OPPORTUNISTIC SYSTEMIC MYCOSIS

 Aspergillosis
 Systemic candidosis
 Cryptococcosis
 Pneumocystis carinii infection
 Penicillium marneffi and others

Aspergillosis

 > 100 spp of Aspergillus but only a few implicated in human disease
 Most important:
- A. fumigates
- A. niger
- A. flavus
- A. terreus
- A. nidulans
 All are mycelial fungi with septate hyphae and distinctive sporing structures: ie:
- The spore-bearing hyphae (conidiophores) terminates in a swollen vesicle surrounded by
1 to 2 rows of cells (sterigmata)
 From sterigmata are produced chains of asexual conidia
 Aspergillus spores are ubiquitious
- Esp. prevalent in decating vegetation like hay
- Spore couns up to 2 x 10^7/m^3 reported! – even inside buildings!
 Aspergillosis most frequently affect the lungs.
 Infections to other sites like:
- Nasal sinuses
- Superficial tissue
= may occur
 Disease is most frequently caused by A. fumigates, through inhalation of spores.
 This may lead to:
- Colonization of existing lung cavities (ASPERGILLOMA form)
- Hypersensitivity reaction (ALLERGIC ASPERGILLOSIS)
 Rarely, Aspergillus spp may cause invasive disease of the lung with dissemination to other
organs (usually in SEVERELY IMMUNOCOMPROMISED PATIENTS!)

ALLERGIC ASPERGILLOSIS

 Usually seen in atopic individuals

 Increase IgE
 About 10-20 % asthamatics react to A.fumigatus
 Asthma with eosinophilia is the more chronic form.
Fungus can grow in airway -> plug it with mycelia -> coughed out!
- If observation under microscope (+) = diagnostic.
 Allergic alveolitis follows after heavy exposure to spores (several hours post-exposure):
- Breathlessness
 - Fever
- Malaise
 Repeated attacks -> Lung damage
 E.g. Maltster’s lung (A. clavatus in barley during malting process)

ASPERGILLOMA (fungal ball)

 Colonizes pre-existing cavities (usually tuberculous) -> compact ball of mycelium. Eventually
surrounded by dense fibrous wall
 Usually solitary
 Patient – usually asymptomatic
But can -> cough with sputum or hemoptysis
 Treatment : Surgical resection

INVASIVE ASPERGILLOSIS

 Usually in severly immunocompromised individuals

 Lung – sole site in 70% cases
 Dissemination to other organ ofren occurs -> widespread destructive growth of aspergillus
spp in tissue
 Can invade blood vessels
 Lead to:
- Thrombosis
- Emboli -> organs
 Prognosis : Poor
 Often diagnosed at P.M
 Endocarditis in immunosuppressed patients or in open-heat surgery
 Paranasal granuloma
- Usually A. favius or A.fumigatus
- Invade paranasal sinuses -> orbit of eye -> brain

Lab Diagnosis

 Depends on clinical form of disease

 Direct microscopy:
Sputum
- Non-pigmented septate mycelium (3-5 icrom)
- Dichotomous branching (characteristic)
- Mycelial head of aspergillus present
 In allergy
– sputum : fungus +++
– Myceliul plugs +
 In aspergilloma –fungus may be difficult to visualize
 Invasive aspergillosis:
- Microscopy usually (-)
- Biopsy = PAS or methenamine-silver
  Culture – Sabouraud’s agar without Cycloheximide
1-2 days : colonies (+)
 Skin test: Ag – A.fumigatus
Treatment: Type I HS
In Eosinophilia: 70% type III HS (Arthus reaction)
 Serology:
- ID, CIE, LPA, RIA, ELISA
- Treatment: Amphotericin B, beta conazole, Itraconazole

CRYPTOCOCCOSIS

 Most frequently recognized as a disease of the CNS

 But primary site: lungs
 Sporadic throughout the world
  with HIV/AIDS
 Famous for being a cause of chronic meningitis

Organism

Cryptococcus neoformans

 Encapsulated yeast
 4 serotypes – A, B, C, D
 2 varieties
- C. neoformans var. neoformans (A & D)
- C. neoformans var. gattii (B & C)
 C. neoformans var. neoformans
- Cause of most of infections
- Commonly found in excreta of birds
= pigeons ( up to 5 x 10^7 cells/g) [bird not infected!? High body temperature]
 C. neoformans var gattii
- Strongly associated with flowers of Eucalyptus camaldulensis (red river gum tree)
disease distribution directly proportional distribution of tree
- Used to blame koala bear!

Pathogenesis (male > female)

 Transmission – inhalation of C. cells (4-10 micrometer) deep into lungs

 Commonest form – mild, self-limiting pulmonary infection
 Symptomatic pulmonary infections:-
- Lesions : small discrete nodules which may heal with residual scar
- May become enlarged, encapsulated & chronic (cryptococcoma form)
- Can be acute pneumonic type
 Meningeal form (meningitis)
- Can occur in apparently healthy individuals
- But frequently in those with abnormal T lymphocute function (Hodgkin’s disease,
sarcoidosis, neoplasms)
 - Most frequently seen in HIV/AIDS (3-20%)
 Meningitis / meningoenceplhalitis
- Insidious
- Headache with low grade fever (like hitting your head against the wall…literally)
- Changes in mental state
- Anorexia
- Visual disturbance
- Coma
- Invariably fatal in untreated (few months – several years)
 Cryptococcal meningitis / meningoencephalitis
- In HIV/AIDS patients are generally more chronic with milder symptoms.
 Cryptococcosis of other organs / sites described:
- Skin
- Mucosa
- Viscera
- Bone
 Disseminated form of cryptococcosis
- Resembles that of tuberculosis

Laboratory Diagnosis

 Specimen:
- CSF
- Sputum } examined after difestion with KOH
- Pus }
- Brain tissue / other tissues (PAS)
 CSF
- Direct microscopy (wet preparation)
- CSF + 1 drop of Indian ink (or nigrosin)
- -> Encapsulated organisms (yeasts)
- 4-10 micromenter
- (+) in 60% cases of Cryptococcus meningitis
- [A picture of the organism under microscope, with mucopolysaccharide capsule
highlighted. I cannot draw on MS Word lah!]
 Culture
- Sabouraud’s agar without cyclohexamide [(25-30 C for mycelia form) and (37 C for yeast
form)[
- 2-3 days (up to 3/52)
- Colonies: creamy white to yellow brown mucoid (encapsulated strains)
 Compared to other yeasts
- C. neoformans : non-fermenter, produce urease, assimilate inositol, grows at 37C
 Serology
Latex
– partical agglutination test
– Most useful
 – CSF (+) > 90% cases
– ELISA

TREATMENT

 Treatment of chouce: Amphotericin B + Flucytosine (combination)

 Fluconazole (oral)
If amphotericin b too toxic (especially in AIDS cases)
 Avoid pigeon

Respiratory infections
Fungal = Systemic mycoses

 Generally result from inhalation of air-borne spores in soil or plant material

 Most are caused by dimorphic fungi
- Saprophytic, vegetative mycelia form in nature and under ordinary laboratory conditions
- Pathogenic, unicellular yeast-like or spherule form in human and animal host tissues
 True pathogens
- Coccidiodomycosis
- Blastomycosis
- Histoplasmosis
- Paracoccidioidomycosis
 Opportunistic pathogens
- Aspergillosis
- Systemic candidosis
- Cryptococcosis
- Pneumocystis infection
- Zygomycosis (mucormycosis)
- Others

INCIDENCE

 Systemic mycoses occur most frequently in those who work in the

- Agricultural sector
- Construction industry
 Before (I.e before the antibiotic era and the subsequent development in medicine) =
Systemic mycoses was very rare
- Even though known since the end of 19 th century
 Often discovered post mortem
 However, since the advent of:
- Antibiotics (mid 1940’s)
- Corticotherapy (1950’s)
- Immunosuppressive therapy (1960’s)
- Catheterization
- Prosthetic devices
- Organ and tissue tansplantation
 - HIV/AIDS (late 1970’s)
 Systemic mycoses started to:
- Develop new clinical aspects
- Occur with much higher frequency
- Begin to become important public health problems
 In fact several opportunistic infections have become nosocomial, hospital-acquired and
invasive infections.

HISTOPLASMOSIS

 Causative organism = H.capsulatum

 Taxonomically H.capsulatum divided into 3 varieties; each with its own distinctive & defining
characteristics
a. H. capsulatun var. capsulatum
- Causes histoplasma capsulate
- Cosmopolitan – endemic in all continents
b. H. capsulatum var. duboisii
- Causes histoplasma duboisii
- Liited to central Africa and Madagascar
- Also called African histoplasmosis
c. H. capsulatum var, farciminosum
- Causes histoplasmosis
- Africa, East Europe, Middle East, Asia, Far East
 All 3 varieties are:
- Saprophytes
- Mitosporic moulds (fungi imperfecti) in nature or in laboratory at 25-30 C
- Transformed into unicellular yeast-like budding organisms
- In mammalian tissue
- At 37 C in enriched media with cysteine in lab

Histoplasma Capsulati

 Genus histoplasma established 1906 when Darling described first case

 Usually either an asymptomatic or relatively mild and self-limiting pulmonary infection
 But can be
- Chronic
- Acute disseminated
 Causative organism: fungus imperfecti histoplasma capsulatum var. capsulatum
- An intracellular parasite
- Found in soil “enriched” with bird and bat droppings (saprophyte)
- Infection, inhalation of spores
- Cosmopolitan [in USA – Mississippi & Ohio river valleys (prevalence: 95%)]
- Mould: fluffy, white or buff brown
- Mycelium: Septate
- 2 types of unicellular asexual spores:
 Macroconidia (8-14 micrometer)
  Microconidia (2-4 micrometer)
- Yest phase cell 2-3 x 3-4 mucrometer
 Note: In birds – not known to be infected. Only transitory infection in chicken (Gallus gallus)
and Pigeon (Columbia livia)

Pathogenesis

 Infection usually asymptomatic or mild (skin test +)

 Sometimes: acute influenza like
 Fever with non-productive cough
 Although self-limiting, patient usually left with discrete, CALCIFIED lesions in the lungs
 Chronic form: usually in adults develop large cavities directly from primary lesions or
reactivation of old lesions (c.f TB)
 Occasionally patient develops acute PROGRESSIVE form with
- Widespread infection of RES
- Diseemination to other organs:
- Joints – arhtralgia/arthritis
- Skin – erythema nodosum & erythema multiforme
- Heart – pericarditis
- Liver }
- Renal } failure -> death
- Respiratory }
- Meningitis, cerebritis or focal brain lesion
 Usually in old aged, infancy and immunocompromised

Histoplasmosis(continued)

LABORATORY DIAGNOSIS

 Microscopy
- Sputum (Wright or Giemsa stain)
- Pus (Wright or Giemsa stain)
- Blood smear may be (+) especially in HIV cases
 Biopsy
- PAS stain
- Methenamine-silver stain

[H. capsulatum: small oval teast cells packed within microorganisms and/or monocytes

 Culture: Sabouraud’s agar

- 25-30 C for 1-4 weeks -> mycelium
- Macro and microconidia visible under microscope
- 37 C in cysteine rich medium -> Yeast form

 Serology
- Precipitation test
- Complement fixation test (CFT)
 - Latex particle agglutination test (LPA)
- ELISA

TREATMENT

 Mild
- Ketaconazole
- Itraconazole

 Severe
- Amphotericin B (disseminated, HIV/AIDS patients)