SUBCUTANEOUS MYCOSES

 Concentrated merthiolate extract of mature fungus

SUBCUTANEOUS FUNGI culture is used as the sample
 Most are saprobes found in dead decaying vegetation  Microscopic immunodiffusion test using commercial
and wood anti-sera
 Mode of Transmission: Trauma  This test is red for lines of identification after 24
MYCOSES hrs of incubation
PHAEOHYPHOMYCOSIS  A serologic identification of etiologic agent
 infection caused by dematiaceous fungi of systemic mycoses
MYCETOMA 4 KINDS OF INFECTIONS
 chronic granulomatous infection I. PHAEOHYPOMYCOSIS
 usually affects one of the extremeties  myctic infection that affects human and lower
 swollen tumor-like areas with sinuses for drainage animals
SPOROTRICHOSIS  Causative agents: Exophiala, Phialophora,
 caused by Sporothrix schenckii Wangiella, Bipolaris, Excerohilum,
 -nodular lesions that suppurate, ulcerate and drain Cladophialophora, Phaeannellomyces,
CHROMOBLASTOMYCOSIS Aureobasidium, Cladosporium, Curvularia and
 verrucoid (wartlike) crusted nodules of the skin Alteraria
 painless if without secondary infections
A. Subcutaneous phaeohypomycosis
SUBCUTANEOUS MYCOSES  Mode of transmission: traumatic implantation of
 Infections usually invlove barefooted agricultural fungal elements
workers  Contaminated soil, thorns or wood splinters
 In the subcutaneous tissue, the disease develops  Immunosuppressed patient are usually prone
slowly over a period of years  There is a presence of lesions and
 Etiologic agents are usually native to the soil and overlying verrucous lesions
became vegetation  Causative agents: Wangiella dermatitidis, Exophiala
 Capable of skin penetration jeanselmei
 Fungi are capable of producing nodules that will
ulcerate
 Spread the etiologic agent to the lymph channels,
producing more nodules
 Such nodules may drain into the skin’s surface,
leading to secondary bacterial infections
 Usually thrive get their nutritions from decaying
vegetation and wood
 Mode of transmission: trauma or break in the skin

B. Paranasal sinus phaeohypomycosis

 Causes sinusitis
 Bipolaris
is a dematiaceous, filamentous fungi
that causes sinusitis. It is
cosmopolitan in nature and is
isolated from plant debris and soil.
 Exserohilum
Specie that causes sinusitis which is
environmental fungi that are
common in grass, soil and less
common in marine environment.
 Curvularia
Specie common in habitants of dead
EXO AG TEST plant material and causative agent of
 Test to determine the diagnosis of subcutaneous fungal keratitis, sinusitis, and
mycoses. onychomycosis.
 Alternaria

1
 SUBCUTANEOUS MYCOSES

species are known as major plant II. MYCETOMA

pathogens. They are also common  May be due to several fungi (eumycetoma) or
allergens in humans, growing indoors actinomycetes (actinomycetoma).
and causing hay fever or  Generally found on the foot where it is given name
hypersensitivity reactions that “watering can foot”- chronic infection of the skin
sometimes lead to asthma. subcutaneous tissues and bone.
C. Cerebral phaeohymycosis  Characterize by discharging sinuses that is filled with
 Rare infection the organism
 Immunosuppressed patients following the inhalation  Mycetoma- granulomatous
of conidia disease
 Fungus is neurotropic and  All This causes chronic
 Dissemination to sites other than the CNS is rare granulomatous infection that
usually affects one of the
LABORATORY DIAGNOSIS extremities and manifested by
1. CLINICAL MATERIAL: swollen tumor like in areas with
 Skin scrapings and/or biopsy sinuses for drainage
 Sputum and bronchial washings  Is a chronic specific
 Cerebrospinal fluid, pleural fluid and bloods granulomatous progressive inflammatory disease.
 Involves the subcutaneous tissue after traumatic
 Tissues biopsies from various visceral organs
inoculation of the causative organism
 Indwelling catheter tips 
2. DIRECT MICROSCOPY:
 Skin scrapings, sputum, bronchial washings and 1. Eumycotic mycetoma- fungi
aspirates  Pseudoallescheria boydii- most common cause of
 10% KOH and parker ink mycetoma
 Calcoflour white mounts 2. Actinomycotic mycetoma- fungus like bacteria
 Exudates and body fluids  Actinomyces, nocardia
 Centrifuged, sediment
 10% KOH and parker ink  CAUSATIVE AGENTS:
 Calcoflour white mounts  Acremonium sp.
 Aspergillus nidulans
 Tissue sections  Madurella grisea
H & E, PAS digest, and Grocott’s methenamine  Madurella mycetomatis
silver (GMS)  Scedosporium apiospermum
3. CULTURE:
 Clinical specimens: primary isolation media (SDA)  Numerous draining
sinuses
 Destruction of bone
 Distortion of the foot

Cladosporium- typical brown

MADURA FOOT
 is a chronic infection of the skin and underlying tissues
caused by both bacteria (actinomycotic mycetoma or
actinomycetomas) and fungi (eumycetomas or
Phialophora- olivaceous, mycotic mycetoma) Mycetoma occurs most often in
black or brown colony for people who work in rural areas, usually in farmers,
dematiaceous hyphomycetes hunter-gatherer populations, and field laborer.
 Form of mycetoma which occurs through skin
abrasions due to walking barefoot on contaminated
soil
4. SEROLOGY:
 No commercially available serological procedures
5. IDENTIFICATION:
 Culture characteristics and microscopic morphology-
conidial and arrangement of conidia
 Cellotape flag and/or slide culture preparations
 SUBCUTANEOUS MYCOSES
 At Room Temp.: mold

 H & E stain tissue station showing black and gray

eumycotic mycetoma specifically Madurella
mycetomatis
CLINICAL FEATURES
1. It starts as a small hard painless lump under the
skin (usually arise on the foot).
2. It grows slowly but eventually involves
underlying muscles and bones, resulting to
deformities.

Mycetoma are more common in men than women

particularly those ages 20-50
It generally presents as a single lesion on an expose
site and may persist years.
3. The middle of the lesion caves in, ulcerates, forms
sinus tracts (holes) that discharge pus and grains.

Secondary bacterial infection which common during

this stage because of presence of holes. There is often
itchiness or burn feeling.
White to yellow grains is indicative of
pseudallescheria boydii
CLINICAL MATERIAL
 Tissue biopsy or excised sinus
 Seroguinous fluid containing the granules
 Vary in size, colour and degree of hardness
DIRECT MICROSCOPY:
 Serosanguinous fluid
 10% KOH and parker ink
 Calcoflour white mounts
Tissue sections
 H & E, PAS digest, and Grocott’s methenamine silver
(GMS)
CULTURE:
 Clinical specimens: SDA
SEROLOGY:
 No commercially available serological procedures
IDENTIFICATION:
 Characteristic clinical specimens
 Microscopic
 Culture features of the fungi for proper identification

III. SPOROTRICHOSIS
 also known as “rose gardener's disease.is an
infection caused by a fungus called Sporothrix
schenckii.
 this causes nodular lesions that suppurate, ulcerate.
 Prick from thorny plant ex: rose
 SUBCUTANEOUS MYCOSES

 Flowerette conidia
 In old culture: conidia SIDE
 At 37°C: Yeast
 Cigar shaped yeast cell
 In tissues: asteroid body:
 Eosinophilic material – produces the antigen-
antibody reaction

SPOROTRICHOSIS
1. Fixed cutaneous sporotrichosis
2. Lymphocutaneous sporotrichosis
3. Pulmonary sporotrichosis
4. Osteoarticular sporotrichosis

1. FIXED XUTANEOUS SPOROTRICHOSIS

 Primary lesions develop at the site of implantation
o Limbs, hands, fingers
 Lesions often start out as a painless nodule
that ulcerates
o Often discharging a serous or
purulent fluid
o This lesion remain localize around the
initial site of implantation and do not
spread around the lymphangitic
channels
o The isolate from these lesions grow
at 35°C but not at 37°C

2. LYMPHOCUTANEOUS SPOROTRICHOSIS
 Primary lesions develop at the site of implantation
 Secondary leions also appear along the lymphangitic
channels
 Isolate from this lesions grow well at 35° and at 37°

3. PULMONARY SPOROTRICHOSIS
 Brought about by inhalation of conidia
 Reported cases: haematogenous dissemination
 Symptoms (nonspecific)
o Cough
o Sputum
o Fever, weight loss and upper – lobe lesion
o Haemoptysis: massive fatal (spiting of
blood from the lungs or bronchial tubes)
 Lung lesion: gradual progression to death

4. OSTEOARTICULAR SPOROTRICHOSIS
 Formation of cutaneous lesion
 Lesions here are confined to the long bones near the
affected joints
 Stiffness and pain in a large joint
 Knee, elbow, ankle, wrist
 Osteomyelitis: seldom occurs without arthritis
  Characterized by verrucoid (wartlike) crusted
LABORATORY DIAGNOSIS nodules of the skin
1. CLINICAL MATERIAL:  Painless if it is without secondary infection
 A tissue biopsy  If not treated, will elevate to resemble cauliflower
2. DIRECT MICROSCOPY (with cayenne pepper appearance)
 Tissue sections: CAUSATIVE AGENTS:
o PAS digest
o Grocott’s methenamine silver (GMS)
 Phialophora verrucosa
o Gram stain  Fonsecaea pedrosoi
 Asteroid bodies – this is are approximately star  F. compacta
shaped with raise eosinophilic material radiating from  Cladophialophora carrionii
a central yeast like cell DEVELOPMENT IN TISSUES
 Dimorphic fungi that is budding  Dermatiaceous (brown-pigmented/ copper
appearance)
 Mode of Transmission: traumatic implantation of
fungal elements into the skin

3. CULTURE
 Primary isolation media
o SDA MICROSCOPIC
o BHIA with 5% sheep blood
 Presence of sclerotic bodies- dark organism
o Interpretation: A positive culture from a
1. Fonsecaea- mixed sporulation
biopsy should be considered significant
2. Cladosporium- appears as conidia in chains
4. SEROLOGY
3. Phialosphora- appears as conidia in clusters
 Serological test: limited value
LABORATORY DIAGNOSIS
5. IDENTIFICATION
1. CLINICAL MATERIAL
 Hyphomycete
 Skin scrapping and/or biopsy
o Thermal dimorphism
2. DIRECT MICROSCOPY
o Clusters of ovoid, denticulate conidia produced
 Skin scrapping:
sympodially on short conidiophores o 10% KOH and Parker ink
 At Room temperature: mold
o Calcofluor white mounts
o Flowerette conidia
 Stains used:
o In old culture: conidia SIDE o H&E
 At 37oC: yeast
o PAS digest
o Cigar shaped yest cell
o Grocott’s methenamine silver (GMS)
o In tissues: asteroid body: radiating
o Eosinophilic material (causes Ag-Ab reaction)
6. CUTANEOUS LESIONS MANAGEMENT
 Saturated potassium iodide: taken in 4-6ml 3 times a
day for 2-4 months
o Itraconazole- 400mg per day
o Terbinafine – 250mg twice a day
 Local heat has also been shown to improve
cutaneous lesions
7. EXTRACUTANEOUS FORMS MANAGEMENT
 Combination of antifungal treatment with 3. CULTURE
Amphotericin B or itraconazole  Primary isolation media: SDA
 With surgical debridement  Interpretation:
 Procedure for treating a wound in the skin o (+) sputum or skin
involves thoroughly cleaning the wound and o Clinical history
removing all hyper-keratotic or thickened skin or o Direct microscopic
callus skin 4. MANAGEMENT
 Surgical excision: margin of uninfected tissue
CHROMOBLASTOMYCOSIS  Flucytosine (w/ or w/o thiabendazole)
 Itraconazole (400 mg/day)
 Terbinafine (500 mg/day) for 6 to 12 months  MOT: local traumatic implantation of fungal elements
(skin)
ZYGOMYCOSIS o Extensive burns
 Also known as Mucormycosis o Diabetes
 Infection that is caused by fungi in the order o Steroid induced hyperglycemia and trauma
Mucorales and ensomophtorales.  Lesions
 Most acute and fulminate fungal infection known o Plaques
o Rhino-facial-cranial area o Pustules
o Lungs o Ulcerations
o Gastrointestinal tract o Deep abscesses
o Skin o Ragged necrotic patches
o Less commonly other organ systems
 Associated:
o Acidotic diabetes
o Starvation
o Severe burns
o Intravenous drug abuse
o Leukemia and lymphoma

 MUCORMYCOSIS: Mucorales
 Rhizopus, Absidia, Rhizomucor,
ULCERATED
Mucor, Cunninghamella, Saksenaea,
CUTANEOUS
Apophysomyces, Cakeromyces, and
ZYGOMYCOSIS
Mortierella

 ENTOMOPHTHOROMYCOSIS: Enthomophtorales
 Conidiobolus and Basidiobolus
1. RHINOCEREBRAL ZYGOMYCOSIS
 Paranasal sinuses
 Inhalation of sporangiospores
 Orbit, palate, face, nose, or brain

5. DISSEMINATED ZYGOMYCOSIS
 Haematological malignancies
 Burns
 Diabetes
 Uraemia – raised level of blood in the urea
6. CENTRAL NERVOUS SYSTEM ALONE:
 Intravenous drug abuse
 Traumatic implantation leading to brain abscess

2. PULMONARY ZYGOMYCOSIS
 Predisposing conditions:
o Haematological malignancies
o Lymphoma and leukemia
o Severe neutropenia
o Treatment with cytotoxins and corticosteroids
o Diabetes and organ transplantation
o Mode of Transmission: inhalation of
sporangiospores
3. GASTROINTESTINAL ZYGOMYCOSIS 1. CLINICAL MATERIAL:
 Gastrointestinal diseases  Skin scraping from cutaneous lesions
o Disrupt the integrity of the mucosa  Sputum and needle biopsies from pulmonary lesions
 Primary infections:  Nasal discharge
o Ingestion of fungal elements  Scrapings
o Present as necrotic ulcers  Aspirates from sinuses in patients with rhinocerebral
4. CUTANEOUS ZYGOMYCOSIS lesions
 Biopsy tissue from patients with gastrointestinal
and/or disseminated disease
2. DIRECT MICROSCOPY:
 Scrapings, sputum and exudates
o 10% KOH & Parker ink
o Calcofluor mounts
 Tissue sections: H&E and GMS
 Examine specimens
o Broad, infrequently septate, thin-walled hyphae
o Show focal bulbous dilations and irregular
branching
3. SEROLOGY:
 Currently no commercially available serological
procedures
 ELISA test for the detection of antibodies to 3. CULTURE
Zygomycetes  Loboa loboi” remains to be cultured
4. SEROLOGY
LOBOMYCOSIS  No currently serological test available
 Subcutaneous mycosis of chronic evolution that is 5. IDENTIFICATION:
caused by Lacazia loboi (formerly Loboa loboi)  Clinical features
 Causative agent: Loboa loboi  geographic location
 Chronic, localized subepidermal infection  Microscopic morphology
 Keloidal , verrucoid, nodular lesions 6. MANAGEMENT
Keloidal  Clofazimine at 100-200 mg/day
o firm rubbery lesion or fibrous shiny
TYPES OF CONIDIATION
nodules that can vary from pink-the color 1. CLADOSPORIUM
of person’s skin or red-dark brown  Chains branch from a conidium (tree;like structure)
o Benign and non-contagious 2. PHIALOPHORA
o Sometimes accompanied by severe  With a vase shaped phialide arising from a
itchiness, pain and changes in texture conidiophore
3. RHINOCLADIELLA
o In severe cases, affect the movement
 Arranged sympodially (resemble a bdy builder) on
of the skin short denticles
 Vegetating crusty plaques and tumours  With primary, secondary and tertiary conidia

Cladosporium carionii
 Disease: chromoblastomycosis
o long term fungal infection on the skin and
subcutaneous tissue
o chronic subcutaneous mycosis
o occurs most commonly in tropical or subtropical
climates often in rural areas
 Microscopic Morphology
o Hyphae: dark septate
o Conidia: cladosporium type

Exophiala jeanselmei
 Di-morphic
 Disease: mycetoma, phaeohyphomycosis
 Microscopic morphology:
o Hyphae: separate branched with bends and
tortuous ends.
LABORATORY DIAGNOSIS
 Tortuous- continuously branching.
1. CLINICAL MATERIAL:
o Conidia: aneloconidia
 Curettage (used to remove tissue inside the uterus)
 Surgical biopsy  Attached to an annellide then to
2. DIRECT MICROSCOPY: an annellophore.
 TISSUE:  With vermiform granules (black pepper)
o 10% KOH and Parker ink on direct examination
o Calcofluor white mounts
FONSECAEA PEDROSOI
 TISSUE: PAS digest, Grocott’s methenamine silver
(GMS) or Gram stain  Disease: chromoblastomycosis, phaeohyphomycosis
 May have secondary infection (Elephantiasis)
 o Elephantiasis – condition that is characterized
by the gross enlargement of an area of the
body specifically more of the lymph’s. cause
of obstruction of lymph system.
 Microscopic morphology
o Hyphae: dark brown septate hyphae
o Conidia: all three types are present.
PHIALOPHORA VERRUCOSE
 Disease: chromoblastomycosis, phaehyphomycosis
 Microscopic morphology:
o Hyphae: dark septate hyphae
o Conidia: Phialophora
PSEUDALLESCHERIA BOYDII
 Synonyms and Teleomorphanamorph Relationships
o Pseudallescheria boydii is the anamorph of
Scedosporium apiospermum and teleomorph
of Graphium eumorphum.
o Obsolete synonym of Pseudallescheria boydii
 Allescheria boydii
 Petriellidium boydii
 Pseudallescheria sheari
 Natural habitats
o It has so far been isolated from the soil, sewage,
contaminated water, and the manure of farm
animals.
 It is an emerging opportunistic pathogen and can
cause various infections in humans.
 Homothallic fungi- self fertile
 Ability to develop sexual structures on routine culture
media.
 Disease: Eumycotic mycetoma
o With white or light-colored granules on
drainage.
o Fungoma- perfect fungus
 Pseudallescheria boydii is among the causative agents
of white grain mycetoma
 The infection is usually acquired via contact with soil
and follows a minor trauma
 Disseminated infections are often fatal if not treated
TREATMENT
 Mycetoma does not resolve without active
treatment
 Eumycetoma is more difficult to treat than
actinomycetoma
o Eumycetoma is a chronic subcutaneous
fungal infection of the skin and soft tissue
that most often affect the lower
extremity typically the single foot
o Actinomycetoma is a chronic bacterial
subcutaneous infection that is caused by
actinomyces that would affect the skin
and connective tissue therefore it is a
form of actinomycosis
o Mycetoma is a broad term that includes
actinomecetoma and eu,ycetoma
 Itraconazole
 Ketoconazole
 Surgery to remove the affected tissue completely
 Amputation if bone is affected
MACROSCOPIC FEATURES
 Colonies of Pseudallescheria boydii grow rapidly at
25°C
 Texture is wooly to cottony
 From the front, the color is initially white and later
becomes dark gray or smoky brown
 From the reverse, it is pale with brownish black zones

 Microscopic appearance:
o Hyphae: hyaline septate and loosely arranged
o Conidia: lollipop shaped or lemon shaped
annelloconidia on annellides.
Pseudallescheria boydii
EUMYCOTIC MYCETOMA
 With white or light colored granules on drainage Agar: Sabouraud dextrose agar
 Fungonoma Shows the typically greyish white, cotonny
Microscopic appearance: colony with greenish black rivers
 Hyphae: hyaline septate and loosely arragned
 Conidia: lollipop shaped or lemon shaped
anneloconida on annellides
 Cleitothecia – it is a fully enclosed fruiting structure
where you can find sexual ascospores that is
enmeshed with hyphae
PATHOGENICITY AND CLINICAL SIGNIFICANCE
 Pseudallescheriasis
o Infections caused by Pseudallescheria boydii
o Affected host is immunosuppressed due
to various reasons such as haematological
malignancies over transplantation or AIDS
 SUBCUTANEOUS MYCOSES

MICROSCOPIC FEATURES
 Cleistothecia, asci, and ascospores are visualized in the
sexual stage.
 Cleistothecium (50 to 250 µm in diameter) is a round,
closed brown, multicellular, sexual fruiting body
 It bears asci and ascospores inside
 At maturation, the cleistothecium burst and releases
the asci that are filled with ascospores
 Ascospores are unicellular, ovoid to ellipsoidal,
smooth, and plae yellow brown to copper in color

REFERENCES
Notes from asynchronous session by Ma’am Gacayan

University of Baguio PowerPoint presentation and

module
SUBCUTANEOUS MYCOSES