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Subject: Microbiology Topic: Fungi associated with RTI 1 Lecturer: Dr.

Padla Date of Lecture: 9/1/11 Transcriptionist: pinkyred Pages: 6

SYSTEMIC MYCOSES
involve any tissue/organ most serious of the fungal infections 2 main groups 1. Endemic respiratory mycoses 2. Opportunistic mycoses 1 cutaneous infection (rare)

ENDEMIC RESPIRATORY MYCOSES acquired from inhalation of conidia (infectious particles) from the soil o portal of entry: respiratory tract o 1 focus of infection: lungs no evidence of [direct] transmission among humans, animals agents: o have restricted geographic distribution o exhibit thermal dimorphism (mycelia in natural environment at room temperature; yeast or spherules in tissues at 37C) o infect otherwise healthy individuals 1. 2. 3. 4. 5. Histoplasmosis Blastomycosis Coccidioidomycosis Paracoccidioidomycosis Penicilliosis marneffei

figure shows calcification in the hilar and mediastinal nodes, chest x-ray mimicking pulmonary tuberculosis CAUSATIVE AGENT Histoplasma capsulatum o a misnomer. o fungi is not capsulated, but was once thought so. Even when it was proven to have no capsule, the name was retained. o anamorphic form ascomycete (teleomorphic form [sexual state]: Ajellomyces capsulatus) thermally dimorphic facultative intracellular (resides intracellularly in the Reticulo-endothelial system [RES]) grows in soil contaminated with bat/bird excreta infectious particle: microconidia tissue form: intra- and extra- cellular yeast cells *There are 2 types of conidia: macro and micro. The former cannot be the infectious particle, simply because it is too big. It takes the smallest particle to reach the lung alveoli LABORATORY DIAGNOSIS Histopathology sections o Giemsa o Periodic Acid Schiff (PAS) o GMS small, round to oval intra- and extra- cellular yeast cells

HISTOPLASMOSIS a.k.a. Darlings/ Cavers/ Spelunkers disease, North American Histoplasmosis Discovered by Samuel Darling (hence, the name, not darling BF/GF) has worldwide distribution but particularly common in Central and Eastern USE, Central and South America, Africa and Far East. Highest distribution in the USA 1 sources of infection: soil, bat/avian habitat may be contracted by occupational exposure (e.g. cave explorers, bat guano miners, etc.). risk factors: exposure to bird (e.g. chicken, turkey, crow, blackbird, starling, etc.) or bat droppings DISEASE Asymptomatic infection (90-95% of cases) Pulmonary infection (5-10%) o acute very mild (e.g. fever, cough, flu-like symptoms) o chronic can mimic any pulmonary tuberculosis Disseminated infection o Reticulo-endothelial system (RES) involvement o muco-cutaneous infection

*No KOH examination, because intracellular yeast cells are difficult to demonstrate using it. Culture at room temperature (RT)

SY 2011-2012

o o o

fine, sepatate hyphae large tuberculate macroconidia (quite diagnostic) small microconidia

Culture at 37C o small, single-budding yeast cells o one has to demonstrate the multi-yeast conversion because it is thermally dimorphic

DISEASE Asymptomatic infection (~50% of cases) Pulmonary infection (acute/chronic) o acute: pneumonia-like o chronic: PTB-like Disseminated infection o skin, bone, GUT, CNS, spleen, kidney Chronic cutaneous infection o verrucous/ulcerative lesions 1 cutaneous infection (rare)

*cultures are the gold standard for diagnosis of endemic respiratory mycoses Identification of culture o exoantigen test o nucleic acid probe *in lieu of the multi-yeast conversion Other diagnostic tests o Skin test: no diagnostic significance o Serology (CF test) o antigen detection TREATMENT AND PREVENTION treatment not required for most cases itraconazole, ketoconazole, fluoconazole (pulmonary), ampho B (systemic) surgical resection of pulmonary lesions wearing protective clothing, masks soil decontamination with 3-5% formalin (when feasible. of course one cannot decontaminate a whole cave) BLASTOMYCOSIS a.k.a. North American Blastomycosis/ Chicagos/ Gilchrists Disease found in North America, Africa, Asia outbreaks associated with activities around moist soil (usually around rivers and creeks) enriched with organic debris, rotting wood natural disease common in cats and dogs (a common veterinary problem) canine blastomycosis is an indicator of the fungus in the area

Left: X-ray shows infiltrates similar to TB Right: verrucous/ulcerative lesions CAUSATIVE AGENT Blastomycoses dermatitidis ascomycete (teleomorphic form: Ajellomyces dermatitidis) thermally dimorphic inhabits decaying wood materials probably a soil saphrophyte very rarely cultured from soils [sic] in endemic areas infectious particle: conidia tissue form: broad-based yeast cells LABORATORY DIAGNOSIS KOH/Histopath o thick-walled yeast cells (8-15 m) with single, broad-based bud (characteristic of Blastomyces dermatitidis) (unlike usual yeast cells which are attached by narrow-based buds) Culture at RT o Pyriform conidia (very infectious) borne singly on sepate hyphae Culture at 37C o reveal double-walled yeast cells with single broad-based bud o demonstrate multi-yeast conversion

Identification of Cultures o exoantigen test o nucleic acid probe *more rapid, more specific, more accurate Other Diagnostic Tests o skin test: not much utility o serology o antibody detection o antigen detection o immunofluorescence

TREATMENT Ketoconazole, Itraconazole, Fluconazole, Ampho B (disseminated) Excision/ corrective surgery for verrucous lesions COCCIDIOIDOMYCOSIS a.k.a. Posadas Disease/ San Joaquin Valley Fever/ California disease/ desert rheumatism endemic in the western hemisphere highest endemicity [sic] in semi-arid regions with alkaline soil (specifically the Somoran Desert) outbreaks occur following dust storms, earthquakes, earth excavations DISEASE Asymptomatic infection (~60% of cases) Pulmonary infection (~30-40% of cases) o chronic: can mimic carcinoma o acute Disseminated infection (<2% of cases) o Infection of CNS, bones, skin o meningitis: commonest (I was surprised to find out this word actually exists.) cause of death

*If a spherule ruptures, it releases thousands of endospores, each with the ability to become a spherule itself. LABORATORY DIAGNOSIS KOH/Histopath o thick-walled spherules (10-80 m) filled with non-budding endospores (25 m)

Figure shows hilar adenopathy, common in the disease CAUSATIVE AGENT Coccidioides immitis a deuteromycete thermally dimorphic infectious particle: arthroconidia o rectangular o very resilient; highly infectious (infectious dose: 1) o abundant in alkaline soil o develop into spherules in the lungs tissue form: spherule

Culture at RT o hyphae bearing barrel-shaped arthroconidia (2-4 x 3-6 m) separated by dysjunctor cells (characteristic of arthrospores of the organism)

Culture at 37C o not routinely performed

Identification of Cultures o Exoantigen test o Nucleic acid probe o Demonstration of spherule production in animals, not in-vitro

Other Diagnostic Tests o Skin test (Coccidioidin/spherulla) o Coccidioidin test using spherullin as antigen: quite useful to determine previous infection o serology (complement fixation [CF] test, immunodiffusion) o CF titer is directly proportional: the higher the antibodies, the poorer the prognosis (unlike the usual case wherein higher Abs mean better prognosis) o immunofluorescence

KOH/Histopath o yeast cells (10-30 m) with multiple, narrow-based buds (characteristic)

TREATMENT AND PREVENTION Acute respiratory disease: not necessary to treat traconazole, Ketoconazole, Fluconazole (for meningitis), ampho B surgery for skin lesions reduce exposure to dust (soil) in endemic areas vaccine development in progress PARACOCCIDIOIDOMYCOSIS a.k.a. South American Blastomycosis/ LutzSplendore-Almeidas Disease incidence higher in males (male to female ratio 9-15:1) o mycelium to yeast conversion inhibited by estrogen (specifically -estradiol) people >30 y/o endemic in Central and South America, Southern Mexico DISEASE Asymptomatic infection Pulmonary infection o acute: pneumonia-like o chronic: PTB like Disseminated infection o granulomatous lesions in oral/nasal mucosa: very characteristic, a.k.a. Mulberry lesions o cell wall polysaccharide (alpha-glucan) stimulates granuloma formation

Culture at RT o septate hyphae with atypical pattern of separation

Culture at 37C o yeast cells with mariners/ steering wheel appearance o could be hidden Mickeys if there are only 2 buds

CAUSATIVE AGENT Paracoccidioides brazillensis A deuteromycete Thermally dimorphic Natural habitat remains unknown found to reside in humid soil rich in protein rarely recovered from endemic areas has been cultivated in fruit bats (can be naturally infected), armadillos (9-banded ones are known hosts, but naturally-occurring infection has not been proven) infectious particle: conidia tissue form: yeast cells with multiple, narrowbased buds LABORATORY DIAGNOSIS

IDENTIFICATION OF CULTURE o Exoantigen test o DNA probe OTHER DIAGNOSTIC TESTS o Skin test (Paracoccidioidin): not so much use o Serology (immunodiffusion [preferred], CF)

TREATMENT AND PREVENTION Ketoconazole, Itraconazole, sulfa drugs, ampho B surgical exision of localized lesions PENICILLIOSIS MARNEFFEI endemic in South East Asia (Thailand, China, HK, Vietnam, Indonesia, Taiwan, India)

naturally-occuring infections have been found in bamboo rats bamboo rats o reservoir of infection o epidemiologic markers has become an early indicator of HIV in endemic areas

Culture at 37C o round to crosswalls

oval

yeast

cells

with

DISEASE Pulmonary infection o acute o chronic Disseminated infection o similar to disseminated histoplasmosis (RES involvement) IDENTIFICATION OF CULTURES o exoantigen test, conversion to yeast forms

TREATMENT Itraconazole, Ketoconazole, ampho B (seriously ill) Left: X-ray shows infiltrates Right: cutaneous manifestation ___________END OF TRANX_____________

CAUSATIVE AGENT Penicillium marneffei Thermally dimorphic (only thermally dimorphic Penicillium) Yeast cells reproduce by schizogony (transverse fission) habitat: unknown infectious particle: conidia tissue form: yeast cells with transverse septum LABORATORY DIAGNOSIS KOH/Histopath o small yeast cells (3-5 m), with transverse septum (characteristic)

Hi to reych, arabels, anabels, eloh, jez, and to gempot! Happy birthday to Quen! And to Ramone, hehehehi din to Cuz! And to my dear roommate maanto Hannah, and rr! ^_^ Happy studying!

Culture at RT o Conidiophores branch into metullae that support the phialides that bear chains of conidia o colonies produce diffusible red pigment (very characteristic)

Left: colonies with diffusible red pigment Right: brush-like, fingerlike: characteristic of Penicillium spp.

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