SUBCUTANEOUS, SYSTEMIC, & OPPORTUNISTIC MYCOSES

Lecture by Cerelyn E. Dacula, MD FEU-NRMF Institute of Medicine Dept. of Microbiology and Parasitology

OTHER FORMS Primary Pulmonary Sporotrichosis Inhalation of conidia mimics chronic cavitary tuberculosis among patients with impaired cellmediated immunity dissemination in eyes, bones, and joints, rarely in the meninges DIAGNOSTICS SPECIMEN biopsy material or exudate from lesions MICROSCOPIC EXAMINATION KOH or Calcoflour white stain Gomoris methenamine silver : black cell wall Periodic Acid-Schiff (PAS) stain: red cell wall Flourescent Antibody Staining H & E stain: asteroid body CULTURE Saborauds agar SEROLOGY Sporotrichin antigen for skin test delayed hypersensitivity Yeast cell Agglutination test 1:160 positive 1:40 recovered patient TREATMENT self-limited (Most fungal infections are self-limited, meaning they are usually seen in immunocompromized hosts) solution of saturated potassium iodide (SSKI) oral Itraconazole or other Azoles (DOC) Amphothercin B for systemic disease II. CHROMOBLASTOMYCOSIS - Occurs mainly in tropics - Saphrophytic in nature - occuring on vegetation and soil MORPHOLOGY AND IDENTIFICATION Dematiaceous fungi o Imperfect fungi that produce varying amount of melanin-like pigments A. PHIALOPHORA VERRUCOSA The conidia are produced from flask-shaped phialides with cup shaped collaretes. Mature, spherical to oval conidia are extruded from the phialide and usually accumulate around it

SUBCUTANEOUS MYCOSES
SPOROTHRICOSIS CHROMOBLASTOMYCOSIS PHAEOHYPOMYCOSIS MYCETOMA MYCOSES These are diseases caused by fungi

I. SPOROTHRICHOSIS Aka Rose Gardeners Disease Sporothrix schenkii Causative agent thermally dimorphic fungus 2 FORMS MOLD : ambient/room temperature YEAST (small budding) : 35-37oC CULTURE Routine agar media (Sabourauds) Young colonies are blackish and shiny; wrinkled and fuzzy with age Microscopic: branching septate hyphae with distinctive small conidia, delicately clustered at the ends of tapering conidiophores EPIDEMIOLOGY Ubiquitous occurs worldwide but most common in tropical and subtropical regions, endemic in Mexico, South Africa, and Japan Isolated from soil and plants (hay, straw, thorny plants esp. roses, sphagnum moss, decaying wood , pine, prairie grass, and other vegetations) 75% of cases occur in males (probably due to increased exposure or X-linked) FORMS Lymphocutaneous - 75% of cases - introduced in the skin by trauma Chronic Fixed

B. CLADOSPORIUM CARIONII Elongated conidiophores with long, branching chains of oval conidia C. FONSECA PEDROSOI Polymorphic, mostly short branching chains phialides chains of blastoconidia sympoidal, rhinocladiella type D. RHINOCLADIELLA AQUASPERA produces lateral or terminal conidia from a lengthening conidiogenous cell Conidia are elliptical to clavate E. FONSECA COMPACTA Blastoconidia are spherical, with a broad base connecting the conidia CLINICAL FINDINGS - introduced trough a trauma in the skin - Verrucous and wart-like over months to years extending along draining lymphatics - cauliflower-like nodules with crusting abscesses - black-dots on warty surface - rarely, Elephantiasis develops LABORATORY DIAGNOSIS SPECIMEN o Scrapings or biopsies from lesion MICROSCOPIC EXAMINATION o 10% KOH: dark spherical cells o H & E stain: sclerotic cells inside an abscess : round, thick-walled, cigar-colored structures CULTURE o Saborauds agar black velvety colony Unable to grow at 370C TREATMENT Surgical excision Flucytosine or Itraconazole Local applied heat Relapse is common III. PHAEOHYPOMYCOSIS - presence of darkly pigmented septate hyphae in tissue - common causative agents are Exiophiala jeanselmei, Phialophora richradsiae, Bipolaris specifera, Wangiella dermatitidis

CLINICAL FINDINGS - vary from solitary encapsulated cysts in the subcutaneous tissue - to sinusitis - to brain abscesses (Cladophialophora bantiana) LABORATORY FINDINGS Culture of Cladosporium and Phialophora showing typical brown, olivaceous black or black colony colour for a dematiaceous hyphomycete. TREATMENT Itraconazole Flucytosine Amphotericin B IV. MYCETOMA - Chronic subcutaneous infection usual cause - Actinomycetoma: caused by Actinomycete - Eumycetoma: Maduromycosis, Madura foot : caused by fungi ETIOLOGIC AGENTS Pseudallescheria boydii Exiophiala jenselmei Madurella mycetomatis Madurella grisea Acromnium falciforme CLINICAL FINDINGS - Suppuration and abscess formation - Granuloma - Draining sinuses containing the granules LABORATORY DIAGNOSIS Histopathologic appearance of black grain mycetoma due to Madurella mycetomatis using a Gridley stain Mycetoma with presence of geotrichum Black grain mycetoma: subcutaneous nodule due to Madurella Mycetomatis TREATMENT Surgical debridement or excision and chemotherapy Topical Nystatin or Miconazole- P. boydii Itraconazole, ketoconazole, Amphotercin B E. jeanselmei

SYSTEMIC MYCOSES
Coccidioidomycosis Histoplasmosis Blastomycosis Paracoccidioidomycosis General features causative agents: thermally dimorphic exist in nature, soil geographic distribution varies Inhalation pulmonary infection dissemination Most systemic mycoses start with inhalation no evidence of transmission among humans or animals otherwise healthy individuals are infected Systemic fungal infections are uncommon Infection requires a large inoculum and a susceptible host Infection often occurs in endemic areas most infections are asymptomatic or self-limiting in immune-compromised hosts, infections are more often fatal I. COCCIDIOMYCOSIS Etio: Coccidioides immitis Microbiology: o Tissue (37C): Spherules filled with endospores o 25C: hyphae, barrel-shaped arthroconidia EPIDEMIOLOGY - Endemic in hot, semi-arid regions (SW USA and Mexico, Central and South America) - Isolated from soil and indigenous rodents - Highest during summer and autumn, when dust is most prevalent - considered to be the most virulent of fungal pathogens - inhalation of a single spore can initiate infection PATHOGENESIS - Inhalation of the infectious particle, arthroconidia and spherule formation in vivo - Engulfment within phagosomes by alveolar macrophages - Activation of macrophages ---phagosome-lysosome fusion ---killing - Immune complex formation - deposition leading to local inflammatory reactions - immunosuppression resulting from the binding of complexes to cells bearing Fc receptors

CLINICAL FINDINGS PRIMARY INFECTION o Asymptomatic (60%) o VALLEY Fever (40%) influenza-like illness fever, malaise, cough, arthralgia, and headache o Nodular lesions in lungs o positive skin test in 2-4 weeks, remain for life SECONDARY (DISSEMINATED) INFECTION (1%) o Chronic / fulminant o Infection of lungs, meninges, bones and skin, GUT, Cutaneous, Ophthalmic LABORATORY DIAGNOSIS Histopathology: o spherules or endospores seen in sputum, exudates or tissue Culture: o SDA: Mould colonies at 25 C o Spherule production in vitro by incubation in an enriched medium at 40C, 20% CO2 Serology: o Complement fixation assay (in cerebrospinal fluid), particle agglutination assay Skin test (coccidioidin and spheruline antigens) o Negative result may rule out the diagnosis o In infected tissues, C. immitis appears as a mixture of endospores and spherules. TREATMENT Symptomatic treatment (primary infection) Antifungal agents: Amphotericin B, Itraconazole Fluconazole(particularly for meningitis) II. HISTOPLASMOSIS Etio: Histoplasma capsulatum Natural reservoir: soil, bat and avian habitats Microscopically: o Yeast cell in tissue (37C) o Hyphae, microconidia and macroconidia (25 C) (tuberculate chlamydospore) EPIDEMIOLOGY May be prevalent all over the world, but the incidence varies widely (most endemic in Ohio, Mississipi, Kentucky) Eastern half of USA, most of Latin America, parts of Asia, Europe, Middle East; var duboisii occurs in Africa

PATHOGENESIS Inhalation of microconidia / primary cutaneous inoculation Conversion to budding yeast cells Phagocytosis by alveolar macrophages Restriction of growth or dissemination to RES by bloodstream Suppression of cell-mediated immunity Immune response: o Cell-mediated responses are of primary importance o Phagocytic activity of macrophage is considered an important component of resistance to drugs. o Activated macrophage can kill yeast cells Evasion of host defense: o Survival in macrophageselevates pH of phagosomes o Yeast cells absorb iron (siderophore) and calcium from host o Alteration of cell surface CLINICAL FINDINGS PULMONARY INFECTION o Asymptomatic (95%) o mild / moderate / severe/ chronic cavitary DISSEMINATED INFECTION (1/200) o RES (liver, spleen, lymph nodes, bone marrow) o mucocutaneous infection PRIMARY CUTANEOUS INFECTION LABORATORY DIAGNOSIS HISTOLOGY CULTURE of blood or bone marrow SEROLOGY o Serological testing for antibody and histoplama antigen in blood and urine. ANTIGEN o In HIV-infected patients with disseminated histoplasmosis, histoplasma antigen detection in serum and urine is at least 50%, and 90% sensitive, respectively. TREATMENT Not required for several cases Antifungal: o Amphotericin B o Itraconazole Surgical resection of pulmonary lesions III. BLASTOMYCOSIS Blastomyces dermatitidis Location: America, Africa, Asia Microbiology: Yeasts at 37C--bud is attached to the parent cell by a broad base Septate mycelium and conidia at 25 C

EPIDEMIOLOGY Most cases are in southern, central, and southeastern USA. Infection is by inhalation of conidia. Risk Factors: Occupational contact with soil owning a dog Living in endemic area PATHOGENESIS Inhaled conidia convert to yeast/ Primary cutaneous inoculation Localized invasion of hosts invokes inflammatory reaction Infiltration of macrophages and neutrophils and granuloma formation Oxidative killing mechanisms of neutrophils and fungicidal activity of macrophages Yeast escapes recognition by macrophages and disseminates via bloodstream Defense system: o Alveolar macrophages provide a modest first line of defense. o T-cell stimulated PMNs kill Blastomyces cells by oxidative mechanisms. o Conidia are more sensitive to killing by PMNs because yeast are too big. o Generation of TH-2 response of primary importance Evasion of Defenses: o Escapes phagocytosis by neutrophils and monocytes by shedding its surface antigen after infection CLINICAL FINDINGS ASYMPTOMATIC INFECTION PRIMARY CUTANEOUS INFECTION PULMONARY INFECTION CHRONIC CUTANEOUS INFECTION o Subcutaneous nodule, ulceration DISSEMINATED INFECTION o Skin, bone, GUT, CNS, spleen o Granulomatous mycotic infection in skin, lungs, or other organs. LABORATORY DIAGNOSIS Direct microscopic exam o KOH o H&E Culture Serology: o Immunodiffusion test o ELISA to detect antibodies to exoantigen A

Skin test (Blastomycin antigen) o Limited/no diagnostic value

TREATMENT Amphotericin B Itraconazole Fluconazole Corrective surgery PARACOCCIDIOMYCOSIS Paracoccidiodes brasiliensis Thermally dimorphic fungi 360C multiple budding yeast cells Saprobic phase Septate hyphae, conidia EPIDEMIOLOGY Mostly in rural areas of Latin America, particularly among farmers Males more than females Not communicable PATHOGENESIS & CLINICAL FINDINGS Inhalation of conidia convert to large multipolar budding yeast ingested but not cleared by macrophages may be dormant for 40 years Initial lesion occurs in the lungs Pulmonary granuloma chronic, progressive disease dissemination May spread into the skin, mucocutaneous tissues, lymph nodes, spleen, liver, adrenals, and other sites LABORATORY DIAGNOSIS Microscopic examination o KOH o Culture Serology o Complement fixation o Immunodiffusion TREATMENT Itraconazole, Ketoconazole Co-trimoxazole, Amphothericin B

I. CANDIDIASIS Normal Flora Most common systemic mycosis Important sp: o Candida albicans o Candida tropicalis o Candida parapsilosis o Candida glabrata o Candida guillermondii o Candida dubliniensis Candida albicans Morphology: Pseudohyphae Clamydoconidia Blastoconidia (Budding yeast) BAP - Moist, opaque colonies SDA - Soft, cream-colored colonies with yeast odor Germ Tube - Differentiating test - Serum; 37C X 90 mins - True hyphae Superficial Candidiasis Thrush o Tongue, Lips, Gums, Palate o Patchy to confluent o Whitish pseudomembrane (Epithelial cell, yeast, pseudohyphae) Vulvovaginitis o Irritating o Pruritic o Discharge o Superficial Candidiasis Cutaneous Candidiasis o Red, moist o May develop vesicles Onychomycosis o Painful o Erythematous swelling of the nail fold (Drumstick appearance) o Destroy nails

OPPORTUNISTIC MYCOSES INFECTION

Candidiasis Cryptococcosis Aspergillosis Mucormycosis Pneumocystis Penicillosis

Risk Factors: AIDS Pregnancy DM Young and old Pills Trauma (Burns, maceration) Treatment with CortIcosteroids/ Antibiotics Cellular immunodeficiency Systemic Candidiasis Candidemia o Indwelling catheters, surgery, IV drug abuse, aspiration, damage to the skin or GIT Endocarditis o Deposition and growth of yeast and pseudohyphae on prosthetic heart valves or vegetations UTI o Foley catheters, Diabetes, Pregnancy, Antibacterial antibiotics Chronic Mucocutaneous Candidiasis Rare Onset: Early childhood Treatment: Superficial: Topical Nystatin / Oral Ketoconazole/ Fluconazole Systemic: Amp B + Oral flucytosine/ Fluconazole/ Caspofungin Eliminate contributing factors Prevention: Avoid disturbance of normal flora NOT communicable II. CRYPTOCOCCOSIS Important sp: o Cryptococcus neoformans o Cryptococcus gattii Reservoir: Bird droppings (Pigeon) Mode of transmission: Inhalation of dessicated yeast/ smaller basidiospres Cryptococcus neoformans Morphology: Spherical, budding yeast Thick non-staining capsule Produce whitish mucoid colonies 2-3 days at 37 C (+) Lactase

Pathogenesis Inhaled yeast cells ingested by macrophages Survive intracellularly Capsule inhibits phagocytosis Capsule and melanin protect from oxidative injury Hematogenous and lymphatic dissemination to the brain Chronic meningitis Headache, Stiff neck, disorientation Fatal if untreated NOT contagious Diff Dx: Brain tumor, Brain abscess, Degenerative CNS disease, Mycobacterial or other Fungal menigitis Dx: Culture (w/o Cycloheximide); Serology (Latex agglutination) Other forms: o Primary cryptococcal pneumonia o Hematogenous dissemination o Genitourinary (prostatic) cryptococcosis o Primary cutaneous cryptococcosis Treatment: Amp B + Flucytosine (Standard) Fluconazole Prevention: Avoid exposure to reservoir III. ASPERGILLOSIS Important sp: o Aspergillus fumigatus (most common) o flavus o niger o terreus o lentulus Morphology: Long conidiospores with terminal vesicles on which phialides produce basipetal chains of conidia Cottony colonies MOT:

Inhalation of conidia Transfer to wound via contaminated tape/bandages

Pathogenesis Inhaled conidia bind to fibrinogen and laminin in alveolus Conidia germinate and hyphal forms secrete proteases and invade epithelium Vascular invasion results in thrombosis and infarction of tissue Hematogenous dissemination Allergic Forms Asthmatic reaction upon exposure Aspergilloma (fungus ball) Inhaled conidia enter preexisting cavities Previous Cavitary Disease (Tuberculosis, sarcoidosis, Emphysema) Cough, dyspnea, weight loss, fatigue, hemoptysis Invasive Forms Spread to GIT, kidney, liver, brain, other organs Treatment Amphotericin B, Itraconazole, Voriconazole, Posaconazole Surgery Prevention Monitor airborne contaminants in patients rooms Reduce visiting Isolate patient IV. MUCORMYCOSIS Important members: o Rhizopus sp. o Rhizomucor sp. o Absidia sp. o Cunninghamella sp. o Mucor sp. Rhinocerebral mucormycosis Germination of the sporangiospores in the nasal passages Invasion of the hyphae into the blood vessels, causing thrombosis, infarction, and necrosis Thoracic mucormycosis Inhalation of the sporangiospores with invasion of the lung parenchyma and vasculature Treatment: Aggressive surgical debridement Amphotericin B Control underlying disease

VI. PNEUMOCYSTIS PNEUMONIA Pneumocystis jiroveci Pneumonia in immunosuppresed patients Previously a Protozoa (cysts and Trophozoite forms) Ascomycetes Reservoir: Maybe an obligate member of the normal flora Transmission: Aerosols Morphology: Thick-walled cysts; spherical to elliptical 4-8 nuclei Thin-walled trophozoite Giemsa, Toluidine blue, Methamine silver, Calcoflour white Treatment: Trimethoprim-Sulfamethoxazole Pentamidine isethionate VII. PENICILLIOSIS Important spp: Penicillium marneffei Reservoir: Soil; associated with bamboo rats Morphology: Septate, branching hyphae bearing phialides and basipetal chains of conidia In tissue, unicelullar yeast-like cells Green-yellow colonies with diffusible reddish pigment

Manifestation: Cough, fever, fatigue, weight loss, lymphadenopathy Cutaneous and subcutaneous papules, pustules or rashes Treatment: Amphotericin B then Itraconazole 90% mortality if without treatment

Edited by: AOB MD II-C 09/02/13 Happy aral~ and dont forget to take enough rest that we all deserve~ ^_^