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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 inf
ections are classified according to the tissue lev
els 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


This is a chronic, superficial fungal
disease of the skin
Caused by lipophilic yeast Malassezia
furfur
There are at least six different
Malassezia species recognized only
recently

Epidemiology
Normal inhabitant of the superficial
epidermis and clusters around the
openings of hair follicles
Saprophytic on normal skin of trunk,
head, and neck
Sometime affecting more than 60% of
the population in some tropic
environments

Clinical features
The lesions are small hypopigmented or
hyperpigmented macules
Most common site : back, underarm,
upper arm, chest, neck
Most common in adolescent and young
adult males
Associated with increased sweating

Pityriasis versicolor showing hyperpigmented lesions in a


Caucasian and hyphopigmented lesions in an Australian
Aborigine 1
1

http://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)


Superficial infection located most often on the
palms
Caused by a black yeast Phaeoannellomyces
werneckii (Exophiala werneckii)
The lesions are generally dark colored, non
scaling macules and asymptomatic
Most often in tropical or semitropical areas of
Central and South America, Africa, and Asia

Conidia of Phaeoannellomyces
werneckii

TINEA NIGRA

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/ind

Fungal keratitis
This is an infection on the surface of
cornea with usually follows an injury to
the eye.
The fungi involved are :

Fusarium solani,
Aspergillus fumigatus,
Candida albicans,
and several other genera of filamentous
fungi

Fungal otitis externa


Caused by several species of
Aspergillus (most often A.niger), but
Candida albicans is also capable of
infecting this site.
The major symptoms are itching and
feeling of fullness in ear

Fungal otitis externa


Fungal infection of the
external auditory
canal

canal

BLACK PIEDRA

Fungal infection of the scalp hair


Etiologic agent : Piedraia hortae
Frequent in tropical areas
Clinical findings: Discrete, hard,
dark brown to black nodules on the
hair

Black Piedra
Micros.

Septate pigmented hyphae


Asci with unicellular & fusiform
ascospores with polar filament(s)

Culture

Brown to black colonies

Treatment Topical sdalicylic acid


Azole creams

Piedraia hortae

WHITE PIEDRA
Fungal infection of facial, axillary
or genital hair
Etiologic agent : Trichosporon
beigelii
Frequent in tropical and temperate
zones

White Piedra
Clin.findings

Soft , white to yellowish nodules,


loosely attached to the hair
shaft

Microsc.

Intertwinted septate hyphae


Blastoconidia & arthroconidia

Culture

Soft , creamy colonies

Treatment

Shaving, azole creams

White piedra

Black piedra

Cutaneous mycoses
Dermatophyosis
Cutaneous candidiasis

Dermatophytosis
Dermatophytosis (tinea or ringworm) is the
infection of keratinized structures, including
the nails, hair shafts, and stratum corneum
of the skin, by organisms of three genera of
fungi termed the dermatophytes :
Trichophyton
Epidermophyton keratophilic
Microsporum

DERMATOPHYTOSIS
(=Tinea = Ringworm)
Infection of the skin, hair or nails
caused by a group of keratinophilic
fungi, called dermatophytes:
Microsporum
: Hair, skin
Epidermophyton : Skin, nail
Trichophyton
: Hair, skin, nail

Fungi in Cutaneous Mycoses


TRICHOPHYTON
(TRI)

MICROSPORUM
(KUKUNO)

EPIDERMOPHYTON
(RAMBnO)

KULIT

KULIT

KULIT

RAMBUT

RAMBUT

KUKU

KUKU

II.

Cutaneous mycoses: Fungal infections of the


skin, hair, and nails.
Secrete keratinase, an enzyme that degrades

keratin.
Infection is transmitted by direct contact or

contact with infected hair (hair salon) or cells (nail


files, shower floors).
Examples:

Ringworm (Tinea capitis and T. corporis)

Athletes foot (Tinea pedis)

Jock itch (Tinea cruris)

Dermatophytes ecology
Classified in to 3 categories
Geophilic : normally live in soil (e.g.,
M.gypseum)
Zoophilic : primarily parasitize the body
surfaces of animals but can transmitted to
humans (e.g., T.mentagrophytes, M.canis)
Arthropophilic : generally infect humans and
are transmitted between individuals
(e.g.,E.floccosum)

a. Trichophyton
b.Microsporum

canis

c.Epidermophyton

Epidermophyton floccosum

Microsporum

gypseum

Cutaneous Mycoses
Infections strictly confined to keratinized
epidermis (skin, hair, nails) are called
dermatophytoses - ringworm & tinea
39 species in the genera :
Trichophyton,
Microsporum,
Epidermophyton

Communicable among humans, animals, & soil


Infection facilitated by moist, chafed skin

Cutaneous Mycoses

Ringworm of scalp (tinea capitis) affects scalp &


hair-bearing regions of head; hair may be lost
Ringworm of body (tinea corporis) occurs as
inflamed, red ring lesions anywhere on smooth skin
Ringworm of groin (tinea cruris) jock itch affects
groin & scrotal regions
Ringworm or foot & hand (tinea pedis & tinea
manuum) is spread by exposure to public surfaces;
occurs between digits & on soles
Ringworm of nails (tinea unguium) is a persistent
colonization of the nails of the hands & feet that
distorts the nail bed

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

Tinea is transmitted via the feet by desquamated


skin scales in substrates like carpet and matting.3

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

Tinea Unguium
(dermatophyte onychomycosis)
usually caused by Trichophyton sp.

Tinea Barbae

Tinea Manuum

Trichophyton

Ringworm of the extremities

Tinia unguium

Tinia Capitis

Tinea Corporis

Tinea capitis

Tinea corporis

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


ectothrix invasion by M. gypseum. 3

KOH mount of an infected hair showing an


endothrix invasion caused by T. tonsurans3

Tinea capitis
Tinea capitis

Tinea barbae

Tinea cruris

Clinical Classification of the the


Dermatophytes

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
Natural habitat

: soil

Thermally dimorphic

37C: Round/cigar-shaped yeast cells


25C: Septate hyphae, rosette-like
clusters of conidia at the tips of
the conidiophores

Pathogenesis & Clin.Findings


Etiologic
agent

Sporothrix schenckii (dematiaceous,


dimorphic fungi)

Reservoir

Worldwide distribution
Soil, decaying vegetation

Transmission

Traumatic implantation
Inhalation ( ??? )
Occupational disease

Clinical

Subcutaneous nodules, suppuration,


ulceration, and drainage ;spread down
lymphatic course

SPOROTRICHOSIS
Diagnosis
Samples: Aspiration fluid, pus, biopsy
1.Microscopic examination :
. Direct microscopic examination (KOH),
. Histopathological examination with
Gomori methenamine silver stain (GMS)
2.Culture
3.Serology :Yeast agglutination test
4.Sporotrichin skin test

Lab.diagnosis :
Direct microscopy
Poor sensitivity.
Sparse yeast cells, asteroid body

Culture
Good yield and grows on most media
Room temp for isolation & (37oC is slower:yeast
form)

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
round positive budding yeastlike cells. (PAS)

Cigar-shaped, round form


of S.schenckii (GMS-H&E)

Sporothrix schenckii
Laboratory diagnosis
Culture
Conversion

of 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 cauliflower growths
Very slow progression
Uncommon in children (? time or immune)

Treatment - antifungals / surgery / heat

Chromoblastomycosis
Classified by presence of fungal tissue form &
clinical presentation, not etiologic agent
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

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
cycloheximide resistant )
Slow growing (4-6 wks)
Dark velvety colonies (similar)
Contamination can be a problem

Chromoblastomycosis :
Identification
Sclerotic cells are identical for all etiologic
agents
No dimorphism in vitro
Complex and variable conidiation
Fonsecae, phialophora, rhinocladiella, cladosporia

Hyphae elements are clearly dematiaceous

Chromoblastomycosis

Sclerotic body, Medlar body,


copper pennies,muriform.

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
Leptospharia senegalensis
Exophiala jeanselmei

Actinomadula madurae
Nocardia brasiliensis

Pale grains

Streptomyces somaliensis

Fusarium sp.
Acremonium sp.
Scedosporium
apiospermum

Red-pink grains

Yellow-brown grains

Actinomycetoma pelletieri

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.

SYMPTOMS

The lesions are characterized by:


1)
2)
3)
4)

swelling
suppurating abscesses
granulomas
Sinuses

From sinuses oozes out serosanguinous fluid

MYCETOMA
Diagnosis
Clinical findings are nonspecific
Identification of the infecting
fungus is difficult
Criteria used for identification:
Characteristics of the granule,
Colony morphology, and
Physiological tests

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

Subcutaneous mycosis (mycetoma)

Mycetomaa deep fungal infection

Phaeohyphomycosis
Caused by a number of dematiaceous
(brown-pigmented) fungi where the tissue
morphology of the causative organism is
mycelial
Sclerotic bodies ( - )
NB: Chromoblastomycosis : sclerotic
bodies (+).

Causative agents :
Exophiala, Phialophora, Wangiella,
Bipolaris, Exserohilum, Cladophialophora ,
Phaeoannellomyces, Aureobasidium, Clad
osporium, Curvularia and Alternaria

Clinical forms of
Phaeohyphomycosis
Clinical forms range from:
localized superficial infections of the
stratum corneum (tinea nigra)
to subcutaneous cysts
phaeohyphomycotic
cyst
to 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
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

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.

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 chromoblastomycosis, 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

Loboa loboi
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

Candidiasis of skin, mucous


membranes and nails
Cutaneous candidiasis : including
diaper candidiasis,
intertrigo
paronychia ,and
onychomycosis

Candidiasis
Thrush

Vaginal

Candidiasis of skin, mucous


membranes and nails
Vulvovaginal candidiasis and balanitis:
vaginal discharge, dysuria, erythematous
oral contraceptive, pregnancy

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

Chlamydospores of C.albicans

Dont Litter
Keep our class
clean

Candidiasis
Thrush

Vaginal

Cutaneous Mycoses
Infections strictly confined
to keratinized epidermis
(skin, hair, nails) are called
dermatophytoses ringworm & tinea
39 species in the genera
Trichophyton, Microsporum,
Epidermophyton
Communicable among
humans, animals, & soil
Infection facilitated by
moist, chafed skin