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JAMUR-JAMUR PENYEBAB:

MIKOSIS SUPERFISIAL
DERMATOFITOSIS
MIKOSIS SUBKUTAN

Dr.Sofyan Lubis
Departemen Mikrobiologi
Fak.Kedokteran USU
2008
Pendahuluan
When fungi do pass the resistance barriers of
the human body and establish infections, the
infections are classified according to the tissue
levels initially colonized

Superficial mycoses
Cutaneous mycoses (Dermatophytoses )
Subcutaneous mycoses
Systemic mycoses
Opportunistic mycoses
Levels of Invasion
Superficial Mycoses
There are a number of fungi capable of infecting
various superficial structure, including hair, nails,
stratum corneum of the skin, the cornea, and the
lining of the external ear canal

Pityriasis versicolor (common)


Tinea nigra (rare)
Black piedra (rare)
White piedra (common)
Fungal keratitis
Fungal otitis externa
Pityriasis (Tinea) Versicolor

Ini adalah infeksi kronik, dan superficial


jamur di kulit
Disebabkan yeast lipofilik Malassezia
furfur
sedikitnya ada 6 spesies Malassezia
yang sudah dikenali saat ini
Epidemiology
Habitat normal di epidermis superfisial
dan berkelompok disekitar bukaan
folikel rambut
Saprophytic on normal skin of trunk,
head, and neck
Sometime affecting more than 60% of
the population in some tropic
environments
Clinical features
Lesinya makula kecil hipopigmentasi
atau hiperpigmentasi
Lokasi yang sering : Punggung, tangan
bagian bawah, tangan bag. Atas, dada,
leher
biasanya pada laki2 dewasa dan
dewasa muda
Terkait dengan peningkatan keringat
Pityriasis versicolor showing hyperpigmented lesions in a
Caucasian and hyphopigmented lesions in an Australian
Aborigine 1

1http://www.mycology.adelaide.edu.au/Mycoses/Superficial/Malassezia_infections/index.html
Culture of Malassezia furfur on Dixon's agar
(contains glycerol mono-oleate)
Tinea Nigra (palmaris)
Infeksi superfisial, paling sering di telapak
tangan coyy
disebabkan oleh black yeast (rasis bah!)
Phaeoannellomyces werneckii (Exophiala
werneckii)
Lesinya umumnya berwarna gelap, non-
scaling macules dan asimptomatik
Paling sering di daerah tropis atau semitropis
Amerika bagian tengah atau selatan, Africa,
dan Asia
Typical brown to black, non-scaling macules
on the palmar aspect of the hands.
Note there is no inflammatory reaction.2

http://www.mycology.adelaide.edu.au/Mycoses/Superficial/Tinea_nigra/index.ht
Fungal keratitis
Ini adalah infeksi di permukaan kornea
yang biasanya diikuti dengan cedera
mata
Jamur yang terlibat :
Fusarium solani,
Aspergillus fumigatus,
Candida albicans,
and several other genera of filamentous
fungi
Fungal otitis externa
infeksi jamur pada kanal
auditory externa
Fungal otitis externa
Disebabkan oleh beberapa spesies
dari Aspergillus (paling sering
A.niger), tapi Candida albicans juga
mampu menginfeksi daerah ini.
Gejala yang utama adalah gatal dan
terasa penuh di telinga
BLACK PIEDRA
Infeksi jamur pada rambut kepala
Agen Etiologi: Piedraia hortae
sering di daerah tropis
Temuan klinis: Discrete, keras,
nodules cokelat gelap hingga hitam
di rambut
BLACK PIEDRA
Micr. hifa septate berpigmen,
dan ascus ( pl.asci )
Unicellular dan fusiform
ascospores dengan polar
filament(s)
Culture: koloni dengan warna cokelat
kehitaman
Treatm.: Topical salicylic acid, azol
creams
Piedraia hortae
WHITE PIEDRA
Infeksi jamur pada wajah, axila dan
rambut daerah genital
Agen etiologi: Trichosporon
beigelii
Sering di daerah tropis dan
temperate
WHITE PIEDRA
Clinical findings: Soft, nodules putih
kekuningan yang melekat dengan
longgar di rambut (loosely
attached)
Micr.: Intertwined septate hyphae,
blasto- and arthroconidia
Culture: Soft, creamy colonies
Treatm.: Shaving, azoles
White piedra

Black piedra
Conidia of Phaeoannellomyces werneckii
Cutaneous mycoses
Dermatophytosis
Cutaneous candidiasis
Dermatophytosis
Dermatophytosis (tinea or ringworm)
adalah infeksi struktur yang berkeratin,
termasuk kuku, batang rambut, &
stratum corneum di kulit, oleh
organisme yang disebut dermatophytes
;
Trichophyton
Epidermophyton keratophilic
Microsporum
Fungi in Cutaneous
Mycoses
Trichophyton Microsporum Epidermophyton
(TRI) (SHair) ( SNails)

Hair Hair Skin


Skin Skin
Nails Nails
Dermatophytes ecology
Classified in to 3 categories
Geophilic : normalnya hidup di tanah (e.g.,
M.gypseum)
Zoophilic : Primarily menginfeksi
permukaan tubuh hewan tapi bisa
bertransmisi ke manusia (e.g.,
T.mentagrophytes, M.canis)
Arthropophilic : Umumnya menginfeksi
manusia dan transmisi antar individu
(e.g.,E.floccosum)
Epidermophyton floccosum
Tinea Pedis or athletes foot
Caused by anthropophilic fungi :
T.rubrum ,or
T.mentagrophytes var. interdigitale

Usually seen with scaling and


maceration and itching between the
toes, particularly the fourth interdigital
space
Tinea pedis caused by T. rubrum. Sub-clinical infection (left)
showing mild maceration under the little toe and more severe
infection showing extensive maceration of all toe web spaces 3

Tinea is transmitted via the feet by desquamated


skin scales in substrates like carpet and matting.3

3 http://www.mycology.adelaide.edu.au/Mycoses/Cutaneous/Dermatophytosis/index.html
Tinea capitis

Tinea capitis Tinea barbae


Tinea Unguium
(dermatophyte onychomycosis)

usually caused by Trichophyton sp.


Tinea cruris
Tinea Barbae Tinea Manuum
Tinea unguium

Tinea pedis
Tinea Capitis (scalp ringworm)
Three main patterns of hair invasion
Endothrix infections, in which arthrospores
are formed within hair shaft
Ectothrix infections, in which sporulation
occurs outside the hair
Favic, in which the hyphae do not survive
well in hair keratin and cause encrustation
or scutula around the hair follicle
KOH mount of infected hairs showing KOH mount of an infected hair showing an
ectothrix invasion by M. gypseum. 3 endothrix invasion caused by T. tonsurans3
SUBCUTANEOUS MYCOSES
Sporotrichosis
Chromoblastomycosis
Eumycotic Mycetoma
Entomophthoramycosis
Phaeohyphomycosis
Rhinosporidiosis
Lobomycosis
SPOROTRICHOSIS
General features
Chronic inf. involving cutaneous,
subcutaneous and lymphatic tissue
Frequently encountered in
gardeners ,florists
May develop in otherwise healthy
individuals
Most common in Mexico, endemic in
Brasil
SPOROTRICHOSIS
Causative agent
Sporothrix schenkii
Thermally dimorphic
Natural habitat: soil
37C: Round/cigar-shaped yeast cells
25C: Septate hyphae, rosette-like
clusters of conidia at the tips of the
conidiophores
SPOROTRICHOSIS
Pathogenesis & Clinical Findings
Sporothrix schenkii - dematiaceous/dimorphic
Reservoir - soil, decaying vegetation, worldwide
distribution
Transmission
Traumatic implantation, occupational disease
Clinical
Subcutaneous nodules
Suppuration, ulceration and drainage
Spread down lymphatic course.
SPOROTRICHOSIS
Diagnosis
Samples: Aspiration fluid, pus, biopsy
I. Microscopic examination :
. Direct microscopic examination (KOH), .
. Histopathological examination with
Gomori methenamine silver stain
II.Culture
III.Serology :Yeast agglutination test
IV. Sporotrichin skin test
Direct microscopy
Poor sensitivity. Sparse yeast cells, asteroid body
Culture
Good yield and grows on most media
Room temp for isolation (37oC is slower)
Identification
A white to grey mold becoming moist
Hyaline hyphae, mixed hyaline/dematiaceous conidia
Need in vitro conversion to yeast
SPOROTRICHOSIS
Treatment
Spontaneous healing is possible.

Cutaneous inf.: Potassium iodide (KJ)


(Topical/oral)
Disseminated inf.: Amphotericin
Sporothrix schenckii
Sporothrix schenckii
Sporothrix schenckii
Laboratory diagnosis
Direct examination

Section from a fixed


cutaneous lesion showing Cigar-shaped, round form
round positive budding of S.schenckii (GMS-H&E)
yeast-like cells. (PAS)
Sporothrix schenckii
Laboratory diagnosis
Culture
Conversionof mycelial
phase to yeast phase
Sporothrix schenckii
Mycelial form
Hyphae are narrow,
septate, with slender
conidiophores rising at
right angle

Conidia forming
a rosette-like
Sporothrix schenckii
Yeast form
Round, oval and
fusiform budding
yeast cells of
various sizes 2-3 x
3-10 m
Cigar-bodied
370C on BHI agar
Sporothrix schenckii
Sporotrichosis
Subcutaneous, pulmonary sporotrichosis
Scattered worldwide

Cutaneous
sporotrichosis
Sporotrichosis
CHROMOBLASTOMYCOSIS
General features
Reservoir and transmission
Traumatic implantation from decaying vegetation, but
chronicity dictates that it is uncommon in developed
countries.
Clinical presentation is distinctive
Hyperkeratosis and hyperplasia
Tumour like warty cauiliflower growths
Very slow progression
Uncommon in children (? time or immune)
Treatment - antifungals / surgery / heat
Chromoblastomycosis
Classified by presence of fungal tissue form AND
clinical presentation, NOT aetiology

Etiologic agents: - any dematiaceous fungi, e.g.


Cladosporium verrucosa
Fonsecaea compacta,
Fonsecaea pedrosoi,
Phialophora carrionii
Rhinocladiella aquaspersa.

NOT all subcutaneous infections with these


organisms are chromoblastomycosis
Pigmented (dematiaceous) fungi in soil
Arrangement and shape of the spores
vary from one genus to other

Tissue form is SCLEROTIC BODY


Dematiaceous thick walled yeast cell
Non budding, but multiplane septation
Chromoblastomycosis
Phialophora verrucosa
CHROMOBLASTOMYCOSIS
Lab. Diagnosis
Direct microscopy
Sclerotic bodies (usually easily seen)
Occasional hyphae
Culture
Will grow on most media (some are cyclo R)
Slow growing (4-6 wks)
Dark velvety colonies (similar)
Contamination can be a problem
Chromoblastomycosis :
Identification
Sclerotic cells or bodies are identical for all
etiologic agents
Hyphae elements are clearly dematiaceous
Complex and variable conidiation:
Fonsecaeae
Cladosporium
Phialophora
Rhinocladiella

No dimorphism in vitro
Chromoblastomycosis

Sclerotic body, Medlar body,


copper pennies
CHROMOBLASTOMYCOSIS
TREATMENT
Surgery
Antifungal therapy (susceptibility
varies depending on the genus)
Amphotericin B
Flucytosine
Ketoconazole
Heat
MYCETOMA
(=Maduromycosis=Madura foot)
Common in tropical climates
Posttraumatic chronic inf. of
subcutaneous tissue
Causative agents
o Saprophytic fungi (Eumycetoma)
o Actinomyces (Actinomycetoma)
MYCETOMA
Eumycetoma Actinomycetoma
Dark grains White-yellow grains
Madurella mycetomatis Actinomadula madurae
Leptospharia senegalensis Nocardia brasiliensis
Exophiala jeanselmei Yellow-brown grains
Pale grains Streptomyces somaliensis
Fusarium sp. Red-pink grains
Acremonium sp. Actinomycetoma pelletieri
Scedosporium
apiospermum
MYCETOMA
Clinical findings

Variable incubation period.


Swelling hard and painless
Local spread to contiguous tissue
Eventual sinus formation and drainage
Location of lesions linked to exposure
Male to female is 3:1
Therapy is poor for eumycotic but slightly better for
actinomycotic.
MYCETOMA
Diagnosis
Clinical findings are nonspecific
Identification of the infecting
fungus is difficult
Keys for identification :
Characteristics of the granules
Colony morphology
Physiological tests
Lab.diagnosis :
Recover granules black, red, white
Squash prep. microscopy
2-6um = fungal,
<0.5 um = actinomycetes

Culture to cover all ( fungus & actinomyces).


Use selective for fungi plus selective for
actinomycetes, but NOT both.
Dont forget Actinomyces
EUMYCETOMA
Treatment
Surgery
Antifungal therapy
Amphotericin B
Flucytosine
Topical nystatin
Topical potassium iodide
(choice of treatment varies
according to the infecting fungus)
Mycetoma
Mycetoma
Mycetoma
Mycetoma
Phaeohyphomycosis
Caused by a number of dematiaceous
(brown-pigmented) fungi where the tissue
morphology of the causative organism is
mycelial
Sclerotic bodies ( - )
Causative agents :
Exophiala, Phialophora, Wangiella,
Bipolaris, Exserohilum, Cladophialophora ,
Phaeoannellomyces, Aureobasidium,
Cladosporium, Curvularia and Alternaria
Clinical forms of
Phaeohyphomycosis
Clinical forms range from:

localized superficial infections of the


stratum corneum (tinea nigra)
subcutaneous cysts (phaeohypho
mycotic cyst
invasion of the brain
Rhinosporidiosis
Chronic infection
In divers
Polypoid masses at nasal mucosa,
conjunctiva, genitalia and rectum
Begin as small papilloma, become
pedunculated tumors, friable, may resemble
cauliflower
Seropurulent discharge from nasal
lesions
RHINOSPORIDIOSIS
Causative agent
Rhinosporidium seeberi
Natural reservoir: fish, aquatic insects
Spherules ( large sporangia ) filled with
endospores (in tissue)
Has not been cultured in vitro on
artificial media
Endemic in Ceylon and India, but seen in
Argentina and Brazil.
Rhinosporidiosis
Chronic infection of nasal
and other mucosal
surfaces
Rhinosporidium seeberi
It is a protozoan that has
not been isolated in
culture
It is characterized by the
appearance of large
vegetable outgrowths
containing sporangia
Diagnosis Lab.
Rh.seeberi belum dapat dibiakkan
secara in vitro di lab. sehingga deskripsi
morfologiknya adalah berdasarkan
kepada appearance organisme ini di
jaringan tubuh terinfeksi yaitu :

SPORANGIA : a large spherical form, yang


mengandung sejumlah besar sporangiospore (
endospora)
TROPHOCYTE : berbentuk spheris tapi lebih kecil
DIAGNOSIS LABORATORIUM
Histopatologi : H & E stain :

# TROPHOCYTE

# SPORANGIA
RHINOSPORIDIOSIS
Treatment
Ethylstilbamidine
Surgery
(Local injection)
Rhinosporidiosis
Lobomycosis
Syn. Keloidal Blastomycosis
Central and South America
Keloidal plaques +/- sinuses
In ear, may resemble cauliflower ear
Dolphins may harbor this infection
Therapy :: Excision, Amphotericin B
usually unsuccessful
LOBOMYCOSIS
Pathogenesis & Clinical features
Chronic, subcutaneous, progressive inf.
Traumatic inoculation of the fungus
Natural infection : in dolphins
Hard, painless nodules on extremities,
face and ear
Verrucous / ulcerative lesions
Lesions mimic those of chromoblasto-
mycosis, mycetoma, Carcinoma.
LOBOMYCOSIS
Causative agent
Loboa loboi ( Lacazia loboi )
Multiple budding yeast cells
Forming short chains
Asteroid body

Has not been cultured in vitro on


artificial media
Lobomycosis
Lobomycosis
Lobomycosis
Diagnosis Lab.

Dengan pewarnaan GMS dan PAS ,


dan H&E :thick doubly contoured
hyaline cell wall dengan lebih satu
haematoxylinophilic nuclei
Morfologi dan pola dari budding
L.loboi ini harus dibedakan dari :
P.brasiliensis ( multiple buds)
B.dermatitidis dan H.capsulatum
var,duboisii ( tidak dijumpai chains of
cells)
S.schenckii dan H.capsulatum
var.capsulatus ( ukuran lebih kecil)
Lacazia loboi : belum dapat di kultur in
vitro.
LOBOMYCOSIS
Treatment
Surgery

Clofazimine
Amphotericin B
Sulphonamides
Entomophtoramycosis
Subcutaneous zygomycosis
Caused by entomophthorale
Basidiobolus coronatus : Basidiobolomycosis
Conidiobolus ranarum : Conidiobolomycosis
Entomophthoramycosis
Candidiasis of skin, mucous
membranes and nails
Predisposing factors
Infancy, pregnancy, old age
Disorders of immune function, e.g., leukemia,
corticosteroid therapy
Chemotherapy, e.g., immunosuppressive,
antibiotic
Endocrine disease, e.g., diabetes mellitus
Carcinoma
Candidiasis of skin, mucous
membranes and nails
Oropharyngeal candidiasis: including thrush,
glossitis, stomatitis, and angular cheilitis ( perleche )
Candidiasis of skin, mucous
membranes and nails
Cutaneous cadidiasis : including
intertrigo, diaper candidiasis,
paronychia and onychomycosis
Candidiasis of skin, mucous
membranes and nails

Vulvovaginal candidiasis and balanitis:


vaginal discharge, dysuria, erythematous
oral contraceptive, pregnancy
Chlamydospores of C.albicans
Lab diagnosis of C.albicans:
1. Germ tube test
2. Pembentukan khlamidospora di
cornmeal agar
3. Di medium EMB Levine : membentuk
koloni seperti kaki laba-laba
4. Fermentasi sugars
5. Assimilasi sugar