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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:
 Aspergillus
 Bread moulds
(Rhizopus)  Histoplasma
 Coccidioides
 Food spoilage
organisms  Candida
 Pneumocystis
 Rhizomucor
 Sporothrix
 Dermatophytes

4. Deuteromycetes
1. Basidiomycetes: (Fungi Imperfectii):
 Common  Medically &
mushrooms economically imp fungi
 Cryptococcus  Penicillin producing
 Malassezia
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
 Echinocandin
s
 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
 Multiple sinuses granulomatous:
 Unilateral  Opacification of
 No air fluid level sinuses
 Thickening of sinus  Erosion
lining
 Bone destruction
 MRI:
 Chronic invasive:  Cavernous sinus
 Hyperdense mass  Cerebral
 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
 Managemen
t:
 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