OPPORTUNISTIC MYCOSES

CLASSIFICATION ORGANISMS

Yeast Candida
Cryptococcus
Torulopsis
Trichosporon
Rhodotorula
Geotrichium

Molds Aspergillus
Pseudoallescheria
Zygomycetes (Rhizopus, Mucor, and Absidia

Monday, January 16, 2012

 OPPORTUNISTIC MYCOSES
True Pathogenic Fungi Opportunistic Fungi

Diseases Histoplasmosis Aspergillosis

Blastomycosis Candidiasis
Paracoccidioidomycosis Mucormycosis
Coccidioidomycosis Cryptococcosis

Host Normal Abrogated/

Compromised

Portal of Primary infection is Various

Entry pulmonary

Monday, January 16, 2012

 OPPORTUNISTIC MYCOSES
True Pathogenic Fungi Opportunistic Fungi

Prognosis 99% spontaneous resolution Recovery depends on the

severity of impairment of
host defenses
Immunity Resolution results to strong No specific resistance to
specific immunity infection

Host Response Tuberculoid granuloma, Depends on degree of

mixed pyogenic impairment necrosis to
pyogenic to
granulomatous

Morphology in All agents showed No change in morphology

Tissue dimorphism to a tissue
form

Distribution Geographically restricted Ubiquitous

Monday, January 16, 2012

 CANDIDIASIS
C. albicans is the most common (4-6 um;
budding)

Multiplication: blastospore formation

producing either pseudohyphae or
septate hyphae

Identification: assimilation and

fermentation of CHOs; physiologic and
morphologic responses they exhibit
when grown under controlled
nutritional conditions “germ tubes”

Monday, January 16, 2012

 CANDIDIASIS

“chlamydoconidia”

Monday, January 16, 2012

 FACTORS THAT AFFECT CANDIDA
NORMAL POPULATION

poor oral hygiene

use of antibiotics

use of oral contraceptives

diet

presence of antagonistic inhibitory bacteria

Monday, January 16, 2012

 Candida albicans is a resident flora of the
skin, mouth, vagina and stool!

Imbalance will lead to infection....HOW?

Changes in the Physiology: e.g.

pregnancy, use of steroids and diabetes

Prolonged administration of antibiotics

Immunocompromised patients

Monday, January 16, 2012

 MUCOCUTANEOUS CANDIDIASIS
(MC)
a condition caused by a fungus from
the candida family (lives on the
surface of skin) that develops a
diffuse and persistent type of
infection of the mouth, nails, skin, and
at times other organs

affects infants (starts before age 3) and

young adults, is rarely seen in adults
with other diseases

including chronic mucocutaneous

candidaisis or CMCC

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 SYMPTOMS: ORAL

“thrush” “glossitis” “stomatitis”

“cheilitis” “perleche”

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 SYMPTOMS: VAGINITIS &
BALANITIS

“VAGINITIS = female”

“BALANITIS = male”

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 SYMPTOMS: ALIMENTARY

“Esophageal growth”

OTHERS: gastritis, peritonitis, enteric and perianal disease

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 CANDIDIASIS IN NAILS

Monday, January 16, 2012

 CANDIDIASIS IN DIAPER RASH

“Candida may come from fecal origin”

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 SYSTEMIC INVOLVEMENT

Urinary tract

Endocarditis

Meningitis

Septicemia

Latrogenic candidemia

Dissemination to other organ systems

Monday, January 16, 2012
 DISSEMINATED CANDIDIASIS

originate at a gastrointestinal site

CA enters epithelial microvilli through persorption of yeast cells

or by germination (a,c)

In both cases, organisms enter the vasculature (b,d) for

dissemination into tissues such as the kidney (e)

localizes in the cortex (f) where it grows as hyphae/

pseudohyphae

A vigorous host response occurs at this site consisting of both

mononuclear and polymorphonuclear leukocytes

Virulence factors (adhesins, morphogenesis, switch phenotypes,

antioxidant proteins and invasive enzymes) promote the invasion
of the organism

Monday, January 16, 2012

 ALLERGIC CANDIDIASIS

Eczema
Asthma
Gastritis

Monday, January 16, 2012

 LABORATORY DIAGNOSIS:
CADIDIASIS

Direct microscopic
examination

Specimen for examination can

be sputum, skin scrapings,
vaginal swabs, biopsy material,
from any types of organs or
even in blood.

The specimen is treated with

1-2 drops of 10-20% KOH.

Monday, January 16, 2012

 LABORATORY DIAGNOSIS:
CADIDIASIS

The presence of the capsule

and budding yeast cells are
considered as the positive
results.

Aside from KOH, other

stains can be used such as
India ink and Papanicolaou
stain.

Monday, January 16, 2012

 GERM TUBE TEST

Most isolates of
C. albicans produce a
hyphal growth from
blastospores when
they are suspended in
serum at 37°C for 2-3
hours.

Monday, January 16, 2012

 IN CULTURE...

SDA at either room temperature or at 37°C

Colonies: usually develop in 2-3 days as

white, typical yeast colonies

In vitro: monomorphic, growing as non

encapsulated yeast cells at any temperature

Monday, January 16, 2012

 IN CULTURE...

Monday, January 16, 2012

 FROM CORN MEAL AGAR

Monday, January 16, 2012

 TREATMENT OF CANDIDIASIS

Most localized, cutaneous, candidiasis infections may

be treated with any number of topical antifungal
agents (eg, clotrimazole, econazole, ciclopirox,
miconazole, ketoconazole, nystatin).

For Candida onychomycosis, oral itraconazole

(Sporanox)

For Genitourinary tract candidiasis, VVC can be

managed with either topical antifungal agents or

Monday, January 16, 2012

 TREATMENT OF CANDIDIASIS

Caspofungin acetate (Cancidas) as a 70-mg

loading dose is followed by 50 mg/d IV for a
minimum of 2 weeks after improvement or
after blood cultures have cleared.

Chronic mucocutaneous candidiasis is treated

with oral azoles, either fluconazole (Diflucan)

Monday, January 16, 2012

 ASPERGILLOSIS

One of the largest of the fungal genera

Hundred of species have been recorded

The most important species:

A. fumigatus

A. flavus

A. niger

Monday, January 16, 2012

 ASPERGILLUS FUMIGATUS

Aspergillus fumigatus

identified according to
the pattern of
conidiophore
development,
morphologic features
and color of the
conidia

Monday, January 16, 2012

 IMPORTANT PARTS

Monday, January 16, 2012

 SPECTRA OF ASPERGILLOSIS

Toxicity due to ingestion of contaminated foods

Allergy and sequelae to the presence of conidia or transient

growth of the organism in body orifices

Colonization without extension in preformed cavities and

debilitated tissues

Invasive, inflammatory, granulomatous, necrotizing disease of

lungs and other organs

Systemic and fatal disseminated disease

Monday, January 16, 2012

 ALLERGIC ASPERILLOSIS

Allergic aspergillosis maybe benign early on and

severe as the patient grows older

In secondary colonization, a chronic clinical

situation may exist with little distress except
occasional bout of hemoptysis and some
pathological changes in the lungs that may lead to
the formation of fungus ball.

Monday, January 16, 2012

 ALLERGIC ASPERILLOSIS

SKIN FUNGAL SPECIMEN

IN THE TISSUE

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 SYSTEMIC ASPERGILLOSIS

An extreme serious disorder that is usually

rapidly fatal unless diagnosed early and treated
aggressively

The status of the host’s immune system

contributes to the prognosis of the patient

Monday, January 16, 2012

 SYSTEMIC ASPERGILLOSIS

FUNGUS BALL/
ASPERGILLOMA

Monday, January 16, 2012

 Disease Etiologic Factors

Mycotoxicoses Ingestion of contaminated food

products
Hypersensitivity Allergic bronchopulmonary
peumonitis disease

Secondary Colonization of preexisting

colonization cavity (pulmonary abscess)
without invasion into
contiguous tissue

Systemic disease Invasive disease involving

multiple organs

Monday, January 16, 2012

 DISSEMINATED ASPERGILLOSIS

Aerosols of Aspergillus fumigatus conidia are inhaled and

travel to the alveoli

In the healthy host, alveolar macrophages (AM) phagocytose

and kill the organism after swelling of the conidium, an
essential pre-germination stage

The production of reactive oxygen intermediates by AM is

required to eliminate the organism, but
polymorphonuclear cells (PMNs) also contribute

In the immunosuppressed patient, reduced numbers of PMNs

and inefficient AM allow growth of the fungus

Consequently, the conidia germinate and escape from the AM

Monday, January 16, 2012

 LABORATORY DIAGNOSIS

Aspergillosis is easy to isolate and identify....BUT!

also important to distinguish a true pathogen

from a contaminant

If sputum sample is to be collected, it is expected

to be thick and gelatinous

In invasive sampling, lung aspirates or tissue

biopsy is used
Monday, January 16, 2012
 LABORATORY DIAGNOSIS

Direct microscopic examination will show

hyaline, dichotomously branched and septate
hyphae

Occasionally in sputum, in cases of pulmonary

aspergillosis, one may also sees very small, rough
walled spores (3-4 um in diameter).

Monday, January 16, 2012

 PULMONARY ASPERGILLOSIS

Monday, January 16, 2012

 TREATMENT

Amphotericin B was used

for many years BUT!!! with
disappointing results

In 1990 itraconazole was

introduced as a new broad
spectrum anti-fungal agent.

Monday, January 16, 2012

 ZYGOMYCOSIS/PHYCOMYSIS

Class Phycomycetes

Rhizopus

Absidia

Mucor

They formed coenocytic hyphae and reproduce

asexually by producing sporangiosphores within
which develops sporangiospores
Monday, January 16, 2012
 ZYGOMYCOSIS/PHYCOMYSIS

Repeated isolation of the

organisms from consecutive
specimens provides strong
evidence that the organisms
may be relevant, even though
coenocytic hyphal elements
are not seen in
histopathologic examination
of tissue.

Monday, January 16, 2012

 MUCORMYCOSIS (ORAL CAVITY)

Monday, January 16, 2012

 CATEGORIES COMMENTS
Rhinocerebral It is the most frequent presentation overall and classically affects diabetics with
ketoacidosis.

Usually presents with facial and/or eye pain, proptosis and progressive signs of
involvement of orbital structures (muscles, nerves and vessels).

Common complications include cavernous sinus and internal carotid artery

thrombosis.

Pulmonary It occurs most frequently among neutropenic patients.

It presents with nonspecific symptoms such as fever, cough and dyspnea;

hemoptysis may occur with vascular invasion.

Radiological presentation includes segmental consolidation that progresses to

contiguous areas of the lung, with occasional cavitation.

Gastrointestinal Usually affects patients with severe malnutrition

May involve the stomach, ileum, and colon

Clinical picture mimics intra-abdominal abscess. The diagnosis is often made at

autopsy.
Cutaneous It has been reported with minor trauma, insect bites, no sterile dressing, wounds, and
burns.

The necrotic lesions progressively evolve from the epidermis into dermis and even
muscle.
Others Heart, bone, kidneys, bladder, trachea, and mediastinum

Monday, January 16, 2012

 DIRECT EXAMINATION: ZYGOMYCOSIS

A rapid diagnosis is critical

Fungal elements are usually not numerous in discharges

Scrapings from the upper turbinates, aspirated material

from sinuses, sputum in pulmonary disease, and biopsy
material mounted in 10% KOH typically contain thick-
walled, refractile hyphae 6-15 um in diameter

Swollen cells (up to 50 um) and distorted hyphae may be

present

Monday, January 16, 2012

 IN CULTURE...

Sabouraud dextrose agar:

Incubate at 30°C

DON’T: cycloheximide =
sensitive

Sterile bread:

for recovery of Zygomycetes

when other media fail

WHY bread???
Monday, January 16, 2012
 TREATMENT

Control of the diabetes

Aggressive surgical
debridement of involved tissue

High doses of amphotericin B

are recommended

Monday, January 16, 2012