SYSTEMIC MYCOSES

Samuel Essien-Baidoo Ph.D.

Department of Med Lab Science, UCC.
OVERVIEW

Systemic mycoses are those fungal infections that

spread throughout the body as a result of one of the 4
pathogenic dimorphic fungi of the Ascomycota.
(Blastomyces, Histoplasma, Coccidioides,
Paracoccidioides)

These pathogenic fungi are uniformly acquired via

inhalation and all begin as generalized pulmonary
infections that later disseminate via the blood
system to other parts of the body.
 Dimorphic fungi are hazardous to lab personnel.
Precautions must be taken to avoid aerosol
generation- exposure to spores, particularly during
culturing. (Use BSC, protective clothing, face masks
amongst others).
 Blastomycosis
Blastomycosis is a systemic mycotic disease caused by the
dimorphic fungus Blastomyces dermatitidis. 

The disease primarily affects dogs and humans, but has been reported in
cats, horses, sea lions, lions, wolves, ferrets and polar bears.

In humans, blastomycosis is also known as Gilchrist's disease,

Gilchrist’s mycosis, Blastomyces dermatitidis, and Chicago
disease.
Blastomycosis disease is caused by inhalation of spores
(mold conidia) of Blastomyces dermatitidis.

Once the Blastomyces dermatitidis spores are inhaled, and

deposited in the lungs, they invade the lungs.

Sometimes the Blastomyces dermatitidis infection spreads

haematogenously to the skin or focal sites in other tissues as
well.

Most of the Blastomyces dermatitidis infections have an

insidious onset, and usually result in a chronic condition.
If left untreated, Blastomycosis usually develops progressively
over time, and could very well prove to be a life-threatening
disease.
Transmission of Blastomycosis

Blastomycosis transmission involves inhalation of mold

conidia -Blastomyces dermatitidis spores.

Blastomyces dermatitidis spores grow in warm and humid soil that is

enriched with decomposing organic matter. The spores are usually made
airborne when such contaminated soil is disturbed.

Once inhaled, the spores of B. dermatitidis can lodge in the lungs and
cause a localized inflammation. This is known as primary pulmonary
Blastomycosis. The disease does not spread from one person to another.
After inhalation, the conidia are phagocytized by
alveolar macrophages and transform the mycelial
phase to the yeast phase.

The size of the yeast when it grows at body temperature

prevents it from entering the terminal airway in an
aerosol. 

Therefore, aerosol transmission of the yeast phase from

infected animals/persons is not possible.  However,
penetrating wounds can transmit the disease.
Epidemiology

High risk group includes individuals (as well as

their pets/animals) exposed to wooded sites
(moist soil containing decomposing organic debris
especially in barns & paddocks) in regions with
endemic disease.

Risk groups include campers, farmers, forestry

workers, outdoorsmen, hikers, bikers, and hunters -as
well as their pets (especially dogs) and various animals
native to such regions.
Blastomycosis disease is endemic to the South-
central United States, South-eastern United States,
Mid-western United States, Middle Atlantic states,
upstate New York, and southern Canada.

It is also prevalent in parts of Central America,

South America, and Africa.
Symptomatology

Considering that most Blastomycosis infections

have an insidious onset, as well as the fact that
Blastomycosis symptoms are usually nonspecific,
it is common for Blastomycosis patients to remain
asymptomatic.

Symptoms of symptomatic Blastomycosis infection may include:

arthralgia, chills, drenching sweats,
dry hacking cough, dyspnea, flu-like fever,
myalgia, pleuritic chest pain, and
productive cough.
Symptomatology …

The fungus can disseminate and spread

beyond the lungs.

Cutaneous blastomycosis occurs in 60—70%

of cases mainly in the upper body and face.

In about 30% cases the fungus will spread to

the spine, pelvis, craium, ribs & long bones- a
condition known as osteoarticular
blastomycosis.

About 40% of AIDS patients experience

meningitis due to infection of the nervous
system.
 Diagnosis
A positive diagnosis of blastomycosis is made when the
fungus B. dermatitidis is identified by direct microscopic
examination of body fluids such as sputum and prostate fluid
or in tissue samples (biopsies) from the lung or skin.

Another way to diagnose Blastomycosis is to culture and

isolate the fungus from a sample of sputum.

The yeast organisms range from 5-20 μm in diameter and are

characterized by broad based budding with a thick,
refractile, double-contoured cell wall.  Diagnosis is usually
based on finding the characteristic yeasts in cytologic or
histologic preparations. 
Haematology is usually not helpful in the diagnosis since complete
blood count (CBC) results are often normal.  Radiographic
assessment can be helpful in the diagnosis. 

Chest x rays are used to assess lung damage, but alone cannot lead
to a definitive diagnosis of blastomycosis because any damage
caused by other diseases, such as by pneumonia or tuberculosis, may
appear similar on the x ray. Because its symptoms vary widely,
blastomycosis is often misdiagnosed. 

Thoracic radiographs often reveal a nodular interstitial pattern or

diffuse interstitial pattern.  Serology should be used diagnostically
only when a high degree of suspicion for Blastomyces exists and
repeated attempts have failed to demonstrate the organisms.
Treatment

Blastomycosis patients are often prescribed Itraconazole

(orally) and/or treated with Fluconazole.

Patients diagnosed with a severe case of Blastomyces

dermatitidis infection often benefit from Amphotericin B
therapy treatment -usually administered intravenously.
Prognosis/Expectations

Even though pulmonary Blastomycosis infections usually

occur as individual cases of progressive (Blastomyces
dermatitidis) infections, they may result in granuloma
formation, fibrosis, and/or necrosis.

If untreated, blastomycosis could develop into a serious and

potentially life-threatening chronic pulmonary infection
(pulmonary blastomycosis) or a widespread disseminated
infection (extrapulmonary disseminated blastomycosis) not only of
the respiratory system, but also the focal infection of the bone
marrow, brain, epididymis, kidneys, lymph nodes, nasal mucosa,
prostate, skin, subcutaneous tissues, testis, thyroid, and/or
vertebrae.
In some cases, the
Blastomyces dermatitidis
infection invades/spreads
to the meninges as well.
Note:
Consult a
qualified
medical
practitioner
It is also common for some
patients to develop additional if you
complications including Pleural suspect lung
effusion, and/or rapidly
progressive infections such as
disease.
Adult Respiratory Distress Synd
rome
(ARDS.)
 Histoplasmosis
(Due to Histoplasma capsulatum & Histoplasma duboisii)
Introduction

Histoplasmosis refers to the condition caused by the

infection with the dimorphic endemic fungi
Histoplasma capsulatum var. capsulatum.

This anamorphic fungus has a known sexual teleomorph

that carries the name Ajellomyces capsulatus. The majority of
acute cases of infection with this fungus follow a subclinical
and benign course in normal hosts.

However, a disseminated and potentially fatal picture is seen

among immunosuppressed individuals, children less than 2
years old, elderly persons, and people exposed to very large
inoculum.
The infection is acquired through inhalation of Histoplasma
capsulatum microconidia.

The lungs are thus the most frequently affected site and
chronic pulmonary disease may occur.

Clinical picture is frequently associated with preexisting

chronic lung diseases such as emphysema and occurs most
frequently in elderly men.

All stages of this disease may mimic tuberculosis.

Histoplasmosis may coexist with Actinomycosis, other
mycoses, sarcoidosis, or tuberculosis
• Histoplasmosis due to Histoplasma duboisii is a mycotic infection
primarily involving the liver, lung, lymphatic, subcutaneous, and bony
tissues.

• Skin and bone are the most frequently invaded sites. The etiologic
agent grows as a large yeast within giant cells. It may also present with
small cells that are typical of those seen in histoplasmosis due to
Histoplasma capsulatum.

• The primary clinical characteristics of Histoplasmosis duboisii are

nodular and ulcerative cutaneous and osteolytic lesions of bone that
disseminate or remain localized.
 Epidemiology

• Histoplasma capsulatum is particularly prevalent in eastern United States, but also

endemic in Africa and South America.

• It is found in moist soils containing high levels of nitrogen such as those

contaminated with droppings from birds and bats.

• Of the two strains, the capsulatum is widely distributed and the duboisii is
limited to Africa.

• Spores may become airborne and inhaled when contaminated soil is disturbed
by wind or by human activities. Cutaneous inoculation is also possible even
though it is extremely rare cases have been reported.
 Pathogenicity and Clinical Significance
• Histoplasma capsulatum is an intracellular parasite which, upon
inhalation, first attacks the alveolar macrophages in the lungs.
These macrophages then disperse the fungus beyond the lungs via
the blood and lymph.

• Cell-mediated immunity eventually develops, and clears the organism

from healthy individuals.

• Clinically, about 95% of most infected individuals are asymptomatic

and the disease resolve without damage.
Clinical Presentations Of Disseminated Histoplasmosis
The intracellular budding yeasts are approximately 3 µm in diameter,
similar to Leishmania sp., but do not contain a kinetoplast.

In addition, Leishmania does not stain with the special stains used for
fungi. Older lesions show well-developed granulomata and have a
central area of caseation resembling tuberculosis.
Laboratory Diagnosis

Direct examination

The direct detection of fungi in clinical material such as bone marrow,

sputum, and tissue is usually difficult. Material stained by the Giemsa, or

GMS methods is more likely to show the organisms than is a KOH

preparation.

Isolation
Inoculate the clinical material onto Inhibitory Mould agar and/or yeast
extract-phosphate agar and/or BHI agar with 10% sheep blood and/or a
medium containing cycloheximide. Incubate cultures at 30°C and do not
discard until 12 weeks.
• The globose to ovoid, thick-
walled yeasts are 7-15 µm
(average 10 µm) in diameter and
may form rudimentary
pseudohyphae consisting of 4 or 5
cells.

• Large aggregates of yeast cells

can be readily seen within giant
cells and extracellularly following
necrosis of the host tissue.

• Unlike Blastomyces dermatitidis,

the blastoconidia are not attached
to the parent cell by a broad neck.
• Antigen detection

Detection of the capsular antigen of this fungus in urine or serum is a

very powerful tool for the diagnosis of the disseminated forms of this
disease. The test is useful for both diagnosis and monitoring of infection,
and is available from the Histoplasmosis Reference Laboratory.

Laboratory confirmation
Confirmation is necessary to ensure that the fungus is not a species of
Chrysosporium or Sepedonium. This can be accomplished by mould-to-
yeast conversion, exoantigen testing, or by use of DNA probes.

Susceptibility testing
Standardized testing procedures are not available. Microbiological
resistance has been demonstrated with respect to fluconazole, but not
itraconazole. Susceptibility testing is not routinely used to guide therapy
of this disease.
Coccidioidomycosis
Introduction
• Coccidioidomycosis is the
infection caused by the
dimorphic fungus Coccidioides
immitis and C. posadasii and
are thermally dimorphic fungi
found in soil particularly at
warm and dry areas with low
rain fall, high summer
temperatures, and low
altitude.

• San Joaquin Valley fever,

Valley fever.
• The two species are morphologically identical but
genetically and epidemiologically distinct.

• C. immitis is geographically limited to California's San

Joaquin valley region, whereas C. posadasii is found in
the desert southwest of the United States, Mexico,
and South America. The two species appear to co-
exist in the desert southwest and Mexico.

• Although it was recognized for some years that C.

immitis contained the two genetic subgroups, their
description as separate species did not occur until
2002.
• Prior to this, the two groups were simply known as
the California and non-California variants of C. immitis.
Thus, essentially all prior literature treats them as a
single species.

• As the two species can be distinguished only by

genetic analysis and different rates of growth in the
presence of high salt concentrations (C. posadasii
grows more slowly), little is known as yet about
differences in pathogenicity.

• Thus, the remainder of this discussion will simply refer

to the pair of species as C. immitis/posadasii.
Epidemiology
• C. immitis/posadasii specifically inhabits alkaline soil. It is
isolated in rodent burrows at desert-like areas of southwest
United States. It has no known teleomorph.

Coccidioides immitis/posadasii is a pathogenic fungus and is

among the causative agents of true systemic (endemic)
mycoses. It is endemic at southwest United States, Northern
Mexico, and certain areas in Central and South America.

• Imported cases may be observed following travel to endemic

areas.
 Pathogenicity and Clinical Significance
• Coccidioides immitis/posadasii is the causative agent of
coccidioidomycosis in humans. Coccidioidomycosis is one of the
true systemic (endemic) mycoses.

• It is acquired by inhalation and initially presents with a pulmonary

infection which may later disseminate to other organs and systems.

• Airway coccidioidomycosis involving the endotracheal and

endobronchial tissues may develop.

• Inhalation of the dry arthroconidia of Coccidioides

immitis/posadasii, which are carried by dust storms, initiates the
infection.
• Afterwards, hematogenous spread of the organism results in
infection of skin, bones, joints, lymph nodes, adrenal glands, and
central nervous system.

• The clinical picture has a remarkably wide spectrum. The

infection remains as an acute and self-limited respiratory
infection in most exposed hosts, but it progresses to a chronic
and sometimes fatal disease in others.

• Spontaneous healing is observed in as high as 95% of otherwise

healthy hosts.

• Dissemination may occur particularly during pregnancy and

carries a high risk of mortality.
A patient showing the disseminated stage of disease (coccidioidomycosis).
Top right: spherules.
Bottom right: chains of arthrospores interspersed with empty cellular
compartments.
• Coccidioides immitis is
distinguished from other fungal
pathogens by the unique
morphogenetic features of its
growth in host tissue.

• Microscopic morphology shows

typical single-celled, hyaline,
rectangular to barrel-shaped,
thick-walled arthroconidia.

• Typically, these arthroconidia

alternate with empty disjunctor
cells.
Macroscopic Features
• Coccidioides immitis colonies grow rapidly. The colony
morphology may be very variable.

• At 25 or 37°C and on Sabouraud dextrose agar, the colonies

are moist, glabrous, membranous, and grayish initially, later
producing white and cottony aerial mycelium.

• With age, colonies become tan to brown in color.

Microscopic Features
• Microscopic appearance of the fungus depends on the temperature of
isolation:

1. At 25°C
       Hyphae and arthroconidia are produced. Hyphae are hyaline, septate
and thin. Racquet hyphae may occasionally be observed on slides
prepared from young cultures. Arthroconidia are thick-walled, barrel-
shaped, and 2-4 x 3-6 µm in size. Typically, these arthroconidia alternate
with empty disjunctor cells. On the released arthroconidia, annular frills
that are the remnants of the disjunctor cells are observed.
• 2. At 37°C
       Large, round, thick-walled spherules (10-80 µm in diameter)
filled with endospores (2-5 µm in diameter) are observed. Production
of spherules in vitro requires inoculation into a special synthetic
medium, such as converse liquid medium, an incubation temperature
of 37-40°C and presence of CO2 at a concentration as high as 20%.

• Culture identification by the exoantigen test is now the method of

choice.
•
WARNING: Cultures of Coccidioides immitis represent a severe
biohazard to laboratory personnel and must be handled with
extreme caution in an appropriate pathogen handling cabinet.
Health Effects
• Coccidioides immitis continues to grow as a mould and does not
produce spherules at any temperature unless special growth medium
is provided in vitro. This finding indicates that temperature is not the
only variable that controls the spherule formation. Thus, some
authorities prefer not to classify this fungus as thermally dimorphic.
Nevertheless, Coccidioides immitis is commonly classified among
the thermally dimorphic fungi.

       The definitive identification of an isolated Coccidioides immitis

strain requires demonstration of spherule production in vitro, use of
DNA probes, application of exoantigen tests, or demonstration of
spherule production in vivo by animal experiments. Molecular typing
studies have also been initiated and appear useful in identification.
• Laboratory Precautions
•        The arthroconidia of Coccidioides immitis are very infectious.
All manipulations should be done in a biological safety cabinet.
• Diagnosis is obtained by use of a specific blood test (called a
coccidioidal or cocci serology) which measures the level or
titer of antibodies to the fungus.

• A positive titer is usually measured or reported in dilutions of

the patient's serum that continue to react to the fungal antigen.

• Titers are reported as 1:2, 1:4, etc. In early disease, the cocci
serology must be repeated in 2-4 weeks if negative because
the antibody level might be too low to be detected.

• Culture of sputum, tissue, biopsies, or body fluids or

histopathologic (microscopic) evidence from the same sources
are diagnostic.
Paracoccidioidomycosis
Introduction

• Paracoccidioidomycosis refers to the endemic disease produced by

Paracoccidioides brasiliensis. The infection is found beginning at about 23
degrees North latitude in Mexico and extends southwards to Argentina and Brazil.

• The ecologic niche for P. brasiliensis remains obscure and the fungus has only
been isolated four times from soil.

• Inhalation of conidia is presumably the route of acquisition. Primary infection is

asymptomatic in most cases. The fungus can remain dormant for years within
lymph nodes to appear later probably in relation to some type of
immunodeficiency.
• Interestingly, paracoccidiodomycosis affects primarily men
(Men/women ratio 15:1) and people older than 30years. A juvenile
form with a peculiar poor prognosis occurs rarely.

• The adult form usually manifests with painful ulcerated lesions in the
mouth. Other clinical presentations include cutaneous lesions,
lymphadenopathy, dysphagia, and hoarseness.

• Finally a clinical picture identical to pulmonary tuberculosis (fever,

weight loss, and productive cough with blood-tinged sputum) may
also occur.
 Pathogenicity and Clinical Significance
• Infections range from asymptomatic to systemic and follow an
incubation period that can last for years.

• Onset of disease is pulmonary which is slow but manifests

chronic cough, fever, night sweat etc.

• Following dissemination, there’s chronic inflammatory disease

of mucous membranes. There’s also painful ulcerated lesions of
the gum, tongue, lips, and palate which progresses for weeks
and months. Lesions are permanently destructive.

• Lymphatic involvements can occur in younger patients and can

lead to lesions in the intestine, liver, brain and other tissues.
 Laboratory Diagnosis

• Direct examination of sputum, biopsy material (base and outer edge

of ulcers), or crusts/pus from suppurative draining lymph nodes
typically contain the yeast form.

• Material mounted in 10% KOH for examination will show the

fungus, which is characterized by multiple budding with globose
young cells 2-10 um in diameter to globose mature cells 30 um in
diameter or greater at the center. Some cells may reach 60 um in
diameter. The budding looks like a “steering wheel”.

• Isolation
Inoculate the clinical material onto Sabouraud dextrose agar and a
medium containing cycloheximide. Incubate cultures at 30°C and
do not discard as negative until 4 weeks. The colony may require 10
or more days to reach 1 cm in diameter.
 QUIZ 1

• All of the fungal pathogens that cause systemic mycoses,

manifest initially as a pulmonary disease. Explain how you
could ascertain which of the four fungal pathogens a patient
has.
[15 marks]