NAME RESERVOIR MORPHOLOGY
Malassezia furfur N aturally found on the skin surfaces of “Spaghetti and meat balls”
AN-AN many animals, including humans.
AP-AP
Isolated in 18% of infants and 90-100%
of adults.
DERMATOPHYTES Depending on the particular species
Microsporum Soil (geophilic)
Trichopyton Animals (zoophilic)
Epidermophyton floccosum Human (anthropophilic)
Infections due to zoophilic or geophilic
dermatophytes may produce a more
intense inflammatory response than
those caused by anthropophilic
microbes
Sporothrix schenkii Found on rose thorns
Coccidioides immitis Desert areas of the southwestern
United States and northern Mexico
Respiratory transmission
Histoplasma capsulatum Mississippi valley
Present in bird and bat droppings
Respiratory transmission
Blastomyces dermatitidis
Dimorphic, lipophilic fungi
Dimorphic:
Mycelial forms with spores at
25ºC
Yeast forms at 37ºC
Dimorphic :
Mycelial forms with spores at
25oC
Yeast forms at 37oC
Dimorphic:
Mycelial forms with spores at
25oC
Yeast forms at 37oC
CLINICAL SYNDROME
Tinea/Pityriasis versicolor - a common, benign,
superficial cutaneous fungal infection usually
characterized by hypopigmented or hyperpigmented
macules and patches on the chest and the back. In
patients with a predisposition, tinea versicolor may Topical imidazole
chronically recur. The fungal infection is localized to
the stratum corneum.
Dermatophytosis
Tinea corporis (body): “ringworm”
Tinea cruRis (groin): “jock itch”
Tinea pedis (feet): “athlete’s foot”
Tinea capitis (scalp)
Tinea unguium (nail): Onychomycosis
Suppurating subcutaneous nodules that progress
proximally along lymphatic channels
(lymphocutaneous sporotrichosis)
Coccidiodomycosis
Asymtomatic (in most persons)
Pneumonia
Disseminated: can affect the lungs, skin , bones and
meninges
Histoplasmosis
Asymptomatic (in most persons)
Pneumonia: lessions calcify, which can be seen on
chest X-ray (may look similar to PTB)
Disseminated: can occur in almost any organ,
especially in lung, spleen, or liver
Blastomycosis
Asymptomatic (uncommon)
Pneumonia: lesion rarely calcifies
Dessiminated (most common): present with weight
loss, night sweats, lung involvement and skin ulcers
Cutaneuos: skin ulcer
TREATMENT DIAGNOSIS NOTES ANATOMIC LOCATION
Dandruff shampoo (containing Potassium hydroxide (KOH) prep: reveals short, SUPERFICIAL (SKIN)
selenium sulfide) curved, unbranched hyphae with spherical yeast
cells ( look like “spaghetti and meatballs”)
Malassezia is extremely difficult to propagate
in laboratory culture and is culturable only in
media enriched with C12- to C14-sized fatty
acids.
Topical imidazole KOH: branched hyphae Secretes the enzyme keratinase, CUTANEOUS
Oral griseofuivin is used for tinea Wood’s lamp: ceratin species of Microsporum which digests keratin
unguium and tinea capitis will fluoresce under ultraviolet light
Oral terbinafine A fungal culture, which is often used as an For atypical presentations of
adjunct to KOH for diagnosis, is more specific tinea corporis, further
than KOH for detecting a dermatophyte evaluation for HIV infection
infection. Therefore, if the clinical suspicion is and/or an immunocompromised
high yet the KOH result is negative, a fungal state should be considered.
culture should be obtained.
If the above clinical evaluations are
inconclusive, a polymerase chain reaction (PCR)
assay for fungal deoxyribonucleic acid (DNA)
identification can be used.
Itraconazole Dimorphic Primary pulmonary infection SUBCUTANEOUS
Fluconazole Culture at 25ºC will grow branching hyphae (pulmonary sporotrichosis) is
Oral potassium iodide Culture at 37ºC will grow yeast cells rare, as is direct inoculation into
tendons, bursae, or joints.
Definitive diagnosis of sporotrichosis at any site Osteoarticular sporotrichosis is
requires the isolation of S schenckii in a caused by direct inoculation or
specimen culture from a normally sterile body hematogenous seeding.
site.
The organism can be recovered with fungal In rare cases, disseminated S
culture from sputum, pus, subcutaneous tissue schenckii infection
biopsy, synovial fluid, synovial biopsy, bone (disseminated sporotrichosis)
drainage or biopsy, and cerebrospinal fluid occurs, characterized by
(CSF). disseminated cutaneous lesions
and involvement of multiple
visceral organs; this occurs most
commonly in persons with AIDS.
Amphotericin B Biopsy of affected tissue: lung biopsy, skin Common oppurtunisitc infection SYSTEMIC
Itraconazole biopsy, etc. in AIDS patients from the
Fluconazole Silver stain or KOH prep southwest United States
Culture on Sabouraud’s agar SPHERULES WITH ENDOSPORES
Serology
Skin test
Itraconazole Lung biopsy Can survive intracellularly within SYSTEMIC
macrophages
Amphotericin B (in Silver stain specimen
immunocompromised patients
Culture on Sabouraud’s agar will reveal hyphae YEASTS WITHIN MACROPHAGES
at 25oC and yeast at 37oC
Serology
Skin test (test for exposure only)
Urine antigen test
Itraconazole Biopsy of affected tissue: lung biopsy, skin BROAD-BASED BUD SYSTEMIC
biopsy, etc.
Ketoconazole Silver stain specimen
Amphotericin B Culture on Sabouraud’s agar
Serology
Skin test (test for exposure only)
Blastomyces dermatitidis
Cryptococcus neoformans Pigeon droppings
Candida albicans Normal flora of the skin, mouth and
gastrointrointestinal tract
Aspergillius fumigatus Ubiquitous
Aspergillus may cause a broad
spectrum of disease in the human
host, ranging from hypersensitivity
reactions to direct angioinvasion.
Aspergillus primarily affects the lungs,
Aspergillius flavus causing the following four main
syndromes:
• Allergic bronchopulmonary
Aspergillius niger aspergillosis (ABPA)
• Chronic necrotizing Aspergillus
pneumonia (or chronic necrotizing
pulmonary aspergillosis [CNPA])
• Aspergilloma
• Invasive aspergillosis
Rhizopus Saprophytic molds
Rhizomucor
Mucor
Polysaccharide capsule
Yeast form only (Not dimorphic) Subacute or chronic meningitis
Pseudohyphae and yeast
Branching septated hyphae
(acute angles, 45O)
Broad, non-septated, branching Mucormycosis
hyphae (right angles, 90o)
BROAD-BASED BUD SYSTEMIC
Blastomycosis is usually localized to the lungs and Sputum specimens processed with 10%
may present with: potassium hydroxide, cytology smears, or a
fungal stain
A self-limited flulike illness with fever, chills, myalgia, Enzyme immunoassay (EIA) techniques on
headache, and a nonproductive cough sputum, tissue, or bronchoscopic specimens
An acute illness resembling bacterial pneumonia,
with high fever, chills, a productive cough, and
pleuritic chest pain; mucopurulent or purulent
sputum
Chronic illness, with low-grade fever, a productive
cough, fatigue, night sweats, and weight loss
Rapidly progressive, and severe disease, eg,
multilobar pneumonia or ARDS, with fever,
shortness of breath, tachypnea, hypoxemia, and
finally hemodynamic collapse
Cryptococcus Amphotericin B and flucytosine India-ink stain of cerebrospinal fluid (CSF): Most cases occur in SYSTEMIC
(is superior to amphotericin B observe encapsulated yeast immunocompromised person
alone) Cryptococcal antigen test of CSF: detects
polysaccharide antigens
Pneumonia: usually self-limited and asymptomatic Fungal culture MCC of meningoencephalitis in
HIV
Skin lesions: look like acne
YEAST WITH A HALO
Candidiasis in a normal host The choice of antifungal agent KOH stain of specimen YEAST WITH PSEUDOHYPHAE CUTANEOUS or SYSTEMIC
Oral thrush depends on the area involved Silver stain of specimen (normal host, or opportunistic)
Vulvovaginal candidiasis and its severity. Blood culture: growth must be respected
Cutaneous Blood assay for beta-D-glucan
Diaper rash
Rash in the skin folds of obese individuals
Candidiasis in an immunocompromised host
Thrush, vaginitis and/or cutaneous, plus:
Esophageal
Disseminated candidiasis: acquired by very sick
hospitalized patients, resulting in multi-organ
system failure
Chronic mucocutaneous candidiasis
Aspergillosis Allergic bronchopulmonary Allergic brochopulmonary aspergillosis: Rarely found in individuals who OPPORTUNISTIC
Allergic bronchopulmonary aspergillosis (IgE aspergillosis -> treat with High level of IgE (IgE level > 1000 IU/dL) are immunocompetent
mediated): asthma type asthma type reaction with corticosteroids Sputum culture
shortness of breath and high fever Wheezing patient and chest X-ray with fleeting The FDA has approved an
infiltrates intravenous formulation of the
Increased level of eosinophils triazole antifungal posaconazole
Skin test: immediate hypersensitivity reaction (Noxafil), which is indicated for
Asperigilloma (Fungus ball): associated with Aspergilloma: removal via Aspergilloma: diagnose with chest X-ray or CT the prophylaxis of invasive
hemoptysis (blood cough) thoracic surgery scan Aspergillus and Candida
infections in severely
Invasive aspergillosis: necrotizing pneumonia. May Invasive aspergillosis: treat with Invasive aspergillosis: sputum examination immunocompromised adults
disseminate to other organs in voriconazole, possibly and culture who are at high risk of
immunocompromised patients caspofungin. (very high developing these infections.
mortality)
Aflatoxin consumption (produced by Aspergillus Aflatoxins contaminate peanuts,
flavus ) can cause liver damage and live cancer grains, and rice
Amphotericin B and surgery Biopsy The disease is rapidly fatal OPPORTUNISTIC
Rhinocerebral (associated with diabetes): starts on Black nasal discharge
nasal mucosa and invades the sinus and orbit
Pulmonary mucormycosis
Pneumocystis jirovecii Unicellular fungi found in the
respiratory tracts of many mammals
and humans
The organism is found in 3
distinct morphologic stages, as
follows:
The trophozoite (trophic form),
in which it often exists in
clusters
The sporozoite (precystic form)
The cyst, which contains several
intracystic bodies (spores)
PJP – Pneumocystis jirovecii pneumonia occurs when
both cellular immunity and humoral immunity are
defective.
Once inhaled, the trophic form of Pneumocystis
organisms attach to the alveoli. Multiple host immune
defects allow for uncontrolled replication of
Pneumocystis organisms and development of illness.
Activated alveolar macrophages without CD4+ cells are
unable to eradicate Pneumocystis organisms. Increased
alveolar-capillary permeability is visible on electron
microscopy.
TMP-SMX A lactic dehydrogenase (LDH) study is
performed as part of the initial workup.[24] LDH
levels are usually elevated (>220 U/L) in
patients with P jiroveci pneumonia (PJP). They
are elevated in 90% of patients with PJP who
are infected with HIV. The study has a high
sensitivity (78%-100%); its specificity is much
lower because other disease processes can
result in an elevated LDH level. [Clin Invest Med.
1992 Aug. 15(4):309-17.
Quantitative PCR for pneumocystis may
become useful in distinguishing between
colonization and active infection, but these
assays are not yet available for routine clinical
use.
The taxonomic classification of
the Pneumocystis genus was
debated for some time. It was
initially mistaken for a
trypanosome and then later for
a protozoan. In the 1980s,
biochemical analysis of the
nucleic acid composition of
Pneumocystis rRNA and
mitochondrial DNA identified
the organism as a unicellular
fungus rather than a protozoan.
Subsequent genomic sequence
analysis of multiple genes
including elongation factor 3, a
component of fungi protein
synthesis not found in protozoa,