Hossana Health Science College Medical laboratory Group one (1)

Assignmt of Mycology (Opportunistic Mycoses)

NAME AND IDNUMBER (GROUP 1)

1) TILAHUN –TESEMA 044/13

2)BIRHANU -ABIREHAM 009/13

3)DAWIT –DANIEL 014/13

4)MIHRET -ANDUALEM 034/13

5)AMNUEL –YOSEF 005/13

6)DIELABO – AYELE 015/13

7)EDENE –DEGORO 017/13

8)ERITIBAN –ABERA O19/13

9)DEBORA – MOLLA 054/13

10)KIDIST –TAREKEGN 055/13

11)BIRITUKAN –TEMESEGEN 011/13

12)BEREKET – ABERA 006/13

13)MESKEREM –TEAJI 033/13

14)HIRUT – SHIFERAW 025/13

Summited to Muluneh –T. (Msc.In Medical Microbiology)

1|Page
Table of content Page

1) OpportunsticMycoses

• Introudaction……………………………………………......3
• Some are opportunistic……………………………………...3
1.1)Candidiasis………………………………………....3
2.2) Cryptococosis……………………………………....6
3.3) Pneumocystic Carinni (P.jiroveci)…………………..8
4.4) Aspergillosis………………………………………..10

2) Summery………………………………………………………….…13

3) Referance……………………………………………………………13

Objectives

 To describe the etiology, morphology, pathogenesis, clinical spectrum

of opportunistic mycoses

 To elaborate the laboratory diagnosis and treatment of Opportunistic

mycoses.

2|Page
Introduction
• The opportunistic mycoses are caused by fungi that can not infect healthy humans
but can cause serious often fatal mycoses in people whose resistance has been
lowered (immunocompromised patients): AIDs patients,Leukemic
patients,Diabetics, Individuals on chemotherapy for treatment of cancer and
Alcoholics

• Unless the predisposing conditions are corrected, many opportunistic mycosis can
be fatal, even with antibiotic treatment.

• Many fungi previously considered non- pathogenic are now recognized as

etiological agents of the opportunistic fungal infections.

• The laboratory must identify and report completely the presence of all fungi
recovered from immunocompromised patients since every organism is a potential
pathogen.

➢ Although there is an ongoing list of opportunistic mycoses, some are seen more
often and include: ,Candidiasis,Cryptococcosis,Pneumocystosis,Aspergillosis

1.1) Candidiasis
• A relatively common human infection that can take forms of superficial,
mucocutanous or systemic disease.

• Caused principally by three species of genus Candida,namely, C. krusei, C.

tropicalis and C. albicans.

• Candida albicans is the most common cause of infection.

• Since the species of Candida, including C. albicans are part of the normal
endogenous microbial flora, candidiasis is usually the result of autoinfection
during a metabolic or an immunologic disturbance.

• The organisms may be recovered from the oropharynx ,GI, genitourinary tract,
and skin.

3|Page
Pathogenesis and Clinical future
A.Cutaneous Candidiasis (Candidosis)

• Superficial infection occurring on moist cutaneous sites Epidemiology and

Etiology;-

Age: any age; Infants (diaper area).

Sex: both; Women (vulvovaginitis), men penis (balanitis)

• Etiology: Candida albicans; uncommonly, other Candida species.

• Ecology:C. albicans is seldom recovered from skin of normal individuals; usually

endogenous infection.

➢ Candida is a normal inhabitant of mucosal surfaces of oropharynx and GI tract.

➢ In males with balanitis, Candida may be transmitted from female sexual

partner,Occupation: Persons who immerse their hands in water: housewives,
mothers of young children, health care workers, bartenders,florists Other
predisposing factors: diabetes, obesity,hyperhidrosis, maceration, systemic and
topical corticosteroids, chronic debilitation.

Classification
Intertrigo

➢ Body folds: axillae, inframammary, groins

➢ Webspaces: fingers (interdigitalis); associated with frequent wetting of hands,

toes.

Genital

➢ Balanitis

➢ Vulvitis

Diaper dermatitis may be primary or secondary infection

4|Page
B. Mucosal Candidiasis
Classification

Superficial mucosal candidiasis

➢ Vaginal and Vulvovaginal Candidiasis

➢ Oropharyngeal Candidiasis
Erythematous (atrophic) candidiasis

➢ Pseudomembranous candidiasis (thrush)

➢ Candidal leukoplakia (hyperplastic candidiasis)

➢ Angular cheilitis

Deep mucosal candidiasis; esophageal candidiasis (EC), tracheobronchial candidiasis

(TBC), both of which are AIDS defining conditions

Invasive Candidiasis (Systemic)

Candidemia, usually is acquired in the hospital setting and May follow such procedures
as introduction of IV or urinary catheters, corticosteroid or antibacterial antibiotic therapy,
and bowel surgery, or other abdominal surgery can allow Candida species to invade the
bloodstream

• Central Nervous System (CNS) Candidiasis, Candidemia and in, complicated

neurosurgery,

Laboratory diagnosis
• Superficial or mucocutaneous candidiasis is diagnosed by finding the fungus in
tissue scraping and culture.

• Systemic candidiasis;Definitive diagnosis is made by the histopathologic

demonstration of the invasion of tissue by the yeast.

• Specimens from surface lesions, mouth, vaginal,sputum, exudates etc., are

examined using different methods

5|Page
Direct examination

• KOH

Exposed lesions can usually be easily diagnosed by clinical appearance together with
finding typical budding yeast cells and pseudohyphae and/or true hyphae in lesion
scrapings treated with KOH.

• Gram- stain
Gram stain smears show large gram positive budding yeast cells with
pseudohyphae.

Culture and identification

➢ Growth is rapid on Sabouroud’s dextrose blood agar, trypticase soy, and many
other media. Creamy yeast colonies are formed after overnight incubation at
temperature of 21 0C or 37 0C; the optimum growth temperature is around 30 0C.

➢ C. albicans grows as round-to-oval yeast cells that are 4-6µm in diameter.

➢ Pseudohyphae and hyphae also seen, especially at lower incubation temperature

(i.e., 220C-250C) and on nutritionally poor media.

➢ Candida albicans is differentiated from other Candida species by:

Budding of yeast cell

➢ Germ-tube test rapid development of germ tubes when yeast cells incubated at 37
0C for 1-2 hrs. in serum and Chlamydospore formation when incubated at 22 0C
on cornmeal agar.

1.2) Cryptococcosis
Chronic meningitis and meningoencephalitis and pulmonary

➢ Cryptococcosis occurs in sporadic form and as an opportunistic infection

associated with immunosupperession.

➢ Infection occurs via inhalation of desiccated yeast and/or basidiospores in dust

➢ Exposure is common but disease is uncommon

6|Page
 ➢ Infection occurs by inhalation that results in lung infection (Cryptococcal
pneumonia).

➢ The infection spreads to the CNS and meninges

➢ Inhaled desiccated yeast and basidiospores reach alveoli.those that manage to

arrive there are controlled by the immune-normal host

➢ Cryptococcus neoformans is eliminated or else it is confined to the lung within

granulomas, persisting in a dormant but possibly viable state.

➢ Immunocompromised individuals have difficulty killing the inhaled yeast and

basidiospores, resulting in pneumonitis and increasing the probability of
extrapulmonary dissemination

Etiologic Agents.
➢ Cryptococcus neoformans is worldwide Cryptococcus gattii causes fewer than 5%
of cases producing infectious basidiospores

Ecologic Niche.
➢ C. neoformans lives in soil mixed with pigeon droppings

➢ C. gattii is associated with decayed hollows of Eucalyptus and other trees

Pulmonary Cryptococcosis

➢In persons living with AIDS presents with fever, cough, dyspnea, and pleuritic
chest pain thoseCentral Nervous System (CNS) Cryptococcosis

➢ The symptoms are headache, memory loss, dizziness and irritability, and visual
disturbances

Cutaneous Cryptococcosis
➢ Skin lesions occur via hematogenous spread of the fungus from a pulmonary site
in immunosuppressed patients

7|Page
Laboratory Diagnosis
➢ Detection of Cryptococcus neoformans in sputum and CSF.

➢ The organism is characterized by the presence of large gelationous carbohydrate

capsule that surrounds the budding yeast cell.

Direct examination
➢ The capsulated yeast cells are best seen in an India ink preparation (wet mount)
Immunofluorescent stain is applied to dried smear.

Culture and identification

➢ The organism grows easily giving rise to mucoid colonies with the typical
capsulated yeast cells.The organism is urease positive. Color change in the agar
from yellow agar to pink Melanin Production identified by the “brown colony”
effect on “birdseed” agar.

Serologic test
➢ Capsular antigens are detected in csf and in the circulation by using anti-capsular
antibodies and Antibodies can be detected in the serum of patients.

3.3) Pneumocystis carinii (P. jiroveci)

➢ The taxonomy of P. carinii remains in question, with evidence of classification as
both a fungus and a protozoan.

➢ Ribonucleic acid (RNA) sequencing, cell wall composition, ultrastructure, and

method of reproduction seem to indicate the organism is fungus.

➢ P. carinii is wide spread in nature and often found in several mammals; especially
rodents,cats, dogs, sheep, and goats

Etiologic Agent
➢ Pneumocystis jirovecii is an atypical ascomycete fungus.

Ecologic Niche.
➢ Worldwide, P. jirovecii is an endogenous opportunist restricted to humans and it
cannot be cultured in vitro; and there is no known environmental reservoir

8|Page
 ➢ The organism has two forms

Cyst stage
➢ It measures 5-8µm in diameter

➢ May contain up to eight oval interacystic bodies

Trophic or pleomorphic form

➢ It measures 1-4µm in diameter

➢ Covered with tiny projections for attachment to the host epithelial cells.

The cyst form is inhaled and the intracystic bodies are released into the alveoli of the
lungs.

The trophic form develops and multiplies asexually on the surface of the epithelial cells.

The trophic form then rounds up forming a cyst stages.

➢ None of the stages is intracellular.

Pathogenesis and clinical futures

➢ P. carinii produces a symptomatic pneumonia in debilitated or premature infants
who areimmunodeficient, A rapid, progressive pneumonia is also seen is patients
with leukemia, following transplants and in AIDS patients.

➢ P. carinii pneumonia (PCP) was one of the first opportunistic pathogens linked to
AIDS, Today more than half of all AIDS patients have P.carinii infection and it
remains a leading cause of death in these patients.

➢ The infection may disseminate in AIDS patients into the eyes, liver, spleen or
bone marrow.

Laboratory diagnosis
➢ Direct examination

Microscopic observation of the cyst or trophic form in lung secretion or lung tissue after
staining using toluidine blue O, Modified Gomori methenamine silver nitrate, or Giemsa

9|Page
4.4 )Aspergillosis
The serious form is invasive pulmonary disease in the immunocompromised host caused
by Aspergillus fumigatus and related species includes a broad range of clinical forms;-

➢ Allergic responses- bronchopulmonary aspergillosis

➢ Colonization (aspergilloma Otomycosis , Sinusitis

➢ Invasive infection –immunocompromised host—tracheobronchitis and

extrapulmonary dissemination

➢ Mycotoxicosis (aflatoxin of A. flavus) ingestion of peanuts,corn contaminated

with A. flavus toxin (aflatoxin)

➢ Geographic Dsitribution/Ecologic Niche

✓ ,> 200 spp, but the most common causing invasive infection include:

✓ Aspergillus fumigatus (causes approximately 90% of invasive

aspergillosis)A. flavus, A. niger and A. terreus

✓ Worldwide, aspergilli are among the most common environmental molds.

✓ Aspergillus fumigatus is a cellulose decomposer.

✓ Conidia are present in the air, including hospital air.

✓ A. flavus is found naturally in post harvest infestation of grains and nuts

soil, water, food, decaying vegetation

RiskGroups/Factors
✓ Organtransplants
✓ Diabetes
✓ Solid tumors
✓ Radiation theraphy
✓ Stem cell transplant
✓ Hematological machiner
✓ Cystic fibrosis
✓ Prologede neutrophenia
✓ Cytomegalovirus

10 | P a g e
Transmission
➢ Infection is via the respiratory route inhalation of airborne conidia

➢ Less commonly infection may occur by conidia alighting on injured skin by

penetrating injuries,or via fomites such as contaminated or nonsterile tape used to
fasten bandages catheters.

➢ Has become important in recent years –increase number of patients at risk

(transplant, neutropenia, AIDS)

➢ Infection is acquired through:Inhalation of conidia into the lungs,oral or aerosol

exposure to contaminated water and local exposure, (surgical wounds,
contaminated intravenous catheters, arm boards leading to cutaneous infection)

Clinical Syndromes
➢ Conidia Once inhaled, to reach all levels of the respiratory tract,Conidia that
evade phagocytosis can germinate,form hyphae,release proteinases which erode
the lung epithelia,Next, in the immune compromised neutropenic host,the hyphae
can invade the lung parenchyma.

Pulmonary aspergilloma
➢ Aspergilloma is a fungus ball in the lung caused by an Aspergillus a mass of
fungal hyphae embedded in a matrix of cell debris and fibrin, contained in a
preexisting pulmonary cavity.

➢ The cavity wall may become thickened and gradually the fungus ball may move
freely in the cavity,fungus ball begins to fill the entire cavity the air crescent sign

Clinical findings
➢ Relatively asymptomatic in most patients,In some patients invasive pulmonary
aspergillosis, subacute necrotizing form, haemoptysis) cough

➢ Maxillary sinus aspergilloma chronic sinusitis with chronic nasal discharge, sinus
congestion, pain

➢ Otomycosis external otitis media with ear pain and drainage black conidiophores
in the ear canal

11 | P a g e
Tracheobronchitis
➢ Trachea and bronchi;-Clinical form of aspergillosis aspergillus hyphae, which
cause airway Obstructing bronchial aspergillosis is found in persons living with
AIDS and in lung transplant recipients and diagnosis requires bronchoscopy

➢ Allergic Bronchopulmonary Aspergillosis chronic allergic response to

colonization with Aspergillus,episodic bronchial obstruction (asthma) ,peripheral
eosinophilia, skin test reactivity to Aspergillus antigen ,precipitating Aspergillus
antibodies,elevated serum IgE and presence of pulmonary infiltrates

Invasive pulmonary aspergillosis (IPA)

➢ Extrapulmonary dissemination; arises from spread of the organisms from a
primary and pulmonary inoculum or from the paranasal sinuses,hyphal invasion
into blood vessels (a third of patients),non-pulmonary sites become infected by
contiguous spreador via hematogenous spread the CNS (in 10 to 40% of
immunosuppressed patients) and other organs including the liver, spleen, kidney,
skin, bone,and heart

Lab. Diagnosis
➢ Direct Microscopy
Histopathology

➢ GMS or PAS stained tissue section, sputum and hyaline septate hyphae with
parallel cross walls and dichotomously branched at acute angles

➢ Culture
Colonies are usually fast growing, white, yellow, yellow-brown, brown to black
or shades and Conidiophores terminate in a vesicle covered with either a single
palisade-like layer of phialides (uniseriate) or a layer of subtending cells (metulae)
which bear small whorls of phialides (the so called biseriate structure)

Serology
➢ Sandwich ELISA technique that utilizes a monoclonal antibody to galactomannan
antigen and also sensitivity for detecting invasive aspergillosis is more than 90%
with a PPV of >80%

12 | P a g e
Therapy.
➢ Primary therapy with voriconazole (VRC) is superior to amphotericin B (AmB),
to AmB-lipid And Choices for salvage therapy include monotherapy with AmB,
caspofungin (CASF), or posaconazole (PSC), or combination therapy

Summery

✓ Opportunistic mycoses are fungal infection that take advantage of weakened

immune system to cause disease these infections can be difficult to treat and often
require aggressive antifungal therapy. It is important for healthcare providers to
be aware of the risk factors for opportunistic mycoses and to promptly diagnose
and treat these infections in immunocompromised patients.

Referance
 Brooks, Geo.F.etal,(2007);Medical microbiolgy,24ed.

 The McGraw-Hill companies, Inc.New York.----an e book in thelibray

 Murray,P.R.,Rosenthal,K.s.,& Pfaller,M.A(2015).Medical microbiology .Elsevier

Health science

End of page

13 | P a g e
14 | P a g e