Chapter 61

Atypical and Parafungal Agents

 Objectives
 Describe the symptoms of Pneumocystis jiroveci
infection and the cells affected by this organism
 List the appropriate specimen types collected for the
diagnosis of pneumocystis pneumonia
 Discuss the laboratory tests used in the diagnosis of P.
jiroveci, including methodology and biochemical
principles
 List the diseases and morphologic characteristics used
in diagnosing infections of the parafungi Lacazia loboi,
Lagenidium spp., Pythium indiosum and Rhinosporidium
seeberi
 Atypical Fungus
 Pneumocystis jirovecii
 Opportunistic atypical fungus
 Infects individuals who are immunocompromised
 Causes pneumocystis pneumonia (PCP)
 Lifecycle:
 Trophozoite (trophic form)
 Precyst (sporozoite)
 Cyst (ascus)
 Differs from other fungi:
 Cell membrane contains cholesterol
 Trophozoite form is susceptible to osmotic disturbances
 Has 1 to 2 copies of the ribosomal subunit gene
 Epidemiologic Factors
 Worldwide distribution
 Transmission is person-to-person via air-borne particles
 Immunocompetent individuals serve as the reservoir
 The organism is the most common opportunistic
infection in patients with human immunodeficiency virus
or acquired immunodeficiency syndrome (HIV/AIDS)
 Infection is species specific
 Pneumocystis carinii infects rodents
 P. jiroveci infects humans
 Disease
 Inhaled trophic form adheres to pneumocytes
where it replicates extracellularly
 An interstitial mononuclear inflammatory
response occurs
 Symptoms include:
 Nonproductive cough
 Low-grade fever
 Dyspnea
 Chest tightness
 Night sweats
 Laboratory Diagnosis
 Specimens
 Bronchoalveolar lavage fluid (BAL) recommended
 Induced sputum, transbronchial biopsy, tracheal aspirates,
pleural fluid and cellular material from bronchial brushings
 Nasopharyngeal and oropharyngeal may be used with nucleic
acid testing.
 Stains
 Giemsa
 Calcofluor white
 Methenamine silver
 Immunofluorescent staining
 Morphologic Characteristics
 Trophozoites
 Are the predominant form but difficult to visualize
 Have flexible walls (pleomorphic)
 Outnumber cysts, 10 to 1
 Cysts
 Are spherical to concave
 Are uniform in size (4-7 μm)
 Do not bud
 Contain intracystic bodies
Pneumocystis jiroveci
 Direct Detection
 1-3-Beta-D-Glucan
 Cell wall component within the ascus
 Other fungi secrete in low amounts
 Normal human serum will contain low levels
from the presence of commensal yeast (10-40
pg/mL)
 Negative - 60 pg/mL
 Indeterminate – 60-79 pg/mL
 Positive - >80 pg/mL
 Nucleic Acid Detection
 Multiple Methods Available
 Polymerase Chain Reaction
 Real-Time
 Multiplex Assays
 Positive results must be correlated with signs
and symptoms due to the colonization rate of
immunocompetent individuals.
 None are FDA approved for use in the United
States
 Treatment
 Trimethoprim-sulfamethoxazole (TMP-SMX)and
pentamidine isethionate are the predominant
agents used for treatment
 TMP-SMX resistant strains have been identified
 Lacazia loboi
 Lobomycosis
 Rare granulomatous zoonotic fungal infection
 Leprosy-like lesions and nodules
 Organism found in soil, on vegetation and in aquatic
animals
 Transmission results from traumatic injury or from
contaminated water
 Dolphin to human and human-to-human transmission has been
reported
 Diagnosis is by microscopic morphology
 Yeast-like cells in chains, connected by tubules
 Pythium insidiosum (1 of 2)
 Funguslike, aquatic oomycete organism
 Two phases
 Funguslike, mycelium producing
 Biflagellate zoospore (infectious stage)
 Transmission by traumatic injection into the skin
or lesions in the GI tract from contaminated
water
 Develops cutaneous or subcutaneous lesions
 Infective keratitis has also been reported
 Pythium insidiosum (2 of 2)
 Direct Detection
 Tissue samples, direct microscopy
 Immunohistochemical stains or KOH
 Hyphal structures, short or long, sparsely septate,
tubular structures and inflammatory cells
 Culture
 Can be cultures in 2% SAB agar or broth at 37°C
 Nucleic acid testing is recommended
 Limited availability in clinical laboratories
 Lagenidium spp.
 Emerging oomycete
 Mycelial and biflagellate form
 Lagenidiosis
 Invasive skin, subcutaneous, and arterial infections
 Infections also found in cornea, gastrointestinal tract and
extremities
 Organism is found in crabs, mosquito larvae, nematodes
and other organisms.
 Diagnosed microscopically and on fungal media similar
to P. insidiosum
 Microscopically cannot differentiate from P. insidioum.
 Rhinosporidium seeberi (1 of 2)
 Mesomycetozoea protistal eukaryote
 Morphologically similar to Coccidioides
 Organism is found in aquatic environments and resistant
spores are present in terrestrial environments
 Route of transmission is unknown
 Likely by exposure to spores through breaks in the skin or
mucous membranes.
 Infection results in formation of painless polyps on the
mucosa of the nose, eye, larynx, genitalia and rectum
 Rhinosporidium seeberi (2 of 2)
 Rhinosporidiosis
 Greater than 300 µm spherical sporangia with
endospores and negative culture
 Tissue biopsies are the preferred method for
diagnosis
 Wetmounts from polyps demonstrateing
sporangia and endospores are often present
 Treatment of Parafungals
 The organisms are resistant to antifungals
 P. insidiosum
 Maybe treated using combination antibiotics such as
minocycline, linezolid and chloramphenicol
 R. seeberi
 Surgical removal of infected tissue and polyps is
required