You are on page 1of 8

CHAPTER XXIV – THE MEDICALLY IMPORTANT MYCOSES 6.

Treatment
a. Topical application of 2.5% selenium sulfide
Superficial Mycoses
for 10 minutes daily for 7 days
These are caused by fungi affecting the superficial b. Topical miconazole and ketoconazole
layers of the skin such as the stratum corneum and hair. c. Folliculitis – treated with oral ketoconazole
They are asymptomatic but aesthetically displeasing.
B. Tinea nigra (Tinea nigra palmaris)
A. Tine versicolor (Pityriasis versicolor) A. Clinical Features
1. Clinical Features 1. Blackish-brown macular patches resembling
a. It is a chronic and non-irritating superficial faded silver nitrte stain occurring most
infection of the stratum corneum occurring frequently on the falms but also on the
on the chest, upper back, arms, abdomen soles or elsewhere
and rarely on the face. 2. Lesions are not elevated or scaly
b. Lesions are described as superficial B. Causative Agent: Phaeoannellomyces werneckii
brownish scaly areas on light-skinned (Cladosporium or Exophiala werneckii)
persons and lighter areas on dark-skinned C. Laboratory Diagnosis
persons Specimen: Skin Scrapings
2. Causative Agent: Malassezia furfur 1. Direct KOH or calcofluor white
(Pityrosporum orbiculare – yeast phase) examination
3. Predisposing Factors: a. Olive or brown-pigmented, branched,
i. Hot and humid climate septe hyphae ad budding yeast cells
ii. Excessive perspiration that are one- or two-celled
iii. Corticosteroid use b. Older colonies exhibit one- or two-
iv. Malnutrition celled conidia produced by annelids,
v. Heredity that bear successive rings (annelations)
4. Other Diseases Caused by M. furfur 2. Culture (Sabouraud’s medium with and
a. Disseminated infection in infants, young without antibiotics)
children and adults receiving lipid a. Initial colonies are glossy, black, and
replacement therapy yeast-like in appearance
b. Folliculitis b. With age, colonies become
c. Possibly seborrheic dermatitis or dandruff filamentous with velvety-gray aerial
5. Laboratory Diagnosis hyphae
Specimen: Skin Scrapings D. Treatment
a. Direct Microscopic Examination 1. Topical keratolytic solutions of sulfur,
i. 10% KOH salicylic acid or tincture of iodine
ii. Calcofluor white stain 2. Simple shaving of superficial epidermis with
Appearance: blunt-ended short hyphae scalpel blade
and clusters of spherical spores that
form “spaghetti and meatballs” pattern C. Piedra (Trichosporosis)
b. Wood’s light (ultraviolet radiation of lesions A fungal infection of the hair characterized
in a darkened room) by hard nodules distributed irregularly along the
i. Lesions fluoresce golden yellow or length of the shaft which are easily felt by palpation
brownish 1. Black Piedra
c. Culture a. Caused by Piedraia hortai
i. Not required to establish a diagnosis b. Occurs in tropical areas
ii. M. furfur grows on Sabouraund’s c. Crushed nodules in KOH preparation show
medium overlaid with olive oil; a numerous oval asci, containing 2-8 aseptae
related species M. pachydermatis does ascospores; ascospores are spindle-shaped
not require added lipid for growth (fusiform) and have a filament at each pole
d. Any fungal culture medium lacking Colony usually
Thick-walled, spindle-
membranous with
cycloheximide may be used; colonies are feathery periphery;
shaped, multi septate,
rough-walled
black and composed of hyphae and center of colony white 1
M. canis macroconidia some
chlamydospores to buff over orange- week
with a curved tip;
yellow; lemon-yellow
e. Treatment is by cutting the hair microconidia rarely
or yellow orange
seen
2. White Piedra apron and reverse
Thick-walled rough,
a. Caused by Trichosporon beigelii (T. elliptical
Cinnamon-colored,
cutaneum) 1 multiseptated
M. gypseum powdery colony;
b. Occurs commonly intemperate regions week macroconidia;
reverse light tan
microconidia few or
c. Crushed nodules in KOH preparation show absent
hyaline hyphae and arthrospores Many round to
globose microconidia
d. Culture shows cream-colored, soft colonies
most commonly borne
composed of blastospores and septate Different colonial
in grapelike clusters or
types; white to
hyphae which fragment into arthrospores laterally along the
pinkish, granular and
hyphae; spiral hyphae
e. T. beigelii does not ferment carbohydrates T. mentagro- fluffy varieties; 7-10
in 30% of isolates;
phytes occasional light yellow days
but aerobically utilizes certain substrates periphery in younger
macroconidia are thin-
walled, smooth, club-
f. Treatment is the same cultures, reverse buff
shaped &
to reddish brown
multiseptated;
Cutaneous Mycoses (Dermatomycoses) numerous or rare
depending upon strain
These are fungal infections involving the superficial Colonial types vary Microconidia usually
from white downy to teardrop, most
keratinized tissues of the body such as the skin, hair, and pink granular; rugal commonly borne
nails. They are caused by a group of fungi commonly called folds are common;
2
along sides of the
T. rubrum reverse yellow when hyphae; macroconidia
dermatophytes which breakdown and utilize keratin as a colony is young;
weeks
usually absent but
source of nitrogen but are incapable of penetrating the however, wine red when present are
subcutaneous tissue. The three genera associated with color commonly smooth, thin-walled,
develops with age and pencil-shaped
dermatomycoses include: Microconidia are
teardrop or club-
White, tan to yellow shaped with flat
1. Epidermophyton – affecting skin and nails or rust suede-like to bottoms; vary in size
2. Microsporum – affecting skin and hair powdery; wrinkled but usually larger than
7-14
3. Trichophyton – affecting skin, hair, and nails T. tonsurans with heaped or other dermatophytes;
days
sunken center; balloon forms-aged
reverse yellow to tan pleomorphic
A. Morphology and Identification of Common to rust red microconidia;
macroconidia usually
Dermatophytes
rare
Irregularly heaped,
Hyphae usually sterile;
(Table 24-1. Characteristics of Commonly Isolated smooth white to
T. 2-3 many antler-types
cream colony with
Dermatophytes) schoenleinii
radiating grooves;
weeks hyphae seen (favic
Dermatophy Growth chandeliers)
Colonial Morphology Micromorphology reverse white
tes Rate Port wine to deep Branched, tortuous
Macroconidia large, violet colony, may be hyphae that are
Center of colony tends thing smooth-walled, heaped or flat with 2-3 sterile;
to be folded and is multiseptated, clavate T. violaceum
waxy-glabrous weeks chlamydospores
khaki green; periphery 1 and borne singly or in surface; pigment may commonly aligned in
E. floccosum
is yellow; reverse week clusters of two or be lost on subculture chains
yellowish brown with three; microconidia Microconidia rare;
observable folds are absent; numerous large and teardrop
chlamydospores when seen;
Sterile hyphae; Glabrous to velvety macroconidia
terminal white colonies; rare extremely rare, but
chlamydospores, favic T. stains produce yellow- 2-3 form characteristic
Downy white to
chandeliers, and verrucosum brown color; rugal weeks “rat-tail” types when
salmon pink colony; 2
M. audouinii pectinate bodies; folds with tendency to seen; many
reverse tan to salmon weeks
macroconidia rarely sink into agar surface chlamydospores seen
pink
seen – bizarre-shaped in chains, particularly
is seen; microconidia when colony is
rare or absent incubated at 37°C
1. Epidermophyton floccosum (see table 24-1) Anthropophilic species produce relatively mild and
2. Microsporum (for colonial and microscopical chronic infections in humans whereas zoophilic
morphologies – see table 24-1) dermatophytes cause more inflammatory and acute
a. M. audouinii infections that respond better to treatment and usually do
i. Infected hair shafts fluoresce yellow-green not recur.
using a Wood’s lamp
2. Transmission
ii. Addition of yeast extract may stimulate
a. Contact with dermatophytes in soil or in
growth and production of macroconidia
animals
iii. Grows poorly on sterile rice grains (rice
b. Anthropophilic species are transmitted by direct
medium)
contact or fomites (ex. Infected hairs on hats,
b. M. canis
caps, combs, or barber clippers)
i. Infected hairs fluoresce bright
yellow-green using a Wood’s lamp
3. Predisposing Factors
ii. Grows well on sterile rice grains
a. Hot, humid climates
c. M. gypseum
b. Crowded living conditions
i. Infected hairs generally do not
c. Increased perspiration
fluoresce using a Wood’s lamp
d. Heavy exposure
3. Trichophyton (infected hair do not fluoresce under
e. Young individuals
a Wood’s lamp)
f. Genetic predisposition
The most common species recovered in the
clinical laboratory are T. rubrum and T. mentagrophytes
4. Clinical Forms of Dermatophytes
hence; they should be differentiated (for colonial and
Cutaneous mycoses are usually referred to as tinea
microscopical morphologies – see table 24-1)
(ringworm) because of the raised circular lesion which has
a. T. rubrum
an outer ring of an active progressing infection with central
i. No specific nutritional requirement
healing within the ring.
ii. Does not perforate hair in vitro (hair baiting
test) Tinea capitis
iii. Does not produce urease a. Site of lesions
b. T. mentagrophytes i. Scalp
i. Produces urease ii. Endothrix – presence of arthroconidia (from
ii. Perforates hair in vitro (hair baiting test) fragmentation of hyphae) within hairshaft but
c. T. tonsurans without destruction of cuticle
i. Growth enhanced by thiamine iii. Ectothrix – presence of arthroconidia (from
d. T. verrucosum fragmentation of hyphae) around or on the
i. Growth enhanced at 35-37C surface of hairshaft with destruction of cuticle
ii. Growth requires thiamine and inositol b. Most commonly isolated organisms
iii. Grows in media with 4% casein and 0.5% i. Epidemic tinea capitis – T. tonsurans, M.
yeast extract audouinii (most important), T. violaceum
iv. Early hydrolysis of casein ii. Non-epidemic tinea capitis – M. canis, T.
e. T. schoenleinii (see table 24-1) verrucosum, M. gypseum
f. T. violaceum c. Manifestation
i. Growth enhanced with thiamine i. T. tonsurans and T. violaceum – endothrix
B. Clinical Infection type of invasion; circular, scaly patches of
1. Natural Habitat of Common Dermatophytes alopecia; stubs of hair remain in the
Anthropophilic Zoophilic Geophilic epidermis of the scalp after the brittle hairs
(humans) (animals) (soil)
E. floccosum M. canis (dogs, cats) M. gypseum have broken off and give the typical “black
M. audouinii T. mentagrophytes var dot” ringworm appearance
T. mentagrophytes var interdigitale mentagrophytes
ii. T. verrucosum – lesions are deep, pustular,
T. rubrum (rodents)
T. schoenleinii T. verrucosum (cattle) and inflammatory; endothrix and ectothric
T. tonsurans T. violaceum type of invasion; may induce a severe
combined inflammatory and hypersensitivity Tinea pedis (athlete’s foot)
reaction called a kerion. a. Site of lesions
iii. Microsporum species – ectothrix type of i. Feet particularly the toes, webs, and soles
invasion b. Commonly isolated organisms
i. T. rubrum and T. mentagrophytes
Tinea favosa (favus)
ii. E. floccosum
a. Site of lesions
c. Manifestations
i. Scalp
i. Acute; itching, red vesicular lesions
ii. Torso
ii. Chronic; itching, scaling and fissures
b. Causative agent: T. schoenleinii
c. Manifestation Tinea manus
i. Formation of yellowish cup-shaped crusts or A. Site of lesions
scutulae i. Interdigital areas and palm
ii. Extensive alopecia and scarring of the scalp B. Commonly isolated fungi
iii. Mousy odor to scalp a. Same as in tinea pedis
C. Manifestations
Tinea barbae (barber’s itch)
1. Usually associated with tinea pedis
a. Site of lesions
2. Hyperkeratotic (white flakes or vesicular or
i. Bearded area of face and neck
erythematous)
b. Commonly isolated organisms
i. T. rubrum Tinea unguium
ii. T. verrucosum a. Site of lesions
c. Manifestations i. Nails
i. Mild superficial edematous, erythematous b. Commonly isolated dermatophytes
lesions or; i. T. rubrum and T. mentagrophytes
ii. Sever deep pusticular folliculitis ii. E. floccosum
c. Manifestations
Tinea corporis
i. Nails thickened or crumbling distally
a. Site of lesions
ii. White patches on surface or invasive infection
i. Arms
beneath nail plates
ii. Legs
iii. Usually associated with tinea pedis
iii. Torso
b. Commonly isolated fungi Dermatophytid (id reaction)
iv. T. rubrum An allergic response to fungal antigens wherein a
v. M. canis dermatophyte infection in one area (e.g., Tinea pedis) elicits
vi. T. mentagrophytes an allergic reaction elsewhere on the body (e.g., the hands).
c. Manifestations
5. Laboratory Diagnosis
vii. Circular patches with advancing red,
Specimen: skin and nail scrapings, hairs
vesiculated border and central scaling
a. Examination of infected hairs under Wood’s light
viii. Pruritic
b. Microscopic examination using 10-20% KOH (or
Tinea crusis (jock itch) calcofluor white)
a. Site of lesions i. Microsporum species – form dense sheaths
i. Genitocrural folds of spores in a mosaic pattern around the
b. Commonly isolated fungi hair (extothrix)
i. T. rubrum and T. mentagrophytes ii. Trichophyton species – form parallel rows
ii. E. floccosum of spore outside (ectothrix) or inside
c. Manifestations (endothrix) the hair shaft
i. Erythematous scaling lesion in intertriginous iii. T. schoenleinii – favic hairs present
area characteristic air spaces in the hair which
ii. Pruritic are readily filled with fluid in KOH
preparations.
c. Culture iii. Mycelial to yeast conversion at 37C in
i. Mycosel 12-48 hours
ii. DTM 3. Transmission
iii. Cornmeal agar – for production of a. Through traumatic inoculation with
macroconidia contaminated material (e.g., thorn or
iv. Inhibitory mold agar splinter, brushing against a tree bark)
v. Sabouraud’s agar with antibiotics b. Inhalation of infectious particles (in
d. Id reaction is diagnosed by a negative microscopic pulmonary sporotrichosis)
and cultural examination of the reaction site and 4. Clinical Manifestation
finding of dermatophytosis elsewhere on the body a. Lymphocutaneous sporotrichosis (75% of
cases)
6. Treatment
i. Lesions appear first in the cutaneous
a. Topical antibiotics such as cream preparations of and subcutaneous tissue and
tolnaftate, miconazole nitrate, haloprogin, progressively involve the draining
clotrimazole, econazole, or ciclopirox lymphatics
b. Oral griseofulvin for long periods – most effective ii. Initially with a small, movable, non-
especially for scalp and nail infections tender, subcutaneous nodule develops
c. Oral ketoconazole but a small ulcer may also be seen
iii. The subcutaneous nodule becomes
Subcutaneous Mycoses discolored and the skin darkens from
These are infections that involve the skin and subcutaneous red to black which subsequently erupts
tissue which may rarely become systemic or disseminated. to form an ulcer or sporotrichotic
chancre
A. Sporotrichosis (Rose gardener’s disease) iv. After a few weeks, the primary lesion
1. Causative agent heals and new ones develop
a. Thermally dimorphic sporothrix schenkii b. Chronic sporotrichosis
whose natural habitat is living or dead i. After the primary lesion, multiple
vegetation subcutaneous nodules develop along
2. Morphologic and Cultural Characteristics the lymphatic channels and become
a. Mycelial phase hard and cordlike
i. Colonies are usually small, moist and ii. The course is the same and if untreated,
white to cream colored which on becomes chronic, but may heal
further incubation become spontaneously
membranous and coarsely matted, c. Fixed sporotrichosis
wrinkled, with the color becoming i. Presence of only one lesion without
irregularly dark brown or black and the involvement of the lymphatics
colony become leathery ii. Lesion may be ulcerative or appear as a
ii. Microscopically hyphae are delicate, plaque or rash
septate, exhibit branching and bear d. Pulmonary sporotichosis (rare)
one-celled conidia which are borne 5. Laboratory Diagnosis
bouquet-like, in clusters from the tips Specimen: exudates from unopened
of single conidiophores subcutaneous nodules or from open draining
b. Yeast phase lesions; biopsy material
i. Colonies are pasty and grayish a. KOH or calcofluor white preparations
ii. Microscopically they are usually b. Special stains
spherical, oval, singly, or multiply i. PAS
budding cells but some are fusiform, ii. Methenamine silver stain
elongated or cigar-shaped; asteroids iii. Fluorescent antibody stain
may also be seen c. Culture
i. Inhibitory mold agar or
ii. Sabouraud’s agar with antibiotics collarette; clusters of conidia are
iii. Others produced by the phialides through an
d. Serology apical pore
i. Yeast cell agglutination test c. Fonsecae species
ii. Sporotrichin May exhibit Phialophora-type or
e. Treatment Cladosporium-type of sporulation and
i. Oral solution of saturated potassium also produce lateral or terminal conidia
iodid (SSKI) – treatment of choice for froma lengthening conidiogenous cell
cutaneous sporotrichosis (can be resembling a series of bend knees
administered topically also) (conidia are produced sympodially)
ii. Amphotericin B, ketoconazole, i. F. pedrosoi – produce conidial
dihydroxystilbamidine, griseofulvin and heads
flucytosine ii. F. compacte – produce more
compact conidial heads
B. Chromomycosis (Chromoblastomycosis) 4. Laboratory Diagnosis
This is a chronic fungal infection acquired thru Specimens: Scrapings or biopsy from lesions
traumatic inoculation of spores, primarily in the a. Microscopic examination
lower extremities. It is characterized by the i. Scrapings from crusted areas added
development of a papule at the site of injury that to 10% KOH show presence of
spreads to form warty or tumor-like lesions muriform or sclerosis bodies, which
(cauliflower-like). Secondary infection and appear rounded, brown resembling
ulceration may ensue. Rarely, brain abscess may copper pennies that exhibit
occur. transverse septations
1. Causative Agents b. Culture
Chromomycosis is caused by i. Sabouraud’s with or without
dematiaceous fungi which are imperfect antibiotics
fungi that produce varying amount of c. Extraction and detection of exoantigens
melanin-like pigments found in the conidia 5. Treatment
or hyphae or both. a. Flucytosine – the best
a. Cladosporium carrionii b. Amphotericin B and the azoles especialy
b. Phialophora verrucose itraconazole
c. Fonsecae pedrosoi and F. compacta
2. Cultural Characteristics C. Phacohyphomycosis
a. The dematiacous fungi have similar This term refers to infections characterized by
characteristics presence of darkly pigmented, septate hyphae in
b. All are slow-growing and produce tissue. Clinical forms vary from solitary
heaped-up and slightly folded, darkly encapsulated cysts in the subcutaneous tissue to
pigmented colonies with a grayish- brain abscess.
velvety appearance; the reverse side of 1. Causative Agents
the colonies is jet black a. Exophiala jeanselmei
c. Yeas species are usually pleomorphic i. Grows early as a black yeast with
and produce a dark, moist colony dark budding yeast forms seen on
3. Microscopic appearance microscopy of culture
a. Cladosporium species b. Phialophora (see above)
Produce long chains of elliptical conidia c. Wangiella dermatitidis
(blastoconidia) borne from erect, tall i. Early form same as that of
branching conidiosphores Exophiala
b. Phialophora species ii. Produces conidia by phialides that
Produce short, flask-shaped to tubular lack collarettes
phialides, usually with a well-developed
d. Xylohypha bantiana (Cladosporium c. P. boydii, microscopically exhibit
bantianum or Cladosporium trichoides) cleistothecia, which are sac-like
i. Cladosporium type of sporulation structures that contain asci and
ii. Infection usually recognized only at ascospores; the ascopores are oval and
autopsy delicately pointed at each and
e. Other normally saprophytic resembling conidia of the sexual form
dematiaceous fungi 2. Laboratory Diagnosis
2. Laboratory Diagnosis a. Macroscopic examination of granules
a. Microscopic examination (KOH from lesions are white to yellow
preparation) b. Microscopically the granules consist of
i. Irregular dark, hyphae, as well as loosely arranged, hyaline or pigmented,
yeasts and pseudohyphae are seen intertwined hyphae
in tissue 3. Treatment
b. Culture a. Topical nystatin and potassium iodide
3. Treatment: same as in Chromomycosis b. Amphotericin B and miconazole

D. Mycetoma (Madura foot or Maduromycosis) E. Rhinosporidiosis


This is chronic granulomatous infection usually A chronic infection characterized by the
involving the lower extremities. It is characterized development of polypoid masses of the nasal
by swelling, purplish discoloration, tumor-like mucosa caused by Rhinosporidium seeberi.
deformities of the subcutaneous tissue and multiple 1. Laboratory Diagnosis
sinus tracts that drain pus containing yellow, red, a. Histologic examination of infected
white, or black granules. There are two types of tissue
Mycetoma: i. Reveals epithelial hyperplasia and
cellular infiltrate of neutrophils,
Actinomycotic mycetoma
lymphocytes, plasma cells and giant
- Caused by Nocardia,
cells
Actinomadura, Streptomyces and
ii. Large thick-walled sporangia; the
aerobic actinomycetes
cell wall of the spherule is
Eumycotic mycetoma
multilayered and stains with
- Caused by a true fungi, most
mucicarmine
commonly Pseudoallescheria
b. Serologic test for rhinosporidial antigen
boydii which is found in soil and
2. Treatment
sewage; transmitted via
a. Topically, surgically and by local
traumatic inoculation
injection of ethylstilbamidine
1. Culural and Microscopic Appearance
a. P. boydii is a hyaline mold (sexual stage)
F. Lobomycosis
that grows rapidly as white fluffy colony
A chronic subcutaneous infection of
that changes to a brownish-gray
humans and dolphins caused by Loboa loboi
(mousey) mycelium; the reverse of the
(Paracoccidiodes loboi).
colony is black
1. Laboratory Diagnosis
b. The asexual stage is called
Specimens: Skin scrapings, biopsies or
Scedosporium apiospermum and
wet preparations of exudative lesions
microscopically produces elliptical
a. Direct microscopic examination
(sperm-shaped), single-celled conidia
i. Large, spherical or oval yeasts that
borne singly from the tips of long or
exhibit multiple budding and form
short conidiosphores (annelophores);
short chains of three to six or more
clusters of conidiophores with conidia
yeast cells which are
produced at the ends are called
multinucleated and thick-walled
coremia
b. Histologic examination
i. Granulomatous nodules and
occasional asteroid bodies
ii. Yeasts stain with PAS or
methenamine silver and may be
seen inside macrophages
2. Treatment
a. Sulfa drugs
b. Surgical excision

G. Rhinoentomophthoromycosis
(entomophthoromycosis conidiocolae)
A rare infection of the nasal mucosa caused
by Entomophthora coronate (Conidiobolus
coronatus)

Systemic or Deep Mycoses

These are fungal infections that may involve any of the


internal organs of the body as well as lymph nodes, bone,
subcutaneous tissue, and skin. They are caused by
inhalation of thermally dimorphic fungi which exist in two
phases of growth:

A. Yeast phase, parasitic, invasive or tissue form


a. Takes place at 35-37C
B. Mycelial phase, mold or saprobic form
a. Takes place at room temperature 25-30C

Traditionally, the definitive diagnosis of a dimorphic


fungus has been made by observing both the mold and
yeast form. But now, most laboratories consider the
exoantigen test as the most conclusive method.