Opportunistic Mycoses

The Opportunistic Fungi

• Members of the resident human microbiota

• Saprophytes in the environment

With the breakdown of host defenses, they can cause

infections ranging from skin/mucous membrane
involvement to life-threatening, systemic disease
 Opportunistic Infections

The yeast
Candida albicans

The mold
Aspergillus

Pneumocystis, a
frequent cause of
pneumonia in
AIDS patients
 Candida

▪ Candida species grow as 4 to 6 μm

▪ Budding, round or oval yeast-like cells
▪ Certain pathogenic Candida species can also form hyphae
▪ Of the over 150 Candida species, fewer than 10 cause human
infections
 Candida albicans

The most common cause of

human invasive fungal
infections

Form hyphae triggered by

changes in conditions such
as temperature, pH, and
available nutrients
Initial stages of germination from the yeast cell, the nascent hyphae
resemble sprouts and are called “germ tubes”
Being able to recognize these different fungal morphologies can help
clinicians and laboratory personnel to rapidly distinguish C albicans
from other, similar yeast species in clinical specimens
 PATHOGENESIS

Change in the organism, the host, or both

The ability of this microorganism to change between the yeast and

hyphal forms is strongly associated with its pathogenic potential
(The yeast-hyphal switch)
In histologic preparations, hyphae are seen during Candida invasion,
either superficially into the mucosa or within deep tissues

Dissemination in the bloodstream is likely enhanced during the yeast

growth phase

The yeast-hyphal switch can be controlled in vitro by the manipulation

of a wide variety of environmental conditions (serum, pH, temperature,
amino acids)
The yeast-hyphal switch
Candida albicans hyphae have
the capacity to form strong
attachments to human
epithelial cells

Suface hyphal wall protein

Fibronectin, collagen, and
laminin

Proteinases and
phospholipases
Yeast and hyphal
forms
Host-derived
proteins

Once formed, the

biofilm strongly
adheres to tissues and
plastics
Biofilms
Factors predispose to Invasive Candida Infections

▪ Antibacterial therapy

▪ Alterations in innate immunity

▪ Anatomic disruptions of the skin and mucosa

▪ Biofilm formation on the plastics

▪ Diabetes mellitus
 IMMUNITY
➢ Both humoral immunity and cell-mediated immunity

➢ Neutrophils are the primary first-line defense

➢ Yeast forms of C albicans are readily phagocytosed and killed by these

innate immune cells

➢ Many immunodeficiency syndromes involving T-lymphocyte

dysfunction result in severe mucocutaneous candidiasis (AIDS)
 MANIFESTATIONS

White, cheesy plaque that is loosely Oral lesions, called thrush

adherent to the mucosal surface
Diaper rash Chronically irritated area with adjacent
“satellite” lesions
 Dishwashers
Erythematous papules or confluent areas of erythema, tenderness, and
skin fissures
Most people live their entire lives in constant contact with C
albicans but without developing symptomatic infections

This observation largely reflects the ability of normal hosts to

effectively control the growth of this fungus
Esophagus and upper GI tract
 Disseminated infections

The fungus often gains access to the bloodstream through skin

lesions (eg, burns, intravascular catheters), disruption of the GI
tract (eg, intestinal perforations, abdominal surgery), or
prosthetic devices colonized with Candida biofilms
Once in the bloodstream, Candida species can infect many organs, including
the kidneys, brain, and heart valves; however, symptoms are generally not
sufficiently characteristic to suggest C albicans over the bacterial pathogens

Candida endophthalmitis
funduscopic appearance of a white cotton ball expanding on the retina or
floating free in the vitreous humor
 DIAGNOSIS
▪ Exudate or epithelial scrapings examined by KOH preparations
demonstrate abundant budding yeast cells; hyphae

▪ Clinical specimens (sputum) including blood; Cultures

▪ Run the risk of contamination from yeasts present in the normal flora
▪ Deep organ involvement is difficult to prove without a direct aspirate or
biopsy

▪ Candida species often grow in routine blood cultures, and every episode
of candidemia must be carefully evaluated for evidence of dissemination
of involvement of prosthetic devices
 TREATMENT

Candida albicans is usually susceptible to amphotericin B, nystatin,and the

azoles

Superficial infections are generally treated with topical nystatin or azole

preparations.

Measures to decrease moisture and chronic trauma are important adjuncts in

treating Candida skin infections.
All C albicans infections may also require addressing predisposing
conditions

Removal of an infected catheter, control of diabetes, or an increase in

peripheral leukocyte counts can be important aspects of the complete
treatment of infection
Systemic therapy with amphotericin B or azoles is required for
disseminated or deep tissue infections.

The choice of treatment is often guided by speciation and

antifungal susceptibility testing

Antifungal resistance can develop with the prolonged use of

some agents.
Other Candida Species can produce very similar infections to those of C
albicans especially disseminated and urinary tract infections

Nonalbicans Candida species are isolated almost exclusively from patients

with nosocomial infections

Antibiotic use, wounds, and prosthetic devices also predispose

hospitalized patients to infections with diverse Candida species
Some species, such as C glabrata and C krusei, display increased levels of
resistance to the azole antifungals, colonization of these species

Nosocomial transmission of Candida species may occur with poor

adherence to proper handwashing and other infection control practices