MYCOLOGY

FEU-NRMF Institute of Medicine

Dept. of Microbiology and Parasitology

Mycology is the study of fungi.

Mycoses are fungal infections.

General Properties and Classification of Fungi

Fungi grow in two basic forms, as yeasts and mold.

Growth in the mold form occurs by production of multicellular filamentous colonies.
This colonies consists of branching cylindric tubules called hyphae, varying in diameter from
2 to 10 um. The mass of intertwined hyphae that accumulates during active growth is myce-
lium. Some are divided in to cells by cross-walls or septa, which typically form at regular
intervals during hyphae growth.

Yeasts are single cells, usually spherical to ellipsoid in shape and varying in diameter
from 3 to 15 um. Most yeasts reproduce by budding. Some species produce buds that charac-
teristically fail to detach and become elongated; continuation of the budding process then pro-
duces a chain of elongated yeast cells called pseudohyphae.

Some yeasts and molds have melanized cell walls, which impart a brown or black pig-
ment to the fungal colony, such are dematiaceous fungi. Studies have shown that melanin pro-
tects these fungi from host defenses and is associated with virulence.

Fungi are eukaryotic organisms that are distinguished from other eukaryotes by a rigid
cell wall composed of chitin and glucan and a cell membrane in which ergosterol is substituted
for cholesterol as the major sterol component. The surface component of the cell wall mediates
attachment to the host cells in the toll-like receptors. The cell wall attachment stimulates innate
immune response, complement cascade, and release immunodominant antigens that may elicit
cellular immune responses.

Fungi reproduce by the formation of spores that may be sexual (involving meiosis, pre-
cede by fusion of the protoplasm and nuclei of two compatible mating types) or asexual (involv-
ing mitosis only). Spores are usually dormant, readily dispersed, more resistant to adverse con-
ditions, and germinate to form vegetative cells when conditions for growth are favorable. Spores
derived from asexual and sexual reproduction are termed anamorphic or teleomorphic states,
respectively. The asexual spores consists of two general types: sporangiospores and conidia.
Taxonomy of Major Human Fungal Pathogens

Phylum Glomerulomycta, Order Mucorales

Sexual reproduction results in zygospores; asexual reproduction occurs via sporangia.
Vegetative hyphae are sparsely septate.
Examples: Rhizopus, Lichtheimia, Mucor, Cunninghamella
Phylum Ascomycota
Sexual reproduction involves a sac or ascus in which karyogamy and meiosis occur,
producing ascospores. Asexual reproduction is via conidia. Ascomycetous molds have
septate hyphae.
Examples: Most pathogenic yeasts (Saccharomyces, Candida) and
molds (Coccidiodes, Blastomyces, Trichophyton).
Phylum Basidiomycota Sexual reproduction results in dikaryotic hyphae and four progeny ba-
sidiospore supported by a club-shaped basidium. Hyphae have complex septa.
Examples: Mushrooms, Cryptococcus
Growth and Isolation of Fungi
Most fungi occur in nature and grow readily on simple sources of nitrogen and carbohydrate.
1. Direct microscopic examination: KOH, Special stains (India Ink, Calcoflour white, methe-
namine silver)
2. Culture: Saboraud’s agar
3. DNA probe test: at present, available for Coccidiodes, Histoplasma, Blastomyces, and
Cryptococcus
4. Serologic tests

Antifungal agents
(for complete list see Jawetz Table 45-5, page 705)

Important Adverse
Usage Name of Drug Mechanism of action
Reactions

Binds to ergosterol and dis-

Amphotericin B Renal toxicity, fever, and chills
rupts fungal cell membranes

Ketoconazole ihibits human

Azoles, such as fluconazole, cytochrome p450; this de-
ketoconazole, itraconazole, Inhibits ergosterol synthesis creases synthesis of gonadal
voriconazole, posaconazole steroids resulting to gyneco-
mastia
Systemic use
Inhibits synthesis of D-glucan,
(Intravenous, oral) Echinocandins such as caspo-
a component of fungal cell Well-tolerated
fungin, mycafunin
wall

Inhibits DNA synthesis; FC

converted to fluorouracil,
Flucytosine (FC) Bone marrow toxicity
which inhibits thymidine syn-
thetase

Disrupts mitotic spindle by

Griseofulvin Liver toxicity
binding to tubulin

Azoles such as clotrimazole,

miconazole
Inhibits ergosterol synthesis
Terbinafine
Topical use (skin
only); too toxic Tolnalfate Well- tolerated on skin
for systemic use

Binds to ergosterol and dis-

Nystatin
rupts fungal cell membranes
SUPERFICIAL MYCOSES
Pityriasis versicolor
Pityriasis versicolor is a chronic mild superficial infection of the the stratum corneum caused by
Malassezia globosa, Malassezia restricta, and other members of the Malassezia furfur complex.
Lesions are discrete, serpentine, hyper- or hypo pigmented maculae on the skin usually on the
chest, upper back, arms, or abdomen. This common affliction is largely a cosmetic problem. It is
also implicated as a cause of or contributor to seborrheic dermatitis.
Diagnosis is confirmed by direct microscopic examination of scrapings of infected skin treated
with 10-20% KOH or stained with calcoflour white. Short unbranched hyphae and spherical cells
are observed. The lesions also fluoresce under Wood’s lamp.
It is treated with daily application of selenium sulfide. Topical or oral azaleas are also effective.
Tinea Nigra or Tinea Nigra Palmaris
This is a chronic and asymptomatic infection of the stratum corneum caused by the
dematiaceous fungus Hortaea (Exophiala) wernickii.
Lesions appear as a dark (brown to black) discoloration, often on the palm.
Microscopic examination of skin scrapings from the periphery of the lesion will reveal branched,
septate hyphae and budding yeast cells with melanized cell walls.
It responds to treatment with keratolytic solutions, salicylic acid, or azalea anti fungal.
Piedra
Black piedra is a nodular infection of the hair shaft caused by Piedraia hortae.
White piedra presents as larger, softer, yellowish nodules on the hairs caused by Trichosporon
species.

CUTANEOUS MYCOSES (For complete description see Jawetz pg.677-681)

Some Clinical Features of Dermatophyte Infection

Location of Fungi Most Frequently

Skin Disease Clinical Features
Lesions Responsible

Tinea corporis Nonhairy, smooth Circular patches with ad- Trichophytom rubrum ,
(ringworm) skin vancing red, vesiculated Epidermophyton floccosum
border and central scaling.
Pruritic

Tinea pedis Interdigital spaces Acute: itching, red vesicular. Trichophyton rubrum,
(athlete’s foot) on feet of persons Chronic: itching, scaling, fis- Trichophyton mentagrophytes,
wearing shoes sures Epidermophyton floccosum

Tinea cruris Groin Erythematous scaling lesion Trichophyton rubrum,

(jock itch) in intertriginous area. Pruritic Trichophyton mentagrophytes,
Epidermophyton floccosum

Tinea capitis Scalp hair. Endo- Circular bald patches with Trichophyton mentgarophytes,
thrix: fungus inside short hair stubs or broken Microsporum canis, Tri-
hair shaft. Ectothrix: hair within hair follicles. chophyton tonsurans
fungus on surface of Kerion rare. Microsporum-
hair infected hair fluoresce

Tinea barbae Beard hair Edematous, erythematous Trichophyton mentagrophytes,

lesion Trichophyton rubrum, Tri-
chophyton verrucosum
 Some Clinical Features of Dermatophyte Infection

Location of Fungi Most Frequently

Skin Disease Clinical Features
Lesions Responsible

Tinea unguium Nail Nails thickened or crumbling Trichophyton mentagrophytes,

(Onychomycosis distally; discolored; luster- Trichophyton rubrum,
) less. Usually associated with Epidermophyton floccosum
tinea pedis

Dermatophytid Usually sides and Pruritic vesicular to bullous No fungi present in lesion.
(id reaction) flexor aspects of fin- lesions. Most commonly as- May become secondarily in-
gers. Palm. Any site sociated with tine pedis fected with bacteria
on body

SUBCUTANEOUS MYCOSES
SPOROTHRICOSIS
CHROMOBLASTOMYCOSIS
PHAEOHYPOMYCOSIS
MYCETOMA

SPOROTHRICHOSIS
Sporothrix schenkii
- thermally dimorphic fungus

2 FORMS
1. MOLD : ambient/room temperature
2. YEAST (small budding) : 35-37oC

Routine agar media (Sabouraud’s)

- Young colonies are blackish and shiny; wrinkled and fuzzy with age
Microscopic
- branching septate hyphae with distinctive small conidia, delicately clustered at the ends of ta-
pering conidiophores

Epidemiology
- Ubiquitous
- occurs worldwide but most common in tropical and subtropical regions, endemic in Mexico,
South Africa, and Japan
- Isolated from soil and plants
(hay, straw, thorny plants esp. roses, sphagnum moss, decaying wood , pine, prairie grass, and
other vegetations)
- 75% of cases occur in males (increased exposure or X-linked)

Clinical Findings
1. Lymphocutaneous
- 75% of cases
- introduced in the skin by trauma
2. Fixed: single nonlymphangitic nodule, limited, less progressive
3. Primary Pulmonary Sporotrichosis
- inhalation of conidia
- mimics chronic cavitary tuberculosis among patients with impaired cell-mediated im-
munity
4. Dissemination in eyes, bones, and joints, rarely in the meninges

Diagnostic Laboratory Tests

1. Specimen: biopsy material or exudate from lesions
2. Microscopic examination
- KOH or Calcoflour white stain
- Gomori’s methenamine silver : black cell wall
- Periodic Acid-Schiff (PAS) stain: red cell wall
- Flourescent Antibody Staining
 - H & E stain: asteroid body
3. Culture: Saboraud’s agar
4. Serology: Sporotrichin antigen for skin test
- delayed hypersensitivity
: Yeast cell Agglutination test- 1:160 – positive; 1:40 – recovered patient

Treatment
In some cases, infection is self-limited. Solution of saturated potassium iodide (SSKI) in milk is
effective but difficult for patients to tolerate.
The treatment of choice is oral Itraconazole or other Azoles; while Amphothercin B is given for
systemic disease

CHROMOBLASTOMYCOSIS
A subcutaneous mycotic infection that is usually caused by traumatic inoculation of any
of the recognized fungal agents, which reside in soil and vegetation.The infection is chronic and
characterized by the slow development of progressive granulomatous lesions that in time induce
hyperplasia of the epidermal tissue.

All are dematiaceous fungi.

A. PHIALOPHORA VERRUCOSA
The conidia are produced from flask-shaped phialides with cup shaped collaretes. Ma-
ture, spherical to oval conidia are extruded from the phialide and usually accumulate around it

b. CLADOSPORIUM CARIONII
Elongated conidiophores with long, branching chains of oval conidia
c. FONSECA PEDROSOI
Polymorphic, mostly short branching chains
phialides
chains of blastoconidia
sympoidal, rhinocladiella type

d. RHINOCLADIELLA AQUASPERA
Produces lateral or terminal conidia from a lengthening conidiogenous cell. Conidia are
elliptical to clavate
e. FONSECA COMPACTA
Blastoconidia are spherical, with a broad base connecting the conidia

Clinical findings
The primary lesion becomes verrucous and wart-like over months to years extending
along draining lymphatics. Cauliflower-like nodules with crusting abscesses eventually cover the
area. Small ulcerations or “ black-dots” on warty surface. Rarely, elephantiasis develops

Diagnostic Laboratory Tests

1. Specimen: Scrapings or biopsies from lesion
2. Microscopic examination:
- 10% KOH: dark spherical cells
- H & E stain: sclerotic cells inside an abscess
3. Culture in Saboraud’s agar: black velvety colony

Treatment
Surgical excision is the therapy of choice for small lesions. Flucytosine or Itraconazole
may be efficacious for larger lesions. The application of local heat is also beneficial. Relapse is
common.

PHAEOHYPOMYCOSIS
Characterized by the presence of darkly pigmented septate hyphae in tissue.
The common causative agents are Exiophiala jeanselmei, Phialophora richradsiae, Bipolaris
specifera, Wangiella dermatitidis

The clinical forms vary from solitary encapsulated cysts in the subcutaneous tissue to
sinusitis, to brain abscesses (leading cause Cladophialophora bantiana)

Specimens are cultured on routine fungal media.

In general, Itraconazole or Flucytosine is the drug of choice for subcutaneous phaehy-

pomycosis. Brain access is managed with Amphotericin B and surgery.

MYCETOMA
Chronic subcutaneous infection induced by traumatic inoculation with any of several saprophyt-
ic species of fungi or actinomycetous bacteria that are normally found in soil.
Actinomycetoma is caused by Actinomycete (bacteria)
Eumycetoma: Maduromycosis, Madura foot is caused by fungi

Etiologic agents include Pseudallescheria boydii, Exiophiala jenselmei, Madurella myce-

tomatis, Madurella grisea, Acromnium falciforme, among others.

Clinical findings
It is characterized by suppuration and abscess formation, granulomata, and drai
ning sinuses containing the granules
Diagnostic Laboratory Test
Granules can be dissected from the pus or biopsy material for examination and culture in
on appropriate media.

Treatment
- Surgical debridement or excision and chemotherapy
- Topical Nystatin or Miconazole for P. boydii
- Itraconazole, ketoconazole, Amphotercin B for Madurella infections
- Flucytosine for E. jeanselmei

SYSTEMIC/ENDEMIC MYCOSES

Coccidiomycosis Histoplasma Blastomycosis Paracoccidioides

(Refer to Jawetz pp.685-694 for detailed descriptions)

OPPORTUNISTIC MYCOSES
(Refer to Jawetz pp.694-703 for detailed descriptions)
Genus Form in Tissue Geographic Important Clinical Laboratory
seen by location Findings Diagnosis
Microscopy
Genus Form in Tissue Geographic Important Clinical Laboratory
seen by location Findings Diagnosis
Microscopy

Coccidiomycosis Spherule Southwestern US Valley fever in immu- Culture at 20’C grows

and Latin America nocompetent; dissemi-
mold with arthro-
nation in bone and me-
spores; Serological
ninges in immunocom-
test for IgM and IgG
promised, pregnant
women, African-
Americans and Filipi-
nos

Histoplasma Yeasts within Ohio and Mississipi Cavitary lung lesions; Culture at 20’C grows
macrophages River Valleys; granulomas in liver and
mold with tuberculate
worldwide, associ- spleen; pancytopenia
macroconidia; serolog-
ated with birds and and tongue ulcer in
ical test for IgM and
bat immunocompromised
IgG; urinary an†igen

Blastomyces Yeast with sin- Central and south- Culture at 20’C grows
gle broad-based eastern states in
mold
bud US; Africa

Ulcerated lesions of the

Paracoccidiodes Yeasts with Latin America es- skin
Culture at 20’C grows
multiple buds pecially Brazil
mold; serological test
for IgM and IgG

Form in Tissue
Geographic Important Clinical Laboratory
Genus seen by
location Findings diganosis
Microscopy

Candida Yeasts forms Thrush in mouth Gram-positive;

pseudohyphae and vagina; endo- culture grows
(also hyphae) carditis in IV drug yeast colonies;
users C.albicans from
germ tubes

Cryptococcus Yeast with large Meningitis India ink stain

capsule shows yeast with
large capsule; Cul-
Worldwide ture grows very
mucoid colonies

Aspergillus Mold with septate Fungus ball in Culture grows

hyphae lung; wound and mold with green
burn infections; spores; conidia in
indwelling catheter radiating chains
infections; sinusitis
 Form in Tissue
Geographic Important Clinical Laboratory
Genus seen by
location Findings diganosis
Microscopy

Mucor and Mold with nonsep- Necrotic lesion Culture grows

Rhizopus tate hyphae formed when mold mold with black
invades blood ves- spores; conidia is
sels; predisposing enclosed in a sac
factors are diabetic called sporangium
ketoacidosis, renal
acidosis, and can-
cer

CANDIDIASIS
- Members of the yeast genus Candida are members of the normal flora, but are capable of
causing candidiasis
- Most common systemic mycosis
Important sp:
Candida albicans, Candida tropicalis, Candida parapsilosis, Candida glabrata, Candida guiller-
mondii, Candida dubliniensis

Morphology:
Pseudohyphae, Clamydoconidia, Blastoconidia (Budding yeast)
BAP: Moist, opaque colonies
SDA: Soft, cream-colored colonies with yeast odor
Germ Tube
- Differentiating test
- Serum; 37˚C X 90 mins
- True hyphae

Clinical Findings:
1. Cutaneous and Mucosal Candidiasis
A. Thrush: can occur in tongue, lips, gums, or palate; patchy to confluent whitish pseu-
domembrane composed of epithelial cell, yeast, and pseudohyphae
B. Vulvovaginitis: characterized by irritation, pruritus and vaginal discharge I
C. Cutaneous Candidiasis: skin is red and moist and may develp vesicles
D. Onychomycosis: painful, erythematous swelling of the nail fold
2. Systemic Candidiasis
A. Candidemia: can be caused by indwelling catheters, surgery, IV drug abuse, aspira
tion, damage to the skin or GIT
B. Endocarditis: deposition and growth of yeast and pseudohyphae on prosthetic heart
valves or vegetations
C. UTI: Foley catheters, Diabetes, Pregnancy, Antibacterial antibiotics

3. Chronic Mucocutaneous Candidiasis

- Most forms of this rare disease have onset in early childhood, are associated with cel-
lular immunodeficiency and endocrinopathies. Many are unable to mount an effective Th17 re-
sponse.

Treatment:
Superficial: Topical Nystatin / Oral Ketoconazole/ Fluconazole
Systemic: Amp B + Oral flucytosine/ Fluconazole/ Caspofungin
Eliminate contributing factors

Prevention:
Avoid disturbance of normal flora
NOT communicable, since virtually all persons harbor the organism; but can cause nosocomial
outbreaks

CRYPTOCOCCOSIS
Important species:
 Cryptococcus neoformans
Cryptococcus gattii
Reservoir: Bird droppings (Pigeon)
Mode of transmission: Inhalation of dessicated yeast/ smaller basidiospres

Morphology: Microscopically, in culture or clinical material, the spherical, budding yeast cells are
surrounded by thick non-staining capsule. In culture, it produces whitish mucoid
colonies within 2-3 days incubation.
All species are encapsulated and possess urease.
C. neoformans and C. gatti differ from non-pathogenic species by the abilities to
grow at 37’C and the production of laccase.
Both the capsule and laccase are well-characterized virulence factors.

Pathogenesis (Figure 45-26)

Inhaled yeast cells ingested by macrophages the survives intracellularly. The capsule inhibits
phagocytosis, and with melanin, protects from oxidative injury
It disseminates to the brain via the hematogenous and lymphatic route.

Clinical Findings
The major manifestation is chronic meningitis, which can resemble a brain tumor, brain
abscess, degenerative CNS disease or any mycobacterial or fungal meningitis. Patients may
complain of headache, stiff neck, and disorientation. All untreated cases are fatal. The infection
is not transmitted from person-to-person.

Diagnostic Laboratory Test:

Specimens include CSF, tissue, exudates, sputum, blood, cutaneous scrapings, and
urine. For direct microscopy, specimens are often examined in wet mounts, both directly and
after mixing with India Ink, which delineates the capsule. Media with cycloheximide inhibits
Cryptococcus and should be avoided. Test for capsular antigen can be performed on CSF, se-
rum, and urine. Tests can be used are latex agglutination or enzyme immunoassay.

Treatment:
Combination therapy of Amp B and Flucytosine has been considered as the standard
treatment.
HIV/AIDS patients treated with highly active antiretroviral therapy (HAART) have lower
incidence of cryptococcal meningitis. Unfortunately, up to a third of HAART-treated AIDS
patient with cryptococcal meningitis develop immune reconstitution inflammatory syn-
drome (IRIS).

Prevention: Avoid exposure to reservoir

ASPERGILLOSIS
Important sp:
Aspergillus fumigatus (most common), A. flavus , A. niger , A. terreus , A. lentulus

Morphology:
- Long conidiospores with terminal vesicles on which phialides
produce basipetal chains of conidia
- Cottony colonies

Manner of transmission:
Inhalation of conidia
Transfer to wound via contaminated tape/bandages
Pathogenesis:
Inhaled conidia bind to fibrinogen and laminin in alveolus
Conidia germinate and hyphal forms secrete proteases and invade epithelium
Vascular invasion results in thrombosis and infarction of tissue
Hematogenous dissemination

Clinical findings:
1. Allergic Forms
- immediate asthmatic reaction upon subsequent exposure
- Allergic bronchopulmonary aspergillosis occurs when conidia germinate and hyphae
colonize the bronchial tree without invading the lung parenchyma. It is clinically defined
as asthma, recurrent chest infiltrates, eosinophilia, and both type I and type III skin test
hypersensitivity to Aspergillus antigen.
- Extrinsic allergic alveolitis develops in normal hosts exposed to massive doses of co-
nidia
2. Aspergilloma (fungus ball)
- occurs when inhaled conidia enter preexisting cavities, germinate, and produce
abundant hyphae in the abnormal pulmonary space
- patients with previous Cavitary Disease (Tuberculosis, sarcoidosis, Emphysema) are at
risk
- some are asymptomatic; others develop cough, dyspnea, weight loss, fatigue,
hemoptysis
3. Invasive Forms
- hyphae invade the lumens and walls of blood vessels, causing ithrombosis, infarction,
and necrosis
From the lungs it may spread to GIT, kidney, liver, brain, or other organs producing ab-
scesses and necrotic lesions

Diagnostic Laboratory Test

Sputum, other respiratory tract specimens and lung biopsy tissue provide good specimens.
Direct examination with KOH, calcoflour white or histology sections.
Serology by intradermal test for precipitin to A fumigatus.

Treatment
Amphotericin B, Itraconazole, Voriconazole, Posaconazole
Surgery

Prevention
Monitor airborne contaminants in patient’s rooms
Reduce visiting
Isolate patient

MUCORMYCOSIS (ZYGOMYCOSIS)
Important members:
Rhizopus sp., Rhizomucor sp., Lichtheimia sp., Cunninghamella sp., Mucor sp.
The most prevalent agent is Rhizopus oryzae

Clinical findings
1. Rhinocerebral mucormycosis
- Germination of the sporangiospores in the nasal passages
- Invasion of the hyphae into the blood vessels, causing thrombosis, infarction, and necrosis
2. Thoracic mucormycosis
- Inhalation of the sporangiospores with invasion of the lung parenchyma and vasculature
Diagnostic Laboratory Test
Direct examination or culture of nasal discharge, tissue, or sputum will reveal broad hyphae,
with uneven thickness, irregular branching, and sparse septations (Figure 45-28).

Treatment:
Consists of aggressive surgical debridement, rapid administration of Amphotericin B and
control of underlying disease.

PNEUMOCYSTIS PNEUMONIA

Pneumocystis jiroveci causes pneumonia in immunosuppressed patients; dissemina-

tion is rare. P. jiroveci was previously thought to be a protozoa (with cysts and trophozoite
forms) but biologic studies proved it is a fungus with close relationship with ascomycetes.

Pneumocystis species are present in the lungs of many animals (rats, mice, dogs, cats,
ferrets, rabbits) but rarely cause disease unless the host is immunosuppressed.
P. jiroveci is the human specie; while P. carinii is found only in rats.
No natural reservoir has been demonstrated, and the agent may be an obligate member
of the normal flora. The mode of infections unclear, and transmission by aerosols may be possi-
ble.

Pneumocystis jiroveci morphology:

Thick-walled cysts; spherical to elliptical 4-8 nuclei
Thin-walled trophozoite
Giemsa, Toluidine blue, Methamine silver, Calcoflour white

Treatment:
Trimethoprim-Sulfamethoxazole
Pentamidine isethionate

PENICILLIOSIS
Important sp.: Penicillium marneffei
Reservoir:
Isolated from soil and especially soil that is associated with bamboo rats and their habitats
Morphology:
Septate, branching hyphae bearing phialides and basipetal chains of conidia
In tissue, unicelullar yeast-like cells
Green-yellow colonies with diffusible reddish pigment

Manifestation:
Cough, fever, fatigue, weight loss, lymphadenopathy
Cutaneous and subcutaneous papules, pustules or rashes
Treatment:
Amphotericin B then Itraconazole
90% mortality if without treatment