contagious
 Predisposing factors:
 Seborrhic dermatitis
 Psoriasis
 Prolonged use of:
 Topical antibiotics
 Topical corticosteroids
Clinical Manifestations
 C/C:
 Aural fullness
 Pruritis
 Discharge
 Otoscopy:
 Debris
 Erythematous/ oedematous ear canal
 A. niger: (Blotting paper)
 Mat of fungus
 Black sporing heads
 Chronic infection:
 Eczematoid change
 Lichenification
 Diagnosis

 Clinical
 Microscopic
examination
 Culture
 Management

 Removal of debris
 Cleaning
 Antifungal agents:
 Local application
 Gauze packs
 Mercurochrome & boric acid
Mycotic diseases of the
nose and nasal passages
 Entomophthoramycosis
 Rhinosporidiosis
Entomophthoramycosis

 Definition:
Chronic localised subcutaneous fungal infection that
originates from nasal mucosa and spreads painlessly
to the adjacent subcutaneous tissue of the face
 Rare
 Seen in healthy individuals
 Severe facial disfigurement
 C/A: Conidiobolus coronatus
 Management

 Oral antifungal drugs

 Treatment continued 1mnth after lesions
have disappeared
 Surgical resection:
 Hastens spread of infection
 Rhinosporidiosis
 Definition:
 Uncommon granulomatous infection that affects nasal
mucosa, ocular conjunctiva & other mucosa
 Etiology:
 Rhinosporidium seeberi
 Fungi: controversial
 18S small subunit ribosomal DNA: Mesomycetozoa

 In tissues:
 Thick walled sporangium like structures
 Endospores
 Epidemiology
 Geographical distribution:
 South India
 Sri Lanka
 East Africa
 Central & South America
 Natural habitat:
 Stagnant pools of fresh water
 M>F
 Age:15-40yrs
 Clinical Features
 Nasal obstruction
 Rhinoscopy:
 Pink/ Red/ Purple
 Papular/ Nodular
 Smooth surfaced
 Papillomatous/ Proliferative
 Diagnosis:
 HPE:
 Large sporangia filled with spores
 Thick wall
 Operculum
Rhinosporidiosis
 Management:
 Surgical excision
 Cauterization
 Outcomes & Complications:
 Recurrence
 Mycotic Diseases of
Paranasal Sinuses
Classification (Based on HPE & C/F):
1. Invasive Sinusitis:
1. Active Invasive
2. Chronic Invasive
3. Chronic granulomatous invasive or paranasal
granuloma
2. Noninvasive Sinusitis
3. Allergic Fungal Sinusitis
Invasive Fungal Sinusitis

 Diagnosis:
 Evidence of sinusitis:
 Radiographic
 Nasal endoscopy
 Fungal hyphae:
 HPE
 Etiological Agents

 Acute fulminant:  Chronic invasive:

 Rhizopus spss.  Alternaria spss.
 R. arrhizus  Aspergillus spss.
 Absidia spss.  Bipolaris spss.
 Rhizomucor spss.  Curvularia spss.
 Aspergillus spss.  Exserohilum spss.
 A. flavus
 A. fumigatus
 Fusarium spss.  Granulomatous
 S. apiospermum invasive:
 A. flavus
 Epidemiology
 Worldwide
 Adults
 Immunocompromised children
 Risk factors:
 Prolonged neutropenia
 Metabolic acidosis
 Hematological malignancies
 Haematopoetic stem cell transplant recipients
 Diabetics
 Corticosteroid therapy
 Deferoxamine treatment
 HIV infection
Clinical Features
 Acute Invasive:
 Immunocompromised
 Unilateral facial swelling
 Unilateral headache
 Nasal obstruction/ pain
 Serosanguinous nasal discharge
 Necrotic black lesions on:
 Hard palate
 Nasal turbinate
 Periorbital/ perinasal swelling
 Destruction of facial tissue
 Ptosis
 Proptosis
 Ophthalmoplegia
 Loss of vision
 Chronic invasive:
 Nasal obstruction
 Chronic sinusitis
 Thick nasal polyposis
 Thick purulent mucus
 Orbital apex syndrome
 Cavernous sinus thrombosis
 Chronic granulomatous:
 Nasal obstruction
 Unilateral facial discomfort
 Enlarging mass
 Proptosis
 Diagnosis
 CT Scan:
 Acute invasive:  Chronic granulomatous:
 Multiple sinuses  Opacification of sinuses
 Unilateral  Erosion
 No air fluid level
 Thickening of sinus lining  MRI:
 Bone destruction
 Cavernous sinus
 Cerebral
 Chronic invasive:
 Hyperdense mass
 Sinus wall erosion
 Local biopsy:
 HPE
 Direct microscopy:
 KOH mount
 Culture
 Management

 Control of underlying host disorders

 Removal of necrotic & infected tissue
 Effective antifungal therapy
Noninvasive Fungal
Sinusitis
 Fungal ball:
 Dense mass of fungal hyphae
 Aetiological agent:
 Aspergillus fumigatus
 Other Aspergillus spss
 S. apiospermum
 Alternaria
 Epidemiology:
 Older age group
 F>M
Clinical Features
 Asymptomatic
 Nasal obstruction
 Purulent nasal discharge
 Cacosmia
 Facial pain
 Unilateral symptoms
 Unusual symptoms:
 Fever
 Cough
 Proptosis
 Epistaxis
 Diplopia
 Nasal polyp
 Diagnosis
 CT Scan:
 Partial/ total opacification
 Flocculent calcification
 Mucopurulent material:
 HPE:
 Dense matted fungal hyphae separate from
but adjacent to the mucosa of sinus
 No allergic mucin
 No granulomatous reaction
 No fungal invasion
 Management:
 Surgical removal
 No antifungal agents
 Outcomes & Complications:
 Recurrence: Rare
 Intracerebral bleed/ infarct
 Invasive fungal sinusitis
Allergic Fungal Sinusitis
 Noninvasive
 Immunocompetent individuals
 Chronic rhinosinusitis
 Criteria for diagnosis:
 Chronic rhinosinusitis (CT Scan)
 Allergic mucin
 Clusters of eosinophils
 Eosinophillic byproducts
 Noninvasive fungal elements
 Type I (IgE mediated) hypersensitivity
 Nasal polyposis
 Ponikau et al. (1999):
 210 pts with chronic rhinosinusitis
 Fungus in nasal mucus: 202 pts (96%)
 Surgical treatment: 101
 Allergic mucin: 97 (96%)
 Fungal elements in HPE: 82 (81%)
 Conclusion:
 AFS- Underdiagnosed disorder
 Aetiology:
 Aspergillus
 Dematiaceous environmental moulds:
 Alternaria
 Bipolaris
 Cladosporium
 Curvularia
 Drechslera
 Epidemiology:
 Young immunocompetent adults
 Relapsing rhinosinusitis
 Unresponsive to:
 Antibiotics
 Antihistamines
 Corticosteroids
 M=F
 Atopic
 Southern United States
 Clinical Features
 h/o Chronic rhinosinusitis
 U/L nasal polyposis
 Thick yellow-green mucus
 Bone necrosis of thin walls of sinus
 Proptosis
 DNS to opposite side
 Pt with nasal polyposis responding only
to oral corticosteroids
 CT Scan: Diagnosis
 Serpiginous opacification of >1 sinus
 Mucosal thickening
 Bone erosion
 No tissue invasion
 Microscopic Examination of allergic mucin:
 Eosinophils
 Fungal elements
 Histologic examination to r/o invasion
 Lab tests:
 Eosinophilia
 Total serum IgE
 Specific IgE against fungal Ags
 +ve skin prick tests
 Fungal cultures
AFS
 Management
 Surgical debridement
 Adjunctive medical management:
 Oral corticosteroids
 Specific allergen immunotherapy
 Nasal corticosteroids
 Antihistamines
 Antileukotrienes
 Sinonasal saline lavage
 Systemic antifungals: not effective
Mycotic Diseases of the
Throat
 Candidiasis
 Histoplasmosis
 Paracoccidioidomycosis
 Blastomycosis
 Coccidioidomycosis
 Cryptococcosis
 Candidiasis
 Infections caused by organisms of genus
Candida
 Etiological Agents:
 C. albicans
 C. glabrata
 C. krusei
 C. tropicalis
 C. parapsilosis
 Epidemiology
 C. albicans:
 Commensal in the mouth of 40% ppl
 No. ↑es with:
 Tobacco smoking
 Dentures
 Host factors:
 General:
 Debilitated pts.:
 Broad spectrum antibiotics
 Corticosteroids
 DM
 Severe nutritional deficiencies
 Immunosuppressive diseases eg AIDS
 Local:
 Trauma:
 Unhygienic dentures
 Ill fitting dentures
 Tobacco smoking
Clinical Manifestation

 Clinical forms:
 Pseudomembranous
 Erythematous (or atrophic)
 Hyperplastic (or hypertrophic)
 Pseudomembranous
 Pts using steroid inhalers
 Immunocompromised individuals
 Neonates
 Terminally ill pts
 Lesions:
 Raised white
 Surface of:
 Tongue
 Soft & hard palate
 Buccal mucosa
 Tonsils
 Confluent plaques
 Painless
 Throat involvement: Severe dysphagia
 Pseudomembrane wiped off: Pseudomembranous
Candidiasis
Candidiasis
 Erythematous
 Associated with:
 Broad spectrum antibiotic treatment
 Chronic corticosteroid use
 HIV
 Any part of oral mucosa
 Lesions:
 Flat
 Red
 Tongue: depappillated areas
 Hyperplastic (Candida
leukoplakia)
 Lesions undergo malignant transformation
 Lesions:
 Small, palpable, translucent white areas
 Large, dense, opaque plaques, hard, rough
 Lesions cannot be removed
 Site:
 Inner surface of both cheeks
 Tongue
Other Candidal Lesions
 Chronic atrophic candidiasis:
 Denture stomatitis
 Associated with oral prostheses
 Asymptomatic
 Soreness
 Cheilitis
 Laryngeal Candidiasis:
 Hoarseness
 Dysphagia
 Stridor
 Plaques on laryngeal mucosa
 Diagnosis:
 Clinical
 Microscopy
 HPE
 Culture
 Management:
 Antifungals
 Topical
 Systemic
Mycotic Colonization of Tracheo-
oesophageal Voice Prostheses
 Biofilm formation
 Invasion of silastic
 Causative agents:
 C. albicans
 C. glabrata
 C. krusei
 C. tropicalis
 Results in:
 Valve failure
 Device replacement
 Local antifungal therapy: inadequate
 Metal coating of prostheses
Thank you