SUBCUTANEOUS MYCOSES

SUBCUTANEOUS MYCOSES
Reside in soil or on vegetation
Enter skin or subcutaneous tissue by traumatic inoculation
with contaminated material
Lesions in general:
o Granulomatous
o Expand slowly from the area of implantation
Extension via the lymphatics draining the lesion is slow
except in sporotrichosis
Usually confined to the subcutaneous tissues
Become systemic and produce life-threatening disease
(rare)
I.

SPOROTHRIX SCHENKII
Thermally dimorphic fungus
Lives on vegetation
Associated with grasses, sphagnum moss, rose
bushes, & other horticultural plants
Grows as a mold in ambient temperature
o Branching, septate hyphae & conidia
Grows as a small budding yeast in tissue or in
vitro at 35-37 0C
Causes sporotrichosis
o Chronic granulomatous infection
o Initial episode is typically followed by
secondary spread with involvement of the
draining lymphatics and LN
Morphology & Identification
o Grows well on routine agar media
o Blackish & shiny @ RT
o Wrinkled & fuzzy with age
o Strains vary in pigmentation

From black & gray to whitish

o Produces branching, septate hyphae &
small (3-5 um) conidia
o Thermally dimorphic
o Converts to growth as small,, often multiply
budding yeast cells (fusiform) at 35 0C
Antigenic structure
o Heat-killed saline suspensions of
cultures or carbohydrate fractions
(sporotrichin)
Elicit positive delayed skin tests in
infected humans or animals
o Have specific or cross-reactive antibodies
Pathogenesis & Clinical Findings
o Hx: trauma associated with outdoor
activities & plants
o Location of initial lesion
Extremities
Children: facial lesions
o 75% lymphocutaneous
Initial lesion: granulomatous nodule
Progress to form a necrotic or
ulcerative lesion

Draining lymphatics become thickened

& cord-like
Multiple subcutaneous nodules and
abscesses occur along the lymphatics
o Fixed sporotrichosis
Single nonlymphangitic nodule that is
limited and less progressive
More common in endemic areas
(Mexico) where there is high level of
exposure and immunity in the
population (immunity limits local spread
of the infection)
o Systemic illness:
Pulmonary Sporotrichosis
Results from inhalation of the
conidia
Chronic cavitary tuberculosis
Occur in patients with impaired
cell-mediated immunity
Diagnostic Laboratory Tests
o Specimens:
Biopsy material or exudates from
ulcerative lesions
o Microscopic examination
KOH
Calcoflour white
Routine fungal cell wall stains (more
sensitive)
Gomoris methenamine silver
Stains the cell wall black
Periodic acid-Schiff stain
Imparts red color to the cell
walls
Fluorescent antibody staining
Yeasts are 3-5 um
Spherical to elongated
Asteroid body (Mexico, South
Africa, Japan)
H & E Stain
Asteroid body: central basophilic
yeast cell surrounded by radiating
extensions of eosinophilic material
(depositions of Ag-Ab complexes
& complement)
Culture
o Most reliable method of diagnosis
o Inhibitory mold agar or Sabourauds agar
Confirmation: Growth at 35 0C and
converted to the yeast form
Serology
o Not always diagnostic
Treatment
o Self-limited
o Oral administration of saturated solution of
potassium iodide in milk
Quite effective

o
o

II.

Difficult for many patients to toletrate

Oral itraconazole or another of the azoles
Treatment of choice
Amphotericin B
for systemic disease

Epidemiology
o Occurs worldwide in close association with
plants
o Contact with sphagnum moss, rose thorns,
decaying wood, pine straw, prairie grass, &
other vegetation
o 75% males
Increase exposure
X-linked difference in susceptibility
o Incidence higher among agricultural workers
o Occupational risk for forest rangers,
horticulturists, & similar workers
Prevention
o Measures to minimize accidental inoculation
o Use of fungicides to treat wood

CHROMOBLASTOMYCOSIS (Chromomycosis)
Caused by trau;matic inoculation by any of five
recognized fungal agents that reside in soil and
vegetation
All are dematiaceous fungi, having melaninized
cell walls
o Phialaphora verrucosa
o Fonsecaea pedrosoi
o Rhinocladiella aquaspersa
o Fonsecaea compacta
o Cladosporium carrionii
Infection is chronic
Characterized by slow development of
progressive granulomatous lesions that in time
induce hyperplasia of the epidermal tissue
Morphology & Identification
o Similar in their pigmentation, antigenic
structure, morphology & physiologic
properties
o Colonies:
Compact
Deep brown to black
Velvety, often wrinkled surface
o Identified by their modes of conidiation
o Tissue:
Spherical brown cells (4-12 um)
MURIFORM or SCLEROTIC
BODIES
Divide by transverse septation
Septation in different planes with
delayed separation
Cluster of 4 to 8 cells
Cells within superficial crusts or
exudates
Germinate into septate,
branching hyphae

1.

PHIALOPHORA VERRUCOSA
Conidia are produced from flaskshaped phialides with cup-shaped
correlates

2.

CALDOSPORIUM
(Cladophialophora) CARRIONII
Produce branching chains of
conidia by distal (acropetalous)
budding
Species are identified based on
differences in the length of the
chains and the shape and size of
the conidia
Produces elongated condiophores
with long, branching chains of oval
conidia

3.

RHINOCLADIELLA AQUASPERSA
Produces lateral or terminal
conidia from a lengthening
conidiogenous cell (sympodial
process)
Conidia are elliptical to clavate

4.

FONSECAEA PDEROSOI
Polymorphic genus
Isolatates may exhibit:
Phialides
Chains of
blastoconidia similar
to cladosporium
species
Sympodial,
rhinocladiella-type
conidiation
Form short branching chains of
blastoconidia as well as sympodial
conidia

5.

FONSECAEA COMPACTA
Blastoconidia are almost
spherical, with a broad base
connecting the conidia
Smaller and more compact than
those of F. pedrosoi

Pathogenesis & Clinical Findings

o Introduced into the skin by trauma,
often of the exposed legs or feet
o Primary lesions:
Verrucous & wart-like extension
along the draining lymphatics
Cauliflower-like nodules with
crusting abscesses eventually
cover the area

Small ulcerations or black

dots of hemopurulent material
on warty surface
Elephantiasis
May result from secondary
infection, obstruction, & fibrosis of
lymph channels
Tough satellite lesions
Due either to local lymphatic
spread or to autoinoculation

Histology:
Granulomatous & dark sclerotic
bodies within leukocytes or
giant cells
Diagnostic Laboratory Tests
o Specimens:
Scrapings or biopsies from
lesions
o Microscopic examination
10% KOH
o Spherical cells
Detection of sclerotic bodies
o Diagnostic regardless of
etiologic agent
Extensive hyperplasia of the
dermal tissue
Culture
o Inhibitory mold agar or Sabourauds
agar with antibiotics
o Many similar saprophytic dematiaceous
molds
o Differ from the pathogenic species in
being unable to grow at 370C and being
able to digest gelatin
Treatment
o Surgical excision with wide margins
Therapy of choice
o Chemotherapy with flucytosine or
itraconazole
For larger lesions
o Local applied heat
o Relapse (common)
Epidemiology
o Occurs mainly in tropics
o Saprophytic in nature (on vegetation or
in soil)
o Occurs chiefly on the legs of barefoot
agrarian workers following traumatic
introduction of the fungus
o Not communicable
Prevention
o Wearing shoes
o Protecting the legs

III.

PHAEOHYPHOMYCOSIS
Characterized by the presence of darkly
pigmented septate hyphae in tissue
Both cutaneous & systemic infections

IV.

Clinical forms:
o From solitary encapsulated cysts in
the subcutaneous tissue to sinusitis to
brain abscesses
Over 100 species have been associated with
dematiaceous molds (all exogenous molds)
Common cause:
o Exophiala jeanselmei
o Phialophora richardsiae
o Bipolaris spicifera
o Wangiella dermatitidis

Others:
o Exserohilum rostratum
o Alternaria species
o Curvularia species
Increased incidence among immunocompetent &
compromised patients
Tissue:
o Hyphae are large (5-10 um) often
distorted & may be accompanied by
yeast cells
o Have melanin in their cells walls
(differentiate from other fungi)
ITRACONAZOLE
o Drug of choice
AMPHOTERICIN B & SURGERY
o Manage brain abscesses
Cladophialophora bantiana
o Leading cause of cerebral
phaeohyphomycosis

MYCETOMA
Chronic subcutaneous infection induced by
traumatic inoculation with any of several
aprophytic species of fungi or actinomycetous
bacteria that are normally found in soil
Clinical features:
o Local swelling & interconnecting,
often draining sinuses that contain
granules (microcolonies of the agent
embedded in tissue material)
Actinomycetoma
o Mycetoma caused by an actinomycete
o More invasive
Eumycetoma
o Mycetoma caused by a fungus
o Maduromycosis
o Madura foot
Occurs among impoverished people who do not
wear shoes
Occur only sporadically outside the tropics
Prevalent in India, Africa, and Latin America
Morphology & Identification
o Fungal agents:
Pseudallescheria boydii

Prevalent species in the

USA
Homothallic
Has the ability to
produce ascospores in
culture
Also cause
pseudallescheriasis
(systemic infection in
compromised patients)
Madurella mycetomatis
Dematiaceous mold
Madurella grisea
Dematiaceous mold
Exophiala jeanselmei
Dematiaceous mold
Acremonium falciforme
o Tissue:
Mycetoma granules range up to 2
mm in size hard & contained
intertwined, septate hyphae (3-5
um in width)
Hyphae are typically distorted and
enlarged at the periphery of the
granule
The color of the granule may
provide information about the
agent
P. boydii & A. falciforme:
WHITE
M. grisea & E.
jeanselmei: BLACK
M. mycetomatis: DARK
RED-BLACK
Pathogenesis & Clinical Findings
o Develops after traumatic inoculation
with soil contaminated with one of the
agents
o Subcutaneous of the feet, lower
extremities, hands & exposed areas
o Pathology: (spread to muscles &
bones)
Suppuration & abscess
formation
Granulomas
Formation of draining sinuses
containing the granules
o Untreated lesions persist for years &
extend deeper & peripherally, causing
deformation & loss of function
o P. boydii
Disseminate in an
immunocompromised host
Produces infection of a foreign
body (cardiac pacemaker)
Diagnostic Laboratory Tests
o Dissection of granules form the pus or
biopsy material for examination &
culture on appropriate culture media

Granule color, texture & size & the

presence of hyaline or pigmented
hyphae
Helpful in determining the etiology
o Draining mycetomas are often
superinfected with Staphylococci &
Streptococci
Treatment
o Surgical debridement or excision
o Chemotherapy
o P. boydii: TOPICAL NYSTATIN or
MICONAZOLE
o Madurella infections: AMPHOTERICIN
B
o E. jeanselmei: FLUCYTOSINE
Epidemiology
o Occur in soil & on vegetation
o Commonly exposed are those barefoot
farm laborers
o

Prevention
o Properly cleaning wounds
o Wearing of shoes