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2/4/2016

MYCOLOGY
Superficial, Subcutaneous &
Systemic Fungal Infection

LISA TENRIESA M.
MICROBIOLOGY DEPARTMENT
HASANUDDIN UNIVERSITY

LEARNING OBJECTIVES
• Fungal taxonomy
• Pathogenic fungi (True, intermediate
virulence and opportunistic fungal
pathogen)
• Superficial, Subcutaneous & Systemic fungal
infection
• Pathogenesis of fungal infections
• Antifungal
• Laboratory examination

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INTRODUCTION
Fungi general characteristics:
• Non-photosynthetic (chemoheterotrophs)
• Generally saprophytic
• Secrete degradative enzymes (cellulases, proteases,
nucleases)
• Some pathogenic to human
• Non-motile eukaryotes
• Cell wall composed of chitin (N-acetylglucosamine
polymer)
• Membrane  ergosterol

Fungal Structure
• Cell wall serves to:
1. Provide shape & form
2. Protect against mechanical injury
3. Prevent osmotic lysis
4. Provide protection against the ingress of potentially
harmful macromolecules
• Plasma membrane  regulates the passage of materials in and
out of the cell (selectively permeable)
• Microtubules  movement of organelles, chromosomes, nuclei
& Golgi vesicles
• Organelles
• Golgi vesicles
• Nuclei

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Fungi Cell Wall & Membrane


a. Mannoproteins
b. β-(1,6)-glucan
c. β-(1,3)-glucan
d. Chitin
e. Cell membran
phospholipid
bilayer
f. Ergosterol

Practical Handbook of Microbiology, 2015.

Fungi Forms
• Three groups of pathogenic fungi form:
a. Yeast-like fungi
b. Mold or filamentous fungi
c. Dimorphic fungi

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Yeast-like Fungi
• Round or oval, unicellular.
• Pseudomycellium  Candida spp.
• Spherical with a capsule  Cryptococcus spp.
• Asexual budding; Ascomycota  sexual reproduction

A Concise Manual of Pathogenic Microbiology, 2013.

Molds or Filamentous Fungi


• Consist of several thallus
• Thallus includes mycelium, sporangiophore or conidiophore, spore
and spore-bearing structure
• Mycelium  hyphae growth
• Hyphae  septate or aseptate

A Concise Manual of Pathogenic Microbiology, 2013.

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Dimorphic Fungi
• Exhibit properties of both yeast (host tissue)
and molds (natural habitat).
• Majority pathogenic

Fungal Reproduction
Asexual Spora Sexual

Conidia Sporangiospora Zygospora

Artroconidia/
Basidiospora
Artrospora

Blastoconidia/
Ascospora
Blastospora

Clamidoconidia/
clamidospora

Phyaloconidia

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Spora Aseksual

Molds or Filamentous Form Yeast form

Sherris Medical Microbiology An Introduction to Infectious Diseases, 2004.

Spora Seksual

Foundations in Microbiology, 2012.

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FUNGAL DIVISION
• Taxonomic divisions of fungi (5 phylum):
a. Zygomycota (Zygomycetes)
Sexual  zigospores
Asexual  mostly sporangiospores, some conidia
Hypha  usually non septate
Examples: Rhizopus, Mucor, Absidia, Circinella
b. Ascomycota (Ascomycetes) (85% patogen)
Sexual  ascospores
Asexual  conidia
Hypha  porous septa
Examples: Trichophyton sp., Microsporum sp., Epidermophyton sp.,
Penicillium, Saccharomyces, Histoplasma, Microsporum, Pneumocystis (carinii)
jiroveci, Coccidioides immitis, Candida albicans, Cladosporium, Stachybotrys

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FUNGAL DIVISION
c. Basidiomycota (Basidiomycetes)
Sexual  basidiospores
Asexual  conidia
Hypha  incomplete septate hyphae
Examples: Cryptococcus neoformans
d. Chytridiomycota  plants
Sexual reproduction  unknown
Asexual reproduction  zoospore
e. Glomeromycota  plants
No sexual reproduction

Phylogeny of dermatophytes

Theodore C. White et al. Eukaryotic Cell 2008;7:1238-1245

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FUNGAL PATHOGENICITY

Foundations in Microbiology, 2012.

Foundations in Microbiology, 2012.

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Diseases of fungi infection

Intermediate
virulence

True
pathogens

Opportunisti
c pathogens

SUPERFICIAL MYCOSIS

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Malassezia sp. (Pityrosporum)


• Disease: Ptiriasis Versicolor/ Tinea
versicolor
• Chronic-mild superficial infection of
stratum corneum
• Phylum: Basidiomycetes
• Lipophylic
• Yeast-like fungus
• Normal flora on the skin and scalp
(abundant in pilocebaceous glands
area)
• Cell wall relatively thick and
multilaminar
Foundations in Microbiology, 2012.

Malassezia sp. (Pityrosporum)

Marcon M.J., Powell D.A. Human Infections Due to Malassezia spp. Clin. Microbiol. Rev. 1992;5:101-119

Pathogenesis of Malassezia sp. (Pityrosporum)


• Important factors: skins local conditions (temperature, humidity),
seborrhea, hyperhidrosis
• Predisposition: genetic factors & cell-mediated immunity differences

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Laboratory examination
• Culture media: Sabouraud agar
• Visible colonies: 2-4 days (34-37˚C)
• pH: 5.5-6.5 (optimum)
Microscopic form of M. furfur:
Spaghetti & meatballs appearance
1. Pytirosporum ovale form:
• Ovoidal, ellipsoidal or cylindrical
• Size: 1,5-4,5 x 2-6,5 µm
2. P. orbiculare form:
• Globose
• Size: 2,5-4,5 µm

Hortaea werneckii
• Disease: Tinea Nigra/ Tinea Nigra
Palmaris
• Phylum Ascomycota
• Yeast-like fungi
• Lipophilic
• Habitat: soil, compost, humus, on
wood in sub-tropical and tropical
regions
• Usually infect the palmar aspect of
hands and occasionally plantar and
other skin surfaces.

Bonifaz A., et al. Studies in Mycology. 2008;61:77-82.

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a. Conidial apparatus
b. Conidia 
chlamydospore-like cells

Pathogenesis
• Nutrient: breakdown of fats
• Risk factor: hyperhidrosis
• Tolerate to salt and a low pH environment
• Resides in stratum corneum and stratum lucidum

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Laboratory examination
• Hypha: brown to dark olivaceous septate
• Yeast-like cells: numerous 2-celled, pale brown, cylindrical to
spindle-shaped

Piedra
• Piedraia hortae (phylum Ascomycota) 
Black Piedra
• Trichosporon sp. (phylum Basidiomycota) 
White Piedra
• Habitat: soil
• Infect hair

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Laboratory examination
Piedraia hortae
Microscopic appearance:
- Dark brown nodule
- Covered whole or part of thread
Trichosporon sp.
Microscopy:
Nodule  light-brown, smooth,
irregular

Pathogenesis
• Keratinophilic affinity & keratinolytic potential
• Binding & adherence to the hair substratum
• Necrotrophic (grow on loose hair and on the hair of dead host)
• Lipophilic (lipid  main nutrient)
• Trichosporon sp.  urophilic (urea & uric acid utilization)

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CUTANEOUS MYCOSIS

Dermatophytes
• Three genus of dermatophytes:
1. Microsporum
2. Trichophyton
3. Epidermophyton
• Disease: dermatophytosis
• Attacks non-viable skin
• Mostly can not grow in 37˚C temperature

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Dermatophytes
• Classification based on habitat:
1. Geophylic  soil (Microsporum gypseum & Trichophyton
terrestre)
2. Zoophylic  animal (Microsporum canis & M. nanum;
Trichophyton mentagrophytes & T. verrucosum )
3. Antropophylic  human (Trichophyton rubrum, T. tonsurans,
T. violaceum; Microsporum audouinii; Epidermophyton floccosum)
• Growth 2 weeks in Sabouraud dextrose agar (25˚C)

Immunology towards Dermatophytes


• Mild or intense inflammatory reaction due to colonization in
dead keratinized tissue
• Active defense mechanisms:
1. α2-macroglobulin keratinase inhibitor
2. Unsaturated transferrin
3. Epidermal desquamation
4. Lymphocytes, macrophages, neutrophils, mast cells
• Dermatophytes antigens:
1. Glycopeptides: protein portion  cell-mediated immunity;
polysaccharide portion  humoral immunity
2. Keratinases  delayed-type hypersensitivity

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Dermatophytosis Pathogenesis

An. Bras. Dermatol. 2011;86(4):726-31

Predisposing Factors to
Dermatophytosis
• Host:
- Variation of sebum fatty acids composition
- Skin surface CO2 tension
- Moisture
- Inhibitors for dermatophytes growth (eg. Transferrin)
• Dermatophytes:
- Dermatophytes cause infection regardless of the patient’s
immune status

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Trichophyton sp.
• Phylum Ascomycota
• Infect hair, skin and nails
• Macroconidia: smooth cell wall, cylinder shape.
• Microconidia: Spherical, pyriform to clavate or of irregular shape
and range from 2-3 x 2-4 mm in size

• Colony:
1. T. mentagrophytes
Generally flat, white to cream in colour,
with a powdery to granular surface

2. T. rubrum
Blood-red colony

3. T. tonsurans
Suede-like to powdery, flat with a raised
centre or folded, often with radial
grooves.
Colour vary from pale-buff to yellow to
dark-brown.

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Microsporum sp.
• Phylum Ascomycota
• Only infect hair and skin
• Macro- and microconidia on short
conidiophore
• Macroconidia hyaline, multiseptate,
variable in form (fusiform, spindle-
shaped to obovate) 7-20 x 30-160
µm in size, thin- or thick- echinulate
to verrucose cell walls
J. Michael Miller, Ph.D., CDC, Atlanta, GA.

• Colony
1. Microsporum canis
Bright golden yellow to brownish
yellow reverse pigment, but non-
pigmented strains may also occur

2. Microsporum gypseum
Central white downy umbo (dome)
or a fluffy white tuft of mycelium
and some also have a narrow white
peripheral boarder

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Epidermophyton floccosum
• Phylum Ascomycota
• Infect skin and nails but do not infect hair.
• Smooth, thin-walled macroconidia,
• No microconidia

• Colony:
Epidermophyton floccosum
Slow growing, greenish-brown or khaki coloured with a suede-like
surface, raised and folded in the centre, with a flat periphery and
submerged fringe of growth

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Dermatophytosis
• Tinea pedis/ athlete’s foot
• Tinea unguium (onikomikosis)
• Tinea corporis
• Tinea cruris
• Tinea capitis
• Tinea barbae

Tinea Pedis
• Causal agents: T. rubrum, t. mentagrophytes, E. floccosum
• Tiga gejala klinik yang biasanya timbul:
a. Tinea pedis intertriginosa kronik (jaringan mati putih di antara
jari kaki)
b. Tinea pedis bersisik kering kronik (sisik hiperkeratotik pada
tumit, telapak kaki, atau bagian samping kaki)
c. Tinea pedis vesikular (vesikel dan vesikupustula)

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Tinea Pedis (cont.)

Tinea Unguium (Onikomycosis)


• Most common by T. rubrum, T. mentagrophytes or E. floccosum
• Nearly always secondary to infection of the feet
• From nail-plates  area under the nail (total deformation) 
loss of infected nail
• Nail become discoloured, thickened, raised and friable
• One or more toenails may involved

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Tinea Unguium (Onikomycosis)

Medical Microbiology, A guide to microbial infection, 2012.

Tinea Corporis
• Known as ringworm of the glabrous skin
• Most common form of dermatophytoses
• Mostly caused by T. rubrum, T. mentagrophytes, & M. canis
• Inflamed, red ring lesions anywhere on smooth skin

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Tinea corporis (cont.)

Tinea Cruris
• Also known as “jock itch”
• Affects groin and scrotal region
• Caused by E. floccosum & T. rubrum

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Tinea Manus
• Nearly always associated with concurrent infection of the foot.
• White and patchy to deep and fissured lesions on the fingers and
palms of the one hand.

Tinea Manus (cont.)

www.webmd.com

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Tinea Capitis
• Scalp infection (“scalp ringworm”)
• Inflammation, ulceration and hair loss (may involve entire scalp)
• Most frequently causative agents are M. canis & T. tonsurans
• Hair shaft can become invaded by Microsporum hyphae

Tinea Capitis (cont.)

Lippincott’s Illustrated Reviews: Microbiology, 2012

Foundations in Microbiology, 2012.

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Tinea Barbae
• Bearded area infection
• Caused by Trichophyton verrucosum, T. mentagrophytes var.
mentagrophytes, T. mentagrophytes var. erinacei
• Scale plaque

Tinea Barbae (cont.)

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SUBCUTANEOUS MYCOSIS

Sporothrix schenckii
• Disease: Sporotrichosis
• Dimorphic fungi
• Phylum Ascomycota
• Habitat: soil & plant materials (wood & Sphagnum moss)

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Pathogenesis
• Putative virulence factors: thermotolerance, melanin, adhesion,
ergosterol peroxide, peptido-rhamnomannans
• Disruption of epidermis integrity  penetrating  yeast form
 localized subcutaneous tissue  adjacent lymphatic vessels 
lymphocutaneous form  hematogenous route  disseminated
cutaneous form or extracutaneous form
• Sporotrochosis according to lesion’s location: cutaneous forms,
mucosal forms, extracutaneous forms

Sporotrichosis

Medical Microbiology,
a Guide to Microbial Infections. 2012

Foundations in Microbiology. 2012

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Laboratory Diagnosis
• Culture of swabs  moist, ulcerated lesions or pus (subcutaneous)

• Hyphal phase: floral cluster (from


conidiophores) or single spores (from the
edge of hyphae

• Tissue phase: ovate budding yeast

Foundations in Microbiology, 8th ed. 2012

Chromoblastomycosis
• Disease of pigmented fungi
• Causative agents: Fonsecaea pedrosoi,
F.compacta, Phialophora verrucosa,
Cladophialophora (Cladosporium) carrionii,
Rhinocladiella aquaspersa (phylum
Ascomycota)
• Habitat: soil and plants
• Dematiaceous (dark-walled fungi)
• Large, thick, yeast-like bodies (sclerotic
cells) Lippincott’s Illustrated Reviews: Microbiology, 2012
• Pathogenesis: traumatic inoculation of
organism (Conidia  penetrate into
traumatic skin (mostly limbs and feet) 
verrucous (month – years))
• None thermal dimorphism
• Port d’ entry  injured skin
• Systemic infection  rare

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Phaeohyphomycosis
• Disease of pigmented fungi
• Causative agents: Alternaria, Aureobasidium, Curvularia, Dreschlera,
Exophiala, Phialophora, Wangiella
• Typically hyphal dematiaceous (dark-walled fungi)
• Port d’ entry  dermis  enlarge subcutaneous cysts  can
spread to bone, brain, lung (endocarditis, diabetes & leukemia
patients)

Mycetoma
• Madura foot
• Causative agent: Madurella grisea &
Exophiala jeanselmei (phylum
Ascomycota)
• Lesions characteristic  colored
grains (black, white, red or yellow)

Foundations in Microbiology, 8th ed. 2012

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SYSTEMIC MYCOSIS

Systemic Infection by True Pathogens


• Dimorphic Ascomycetes
• Restricted to certain endemic regions of the world
• Fungal conidia (soil, etc)  spores inhaled (lower respiratory
tract)  infection
• Spores germinated (lungs)  yeast or yeast-like cells 
asymptomatic or mild primary pulmonary infection (PPI)
• Small number of host  systemic infection (severe, chronic
lesions)
• Skin inoculation  localized granulomatous lesions (few cases)
• Immunity  allergic reaction to fungal infection

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Dimorphism of True Pathogenic Fungi


• Depends on alteration of temperature and/or nutrients
• Nature  mycelial form (produce conidia)  inhaled 
establish in lung tissue
• Cell wall 
- β-(1,3)-glucan (mycelial form);
- α-(1,3)-glucan (yeast form)  higher rigidity, resistance to
phagocytes attack

Transition from
saprophytic  parasitic form

Rev Inst Med trop S Paulo, 1998.

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True Pathogenic Fungal Pathogenesis

Lippincott’s Illustrated Reviews, 2012.

Histoplasma capsulatum
• Phylum Ascomycota
• Disease: Histoplasmosis
• Slow growing colonies
• Highly variable appearance
• Molds form  25˚C; yeast  37˚C
• Hyphae: slender, hyaline, septate
• Macroconidia: spherical, single cell
• Microconidia: short conidiophores/ directly on hyphae
• Yeast cell = Candida
• Putative virulence factors: cell-wall α-1,3-glucan; intracellular
growth; thermotolerance

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Histoplasma capsulatum (cont.)


• Worldwide (prevalent central North America  Mississippi & Ohio
River Valeys )
• Source of infection  soils (birds, chicken or bat droppings)
• Site of infection  lungs (spread to liver, spleen, bone marrow)
• Symptoms  asymptomatic or flu-like set (self limiting)
• Pulmonary histoplasmosis symptoms: non productive cough,
shortness of breath, mild-to-severe chest pain, hemoptysis (later
stage), fever, night sweats, weight loss, malaise.
• Older adults, very young and immunocompromised individual 
disseminated histoplasmosis

Foundations in Microbiology, 2012.

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Laboratory diagnosis
• Definitive diagnosis:
a. Isolation & culture (4-6 weeks)  phase convertion;
b. Urine specimen (exoantigen detection)
c. Skin test (histoplasmin)  non-endemic area
d. Immunodiffusion test
• Sabouraud agar & Brain Heart Infusion agar.
• 25˚C  whitish, fluffy colonies (macroconidia  Ø = 8-14 µm ,
microconidia  Ø = 2-4 µm)
• 37˚C  spherical or oval yeast-like cells, Ø = 1-5 µm (histiocyte)

Histoplasma capsulatum (cont.)

Tuberculate macroconidia

H&E stain of H. capsulatum microconidia.


J. Michael Miller, Ph.D., CDC, Atlanta, GA.

Yeast form
A photographic atlas for the 4th edition microbiology
laboratory, 2011.

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Blastomyces dermatitidis
• Phylum Ascomycota
• Disease: Blastomycosis
• Habitat: soil
• Microconidia (soil)
• Yeast cells: thick-walled, unipolar, broad-based buds.
• Invasive tissue form: broad-based budding yeast
• Putative virulence factors: cell-wall α-1,3-glucan; WI-1
adhesin/antigen

Pathogenesis of Blastomycosis
Initial infection

conidia

Inhaled into the


lung

Asymptomatic Symptomatic
(50%) (incubation 30-45 days)

Acute pulmonary Chronic Cutaneus Systemic


blastomycosis pneumonia blastomycosis blastomycosis
(self-limited)

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Laboratory diagnostic
• Morphology: white to tan, septate
mycelium (low temp.); creamy,
white, wrinkled yeast colonies
(high temp.)
• Smooth-walled, round to oval
conidia borne laterally or
terminally (room temp.)
• Large, ovoid, thick-walled yeast
cells (35˚C)

A Concise Manual of Pathogenic Microbiology. 2013

Coccidioides immitis
• Phylum Ascomycota
• Disease: Coccidioidomycosis
• Putative virulence factors: Extracellular proteinases, EBP
• Habitat: soil in the semiarid regions
• Pathogenesis: arthrospores inhaled  lungs  mild upper
respiratory tract infections (self-limited)
• Disseminated form  CNS involvement
• Laboratory-acquired mycotic disease

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Coccidioidomycosis pathogenesis

Foundations in Microbiology, 2012.

Laboratory diagnosis
• Mycelial phase: barrel-shaped
arthroconidia, borne laterally, 2,5-
4 x 3-6 µm. (room temp.)
• Yeast form produce large
spherule  mature become
sporangiospores

Foundations in Microbiology, 2012.

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Paracoccidioides brasiliensis
• Phylum Ascomycota
• Disease: Paracoccidioidomycosis/
paracoccidioidal mycoses/ South American
blastomycosis
• Restricted distribution  the rarest primary
mycosis
• Most common secondary site of infection:
mucosa of the mouth & nose
• Characteristic yeast form appearance: ship’s Lippincott’s Illustrated Reviews:
Microbiology. 2012
steering wheel (multiple buds)
• Putative virulence factors: estrogen-binding
proteins, cell wall components (β-glucan & α-
1,3-glucan), gp43/ laminin binding proteins

SECONDARY
OPPORTUNISTIC PATHOGEN

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Candida albicans
• Phylum Ascomycota
• Disease: Candidiasis (Oral candidiasis, onychomycosis,
intertriginous candidiasis, cutaneous candidiasis, vaginal
candidiasis, systemic candidiasis)
• Dimorphic
• Normal flora of pharynx, genitalia, large intestine or skin (20%
of human)
• Human epithelial strong attachments  hyphal wall protein
(Hwp1)
• Hypha  proteinases & phospholipases  digest epithelial cells
 invasion
• Systemic infection  patient chronically weakened by surgery,
bone marrow transplant, advanced cancer, intravenous drug
addiction

Candida albicans (cont.)

Macroscopic:
• White colonies
Microscopic:
• Budding Yeast cells
• Pseudohyphae
Gram staining of vaginal smear showing C. albicans,
epithelial cells and many Gram negative rods.
Dan Wiedbrauk, Ph.D. Warde Medical Laboratory, Ann
Arbor, MI

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Pathogenesis

Sherris Medical Microbiology An Introduction to Infectious Diseases. 2004.

Laboratory diagnosis
• Specimen:
a. Exudate, epithelial scrapping  KOH, Gram staining
b. Direct aspirate, bronchoalveolar lavage, biopsy  culture
c. Arterial blood (suspected endocarditis)
• Microscopic  budding yeast, pseudohyphae
• Standard culture  complicated identification with another look-
alike yeast
• Differential Medium  trypan blue  differentiate Candida sp.
from Cryptococcosis yeast.

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Aspergillus spp.
• Phylum Ascomycota
• Disease: Aspergillosis
• Widely dispersed in dust and air
• Can be isolated from vegetation, food, compost matter
• Non dimorphic molds (only exist in hyphal stage)
• Most common species involved in human infection: A. fumigatus
(1st) & A. flavus (2nd)
• Conidia (granaries, barns, & silos air)  inhaled  germinated in
lungs (fungus balls) (extensive exposure of healthy people)
• Benign non invasive infections  sinuses, ear canals, eyelids, &
conjunctiva colonization
• Invasive form  necrotic pneumonia  brain, heart, skin, &
other organs

Aspergillus spp. (cont.)

A. fumigatus conidia.
Mycology Online.

A. flavus conidia.
Mycology Online.

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Aspergillus fumigatus colony in


Saboraud dextrose agar
• Rugose topography
• Green and granulare appearance
• White margin

A. fumigatus.
Mycology Online.

A. flavus.
Mycology Online.

Cryptococcus neoformans
• Disease: Cryptococcosis/ Busse-Buschke’s disease/ Europian
Blastomycosis
• Phylum Basidiomycota
• Habitat: soil, old dried pigeon excreta (more frequent), plant
materials
• Dimorphic
• Utilize creatinine (source of nitrogen)
• Melanogenesis fungi
• Airborne infection (lungs (primary site)  central nervous
system)

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C. Neoformans (cont.)
• Thick capsule (polysaccharide)
• Spherical yeast
• Multilateral budding

India ink staining of CSF. (600X)


J. Michael Miller, Ph.D., CDC, Atlanta, GA.

Foundations in Microbiology, 2012.

Pathogenesis
• Port’ d entry: respiratory tract
• Most patient: Yeast inhaled  lung infection (subclinical 
resolved)
• Few patient: Yeast inhaled  pulmonary cryptococcosis 
nodules in the lungs  escape into the blood  skin, bones,
viscera  crossing the blood brain barrier  brain & meninges
(extreme affinity)

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Laboratory diagnosis
• Clinical specimen: CSF, bronchial washing, sputum, puss, blood,
urine.
• Medium: Sabouraud agar & Staib’s bird-seed agar (25˚C)
• Colonies: mucoid, white to cream-colored (Sabouraud agar);
brownish to dark brownish (Staib’s bird-seed agar)
• Microscopic: spherical (Ø = 4-20 µm), mucoplolysaccharide
capsule

C. neoformans in bird-seed agar.


Mycology Online.

Pneumocystis (carinii) jiroveci


• Phylum Ascomycota
• Disease: Pneumocystis (carinii) jiroveci pneumonia (PCP)
• Lacks ergosterol, weak cell wall, obligate parasite
• Spread in droplet  multiplies intra- & extracellular (immune
deficient)  epithelial cells slough off  foamy exudate
• Most frequent opportunistic infection in AIDS patient.
• Diagnosed by symptoms and direct examination of lung
secretions (Broncho Alveolar Lavage) and tissue (lung biopsy) 
staining (Wright-Giemsa staining; Gomori’s Methenamine Silver
(GMS) staining)

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Pneumocystis (carinii) jiroveci (cont.)

Silver stain of P. carinii in human lung biopsy specimen.


J. Michael Miller, Ph.D., CDC, Atlanta, GA.

Zygomycosis/ Mucormycosis
• Causative agent: (see Table 1)
• Phylum Zygomycetes
• Found in soil, decaying vegetation,
manure, variety of food stuffs
(bread, fruits, seeds)
• Identification: macroscopic &
microscopic morphology,
carbohydrate assimilation,
maximum temperature compatible
with its growth.
Clin Microbiol Infect, 2006.

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Pathogenesis
• Spores  inhalation, percutaneous inoculation or ingestion 
lungs, subcutaneous tissue  oxidative metabolites & defensin
(phagocyte of healthy person)  spores eradication
• Severely immunocompromised (neutropenic & phagocyte
dysfunction)  higher risk of mucormycosis

Laboratory diagnosis

• Microscopic: Ribbon-like non-


septate hyphae (tissue) &
sporangiospores

Mycology Online.

Foundations in Microbiology, 2012.

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Penicilliosis Marneffei
• Causative agent: Penicillium marneffei
• Phylum Ascomycota
• Microscopic: fission arthroconidia or unicellular round to oval
cells
• Specimen from bone marrow aspirate, blood smear, skin or
lymph nodes biopsy

Clinical Microbiology Reviews. 2006

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Identifying fungal isolates

Foundations in Microbiology, 2012.

Common Fungal Culture Media


Non-selective Medium:
• Brain-heart Infusion (BHI) agar: nonselective, for primary recovery of saprophytic and
dimorphic fungi
• Potato Dextrose Agar (PDA): rich medium for wide range of fungi

Selective and Differential Medium:


• Czapek’s agar: for subculture of Aspergillus species
• Inhibitory mold agar (IMA): recovery of dimorphic pathogenic fungi (inorganic salt,
chloramphenicol, gentamycin)
• Mycosel/ Mycobiotic agar:
- Generally Sabouraud’s dextrose agar + cycloheximide + chloramphenicol, for
dermatophytes recovery;
- Niger seed agar: isolation of C. neoformans, differentiate between C. albicans & C.
dubliniensis.
• Sabouraud’s Heart Infusion (SABHI) agar: primary recovery saprophytic & dimorphic
fungi (fastidious strain)
• Malt Extract agar: zygomycetes recovery, environmental cultures
• Dermatophyte Test Medium: selective and differential medium recommended for the
cultivation and isolation of pathogenic dermatophytic fungi

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Other test used to


identify fungal infection
• Differential media: trypan medium
• Biochemical test: rapid yeast identification system (RapID Yeast
Plus System; API 20C System; Uni-Yeast Tek System; Vitec Yeast
Biochemical Card)
• Antigen test: Latex agglutination, Radioimmunoassay (RIA)
• Germ tube test
• Genetic probe
• Serological test: Precipitation reactions, immunodiffusion test,
complement fixation test, ELISA, EIA

ANTIFUNGAL
• Five classes antifungal based on their mechanism of actions:
1. Polyenes
2. Azoles
3. Allylamines
4. Echinocandins
5. Others: griseofulvin & flucytosine

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Polyenes
• Interact with sterol in the cell membrane (ergosterol in fungi,
cholesterol in human)  channels  small molecules leak 
fungal cell death
• Amphotericine (conventional AMB or AMB deoxycholate,
AMB lipid complex & liposomal AMB) & nystatin

Azoles
Inhibit cytochrome P450-dependent enzymes (particularly C14-
demethylase) involved in the biosynthesis of ergosterol
Two groups:
• Imidazoles (R/ vaginal candidiasis & dermatophytosis)
Ketoconazole, Miconazole, Clotrimazole, Econazole,
Sulconazole, Tioconazole
• Triazoles (affinity for fungal compared with mamalian p450
enzymes  safety > imidazoles)
- First generation: Fluconazole, Itraconazole, Ketoconazole
- Second generation: Voriconazole &Posaconazole

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Allylamines
• Inhibit ergosterol biosynthesis at the level of squalene
epoxidase
• Terbinafine (DOC for onycomycosis) & naftifine

Echinocandins
• Damaging fungal cell wall
• Caspofungin (mucosal & systemic candidiasis),
• Micafungin
• Anidulafungin (non-neutropenia adult candidemia)

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Griseofulvin
• DOC for chronic dermatophytosis
• Binds with microtubule-associated proteins involved in the
assembly of the tubulin dimers  stops mitosis at metaphase

Flucytosine
• Analog of the nucleotide cytosine
• Intracytoplasmic conversion of 5-flourocytosine to 5-flourouracil
 DNA and RNA synthesis inhibition

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Medical Microbiology, A Guide to Microbial Infections. 2012.

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