FUNGAL

INFECTIONS
(MYCOSES)

INTRODUCTION
There are three groups of fungi which

cause human disease.

Multinucleate

branched filamentous
forms (moulds) e.g. trichophyton.

Round or ovoid single cells known as

yeasts e.g. Cryptococcus neoformans .

Dimorphic fungi that have certain of

the growth characteristics of both. E.g.

Candida albicans.

Certain fungi cause only superficial

infections while others can cause

invasive disease.

Fungi e.g. Candida can cause both

superficial and deep infection.

Some fungi are opportunistic and will

not normally invade unless the

defense mechanisms are impaired, as
in an immunocompromised host.

Fungal

infections are transmitted by

spores or hyphae and normally enter the
body through the lungs or skin, where
they may cause disease, or from where
they may disseminate to other parts of
the body.

Fungal infections tend to be chronic, and

often require prolonged chemotherapy.

For some infections there is still no

effective treatment.

Fungi also cause disease through

allergy and from toxins such as ergot,

muscarine and aflatoxin.
Mycoses may be classified as

superficial, cutaneous, subcutaneous,

systemic, and opportunistic.

Superficial mycosis those involving

the superficial layers of the skin; typical

of infections caused by dermatophytes.
Systemic

mycosis fungal infection

spread via the bloodstream and
characterized
by
multiple
granulomatous lesions in many organs.
Eg
aspergillosis,
blastomycosis,
coccidioidomycosis,
cryptococcosis,
histoplasmosis, mucormycosis.

Cutaneous mycoses extend deeper

into the epidermis, and also include
invasive hair and nail diseases.

Subcutaneous mycoses involve the

dermis, subcutaneous tissues, muscle,

and fascia.
Opportunistic mycosis a fungal or

fungus-like disease occurring in an

individual with a compromised immune
system.

Superficial mycoses
These are superficial fungal infections of the skin, nails or

hair shaft.
No living tissue is invaded and there is usually no cellular
response from the host.
Essentially no pathological changes are elicited.
They are innocuous that patients are often unaware of their
condition.
Fungi associated with superficial mycoses may include:
1. Malassezia furfur
2. Trichosporon beigelii
3. Dermatophytes

4. Exophiala werneckii
5. Piedraia hortae
6. Candida

MALASSEZIA FURFUR
Malassezia furfur is the causative agent of Pityriasis

versicolor, Pityriasis folliculitis

Pityriasis versicolor
chronic, mild, superficial fungal disease of the cornified

skin (stratum corneum)

Xtic well-demarcated white, pink, fawn, or brownish

lesions, often coalescing, and covered with thin furfuraceous

scales

colour varies according to:

-Normal skin pigmentation of the patient,

-Exposure of the area to sunlight,
-Severity of the disease
Lesions can be found on the:

-chest, upper back, shoulder, arms, abdomen

-rarely on neck and face.
Pityriasis versicolor:

- affect mostly young adults,

-may occur in childhood and old age

Pityriasis folliculitis
Inflammation of the hair follicle
This is 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.

Superficial mycoses

Pityriasis versicolor showing hyperpigmented lesions

Superficial mycoses

Pityriasis folliculitis showing follicular papules

Laboratory diagnosis: Malassezia furfur infections

Clinical materials: Skin scrapings, skin biopsy

Direct Microscopy:
Skin scrapings, can be mounted in 10% KOH or stained with

glycerol and Parker ink solution.

This show characteritic clusters of thick-walled, round,

budding yeast-like cells and short angular hyphal forms up

to 8um.

Grocott's methenamine silver stained skin biopsy shows

characteristic spherical yeast cells and short pseudohyphal

elements typical of M. furfur

Scrapings or biopsy specimens from pityriasis folliculitis

patient show numerous yeasts occluding the mouths of the

infected follicules.

Superficial mycoses

GMS stained skin biopsy showing characteristic spherical yeast

cells and short pseudohyphal elements typical of M. furfur

Superficial mycoses

10% KOH with Parker ink mount showing characteristic spherical

yeast cells and short pseudohyphal elements typical of the fungus

Culture:
Necessary in cases of suspected fungaemia.
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 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).

Culture of M. furfur on Dixon's agar

Identification:
-Microscopic evidence of unipolar, broad base budding yeast
cells and special lipid requirements for growth in culture are
usually diagnostic.

Serology:
- currently no commercially available serological procedures
for the diagnosis of Malassezia infections.

Treatment

Pityriasis versicolor:
local treatment is preferred: selenium sulphide shampoo
(antifungal and degreasing)
shampoo with azoles (econazole, ketoconazole) twice
weekly for 4 weeks (80% cure),
creams and lotions with 1-2% azoles, terbinafine gel twice
daily for 2 weeks.
Pityriasis folliculitis
Most cases respond well to topical imidazole treatment,
however patients with extensive lesions often require oral
treatment with ketoconazole or itraconazole.

PIEDRAIA HORTAE
Black piedra is a superficial fungal infection of the hair

shaft caused by Piedraia hortae, an ascomycetous fungus.

It forms hard black nodules on the hair shaft of the:
scalp,
beard,
moustache and
pubic hair.
It is common in Central and South America and South-East

Asia.

Clinical manifestations

This usually localizes to the hairs of the scalp but may also

be seen on hairs of the beard, moustache and pubic hair.

mostly affects young adults

epidemics in families following the sharing of combs

hairbrushes and even towels

Infected hairs generally have a number of hard black

nodules on the shaft.

Black piedra may be confused with trichorrhexis nodosa

and trichonodosis but mycological examination confirms the

diagnosis.

Black piedra

Darkly pigmented nodules that partially or completely

surround the hair shaft

Laboratory diagnosis
Clinical Material:
Epilated hairs with hard black nodules present on the shaft.
Direct Microscopy:
Hairs examined in10% KOH and Parker ink or calcofluor
white.
Xtics: darkly pigmented nodules that partially or completely
surround the hair shaft. Nodules are made up of a mass of
pigment with a stroma-like centre containing asci.

Culture:
Hair fragments implanted onto primary isolation media

-SDA.
Colonies:
2-3 weeks to appear
colonies are dark, brown-black in colour
Identification: Characteristic clinical, microscopic and
culture features.

Management:
usual treatment: shave/ cut the hairs short,
often not considered acceptable, particularly women.
In-vitro susceptibility tests have Piedraia hortae is

sensitive to terbinafine
and it has been successfully used, at a dose of 250 mg a day

for 6 weeks,

TRICHOSPORON BEIGELII
White piedra is a superficial cosmetic fungal infection of the

hair shaft caused by Trichosporon beigelii

Infected hairs develop soft greyish-white nodules along the

shaft. Essentially no pathological changes are elicited.

White piedra is found worldwide, but is most common in

tropical or subtropical regions.

Clinical manifestations:
Infections are usually localised to the hairs of 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

xtic of white piedra

White piedra

Irregular, soft, white nodule xtic of white piedra

Laboratory diagnosis
Clinical Material:
Epilated hairs with white soft nodules present on the shaft.
Direct Microscopy:
-Hairs examined with 10% KOH and Parker ink or calcofluor
white mounts.
Xtics: irregular, soft, white or light brown nodule, 1.0-1.5
mm in length, firmly adhering to the hairs.

Culture:
Hair fragments,implanted onto primary isolation media -

SDA
Colonies: white or yellowish to deep cream colored,

wrinkled, velvety, dull colonies with a mycelial fringe.

Management:
Shaving the hairs is the simplest method of treatment. Topical
application of an imidazole agent may be used to prevent
reinfection for 6 weeks,

HORTAEA WERNECKII
Tinea nigra is a superficial infection of skin characterised by

brown to black macules which usually occur on the palmar

aspects of hands and occasionally the plantar and other
surfaces of the skin.
common saprophytic fungus believed to occur in soil,

compost, humus and on wood.

World-wide distribution, common in tropical regions of

Central and South America, Africa, South-East Asia and

Australia.

Clinical manifestations:
Skin lesions are characterised by brown to black macules

usually occur on the palmar aspects of hands and

occasionally the plantar and other surfaces of the skin.

Lesions are non-inflammatory and non-scaling.

Familial spread of infection has also been reported.

Hortaea werneckii

Typical brown to black, non-scaling macules on the palmar

aspect of the hands

Laboratory diagnosis
Clinical Material: Skin scrapings.
Direct Microscopy:
Skin scrapings, examined using 10% KOH and Parker ink
or calcofluor white mounts.
shows pigmented brown to dark olivaceous (dematiaceous)

septate hyphal elements and 2-celled yeast cells producing

annelloconidia typical of Hortaea werneckii.

Hortaea werneckii

Skin scrapings mounted in 10% KOH showing pigmented brown to dark

olivaceous (dematiaceous) septate hyphal elements and 2-celled yeast cells
producing annelloconidia typical of Hortaea werneckii.

Management:

Usually, topical treatment with Whitfield's ointment

(benzoic acid compound)

imidazole agent twice a day for 3-4 weeks is effective.

DERMATOPHYTOSIS
Dermatophytosis (tinea or ringworm) of the scalp, glabrous

skin, and nails is caused by dermatophytes which have the

ability to digest and utilise keratin as a nutrient source using
the enzyme keratinase.

The type and severity of the host response is often related to

the species and strain of dermatophyte causing the infection.

Tinea pedis: Dermatophytosis of the toes

Infection caused by the shedding of skin scales containing

viable infectious hyphal elements (arthroconidia) of the

fungi Trichophyton rubrum, T. interdigitale and
Epidermophyton floccosum.

Tinea pedis

Tinea pedis affecting the toe web spaces

Desquamated skin scales may remain infectious in the

environment for months or years after the infective debris

has been shed.

Substrates like carpet and matting that hold skin scales

make excellent vectors.

The toe web spaces are the major reservoir on the human
body for these fungi.

Tinea cruris
Tinea cruris refers to dermatophytosis of the proximal

medial thighs and buttocks.

It occurs more commonly in males and is usually due to

spread of the fungus from the feet. Thus the usual causative
agents are T. rubrum, T. interdigitale and E. floccosum.

Tinea cruris

Tinea cruris of the proximal medial thigh and buttocks

Tinea unguium (dermatophyte onychomycosis)

Dermatophytosis of the nails may be classified into two
main types:
(1)superficial white onychomycosis in which invasion is
restricted to patches or pits on the surface of the nail; and
(2) Invasive, subungual dermatophytosis in which the lateral,
distal or proximal edges of the nail are first involved, followed
by establishment of the infection beneath the nail plate.
The fungus invades the distal nail bed causing

Hyperkeratosis of the nail bed with eventual onycholysis, and

thickening of the nail plate.

Tinea unguium

Tinea unguium of the finger nails

Trichophyton rubrum and T. interdigitale are the dominant

dermatophyte species involved.

Tinea corporis
Tinea corporis refers to dermatophytosis of the glabrous skin

and may be caused by anthrophophilic species such as

Trichophyton rubrum and Epidermophyton floccosum.
It is xterised by circular patches with advancing red,

vesiculated border and central scaling.

Tinea capitis
Tinea capitis refers to dermatophytosis of the scalp. Two types

of in vivo hair invasion are recognised: The ectothrix and

endothrix

Tinea corporis

Tinea corporis affecting the glabrous skin

Tinea capitis

Tinea capitis affecting the scalp

1.Ectothrix invasion is characterised by the development of

arthroconidia on the outside of the hair shaft. Common
agents include M. canis, M. gypseum, T. equinum and T.
verrucosum.
2. Endothrix hair invasion is characterised by the development
of arthroconidia within the hair shaft only. All endothrix
producing agents are anthropophilic eg T. tonsurans and T.
violaceum.

Laboratory diagnosis
Clinical Material
Skin Scrapings, nail scrapings and epilated hairs.

In patients with suspected dermatophytosis of skin, any

ointments or other local applications present should first be

removed with an alco wipe.

Using a blunt scalpel or tweezers, firmly scrape the lesion,

particularly at the advancing border.

In cases of vesicular tinea pedis, the tops of any fresh

vesicles should be removed as the fungus is often plentiful in

the roof of the vesicle.

In patients with suspected dermatophytosis of nails

(onychomycosis), the nail should be pared and scraped using

a blunt scalpel to enable the collection of white keratin
debris beneath the free edge of the nail.

Direct Microscopy
Skin Scrapings, nail scrapings and epilated hairs should be

examined using 10% KOH and Parker ink or calcofluor

white mounts.

A positive microscopy result showing fungal hyphae and/or

arthroconidia is generally sufficient for the diagnosis of

dermatophytosis.

In ectothrix invasion, the cuticle of the hair is destroyed and

infected hairs usually fluoresce a bright greenish yellow

colour under Wood's ultraviolet light.

Common ectothrix agents include Microsporum canis, M.

gypseum, T. equinum and T. verrucosum.

In endothrix invasion, the cuticle of the hair remains intact

and infected hairs do not fluoresce under Wood's ultraviolet

light.

All endothrix producing agents are anthropophilic eg T.

tonsurans and T. violaceum.

Culture
Specimens should be inoculated onto primary isolation
media, like Sabouraud's dextrose agar containing
cycloheximide or dermatophyte test medium and
incubated at 26-28C for 4 weeks. The growth of any

dermatophyte is significant.

Dermatophytes change the color of the medium from yellow

to red within 14 days.

Management
Tinea capitis griseofulvin for 4-6 weeks, shampoo and

moconazole cream.
Tinea corpori, T. pedis itraconazole and terbinafine are

very effective.topical preparation of cotrimazole.

Tinea unguium oral administration of itraconazole and

terbinafine and surgery.

CANDIDIASIS
Candidiasis is a primary or secondary mycotic infection

caused by members of the genus Candida.

The clinical manifestations may be acute, subacute or

chronic to episodic. Superficial involvement may be

localized to the skin, scalp, fingers and nails.

In healthy individuals, Candida infections are usually due

to impaired epithelial barrier functions and this may occur in

all age groups, but are most common in the newborn and the
elderly.

They usually remain superficial and respond readily to

treatment.

Diaper candidiasis
is common in infants under unhygienic conditions of

chronic moisture and local skin maceration associated with

ammonitic irritation due to irregularly changed unclean
diapers.

Once again, characteristic erythematous lesions with

erosions and satellite pustules are produced, with prominent

involvement of the skin folds and creases.

Paronychia
of the finger nails may develop in persons whose hands are

subject to continuous wetting, especially with sugar

solutions or contact with flour, that macerates the nail folds
and cuticle.

Lesions are characterized by the development of a painful,

erythematous swelling about the affected nails.

In chronic cases, the infection may progress to cause

onychomycosis with total detachment of the cuticle from the

nail plate.

Laboratory diagnosis
Clinical Material: Skin and nail scrapings
Direct Microscopy:
Skin and nails should be examined using 10% KOH and
Parker ink or calcofluor white mounts;
Demonstration of pseudohyphae in scrapings or smears
from skin and nail is positive.

Culture:
Colonies are typically white to cream colored with a smooth,
glabrous to waxy surface when cultured on SDA.

Biochemical test:
Urea, nitrate, and sugar assimilation test can be use to

distinguish the various species. Candida is urea negative and

C albians is sucrose positive while C stellatoidea is sucrose
negative. C albians and C stellatoidea are germ tube
positive.

Management:
Control of excessive moisture, heat and friction which cause
local skin maceration and treatment with a topical imidazole
compound is usually effective

To abate superficial mycosis, please avoid sharing

Towel,
Comb
Sponge
And other personal belongings with friends.