MYCOLOGY

Quick Review
 Classification
On basis of sexual spores (Teleomorph) into 4 classes
• Zygomycetes/phycomycetes- nonseptate hyphae & form asexual spores
called sporangiospores contained in sporangia and sexual spores known
as zygospores eg. Mucor, Rhizopus

• Ascomycetes – form sexual spores ascospores eg. Piedra hortae,

aspergillus

• Basidiomycetes – sexual spores Basidiospores, cryptococcus

• Deuteromycetes or fungi imperfecti – Fungi that lack a known sexual

state eg. Coccidioides. Most of the fungi of medical importance belong to
this class.eg-candida, dermatophytes,systemic fungi.
 ASCOMYCETES
• Ascus / Sac shaped sexual
spores k/a ascospores
• Eg. Aspergillus,
cladosporium, piedra,
phaeoid fungi
 BASIDIOMYCETES
• Club shaped sexual spores k/a
Basidiospores
• Eg. Mushrooms, Agaricus,
Rhodotorula, Cryptococcus
neoformans, Basidiobolus.
• Character: Diazonium Blue B
test Positive

A close-up of basidiospores borne on

a basidium.
 Morphological classification
Yeasts
• Oval, round elongated unicellular fungi
• Reproduce sexually by budding e.g Saccharomyces – non pathogenic
Cryptococcus neoformans – pathogenic yeast

Yeast like
• Like Candida, bud remains attached to the mother cell & elongates forming as
pseudohyphae.
• pseudohyphae – have constriction at the septa & septa are also present at the
branching points

• Moulds
•  Spores germinate to produce branching filaments called hyphae
•  May be septate or nonseptate (coenocytic )
•  Hyphae grow & branch to form tangled mass of growth called mycelium e.g –
Penicillium, Mucor, Rhizopus etc.
 Special info on yeasts
• All pathogenic yeasts divide by budding except the
following undergo binary Fission:
– Penicillium marneffei
– Pneumocystis jiroveci
• All have narrow based budding
Except (Broad based budding):
– Blastomyces dermatidis
• Multipolar budding
– Paracoccidioides brasiliensis
 Fungi that can’t be grown on artificial culture
media
• Rhinosporidium siberi
• Pneumocystis jiroveci
Difficult to grow:
• Malassezia furfur (Lipophilic, requires Olive oil on SDA media)
Other organisms (bacteria) that doesn’t grow on artificial media:
• Klebsiella granulomatis (previously Calymmatobacterium: causing
Donovanosis / Granuloma Inguinale)
• Treponema palidum
• Mycobacterium leprae
 Fungi that can’t grow in Cycloheximide added SDA
Normally Cycloheximide is added in Sabouraud’s Dextrose Agar to
prevent contamination as Fungal cultures are incubated for a long
time.

But the following fungi are inhibited by Cycloheximide:

• Aspergillus
• Penicillium
• All agents of Mucormycosis e.g. Rhizopus, Mucor, Absidia
• All agents of Eumycetoma
• Cryptococcus
• Some Candida except ALBICANS
 Dimorphic fungi

• Have yeast form in host & in vitro at 370 C on enriched media and hyphae
(mycelial) form in vitro (250C)

•  Histoplasma capsulatum
•  Coccioides immitis
•  Paracocciodes brasiliensis
•  Blastomyces dermatitidis
•  Sporothrix schenkii
•  Penicillium marneffi
 Fungal stains
• Best stain to for demonstration of fungal cell wall is
Methanamine silver.
• Direct sample: KOH, Calcoflour white (fluorescent stain)
• Lacto phenol cotton blue is used for culture identification
• Nigrosin and mucicarmine are important only in negative
staining of Cryptococcus
• PAS is a used for demonstration of fungi in tissue sections.
LACTOPHENOL COTTON BLUE STAIN (LPCB)

Lactic acid preserves the fungal structure

Phenol kills the fungus

Glycerol is a preservative & prevents drying up of

the preparation as well

Cotton blue stain is absorbed by the

hyaline fungal structures to make them
more distinct
 Human fungal infections

Superficial mycosis
• Common
• Affects skin, hair , nails
• Specialized saprophytes - Can digest keratin
• Causes :- 1) Surface infections
2) Cutaneous infections
• Fungi of medical importance belong to
a. Basidiomycetes
b. Ascomycetes
c. Phycomycetes
d. Deuteromycetes

• Only pathogenic true yeast is

a. Candida
b. Sachharomyces
c. Trichophyton
d. Cryptococcus

• Special stain for fungus

a. Masson trichome
b. Congo red
c. Alzian blue
d. Silver methanamine

• Stain used for degenerated fungi are

a. PAS
b. H&E Gomori mrthanamine stains both live and dead cells
c. Muciramine
d. Gomori methanamine
• All are dimorphc except
a. Histoplasma
b. Paracoccidioides
c. Cryptococcus
d. Blastomyces

• Most common fungal infections are

a. Basidiomycetes
b. Ascomycetes
c. Zygomycetes
d. Deuteromycetes

• Fungus that cant be grown on artificial media

a. Rhinosporidium seeberi
b. Penicillium merneffei
c. Aspergilus flavus
d. Deuteromycetes

• Fungal spores formed by condensation of

hyphal elements?
a. Ascospores
b. Conidiospores
c. Basidiospores
d. arthrospores
• Which dye is suitable for fungus demonstration in
biopsy? PAS-
a. Alizarin red •Best for tissue sections
b. Mansons trichrome •Only stain live fungi
c. Veirhoff dye •Nuclei-blue
d. PAS •Fungi-magneta

• Correctly matched
a. muciramine-cryptococcus
b. Giemsa-candida
c. Methaamine silver-histoplasma
d. Grams-p.carinii

Organism Dye
Cryptococcus Capsule-indian ink/nigrosin/alcian blue
Melanin-masson fontana
Cell wall-mayers mucicaramine
Biopsy- H & E, PAS, methanamine silver,calcoflour
whitw

Candida Gram/calcoflour white/ H & E

Histoplasma Giemsa/PAS/methanamine silver
Pneumocystis Methanamine silver
• A tangles mass of hyphae constitutes
a. Conidia
b. Germinal spores
c. Pseudopodia
d. Mycelium

• A sporangium contains
a. Spherules Spherules can be seen in-
b. Sporangiospores •Coccidioidomycosis
•R.seberii
c. Chlamydospores
d. Conidia

• Fungal spores may be produced

a. Singly
b. In chains
c. In sporangium
d. all
 Superficial mycoses

Surface infections Cutaneous infections

• Fungi live on dead layers of • Cornified layers of skin
skin and appendages
• No inflammatory response • Inflammatory response
 Tinea / Pityriasis versicolor • Hypersensitivity
 Tinea nigra  Dermatophytosis
 Piedra white
 Candida infection
 Piedra nigra
 Pitryasis Versicolor
• Synonyms- Tinea versicolor, Tinea Flava, Liver Spots,
Furfuracea

Superficial infection of horny layer (stratum corneum) of skin

Causative agent- Pityrosporum orbiculare (now

Malassezia furfur)

Sites -- chest, abdomen, thighs ,back

 Clinical presentation
• Fawn white superficial patches
• Sharp margins
• Covered with scales
• Non inflammatory
• No itching
• Cosmetic problem
• Culture
– Lipophilic fungi- lipids (olive oil / glycerol) added in media

• Appearance in KOH preparation: Spaghetti and meatball

or banana and grapes appearance from tissue.
 Laboratory diagnosis
Woods lamp – Flourescent patches
Microscopy
 10% KOH
 PAS
 Abundant yeast cells-A,
 short branched hyphae -B
Culture -not required. Lipophillic
fungus
Serology - no role
 Tinea nigra

– Brown/black sharply
demarcated spot most
commonly on palm.
– Cladosporium werneckii or
Exophiala werneckii
 Tinea nigra
• Localized to stratum corneum
• Brown to black discoloration
• Palms and sole
• Eitiological agent - Cladosporium werneckii or
Exophiala werneckii

 Clinical presentation
 Darkly pigmented macules
 Non scaling
 Sharply marginated
 Usually asymptomatic
 No inflammation
 BLACK PIEDRA (Piedra Nigra)
 Disease of hair characterized by dark
brown/black nodule (gritty and hard)
adherent to distal 1/3 of hair

Etiological agent- Piedraia hortae

Clinical features :
• localized to scalp
• small nodules 1-2 mm diameter
adherent to hair
• Hair not invaded
 White Piedra
• White piedra (piedra alba), Beigels
disease

• Chronic benign disease of hair

shafts of scalp, moustache, beard

• Characterized by grayish white

softer nodules on the hair shaft-
adherent
• Etiological agent- Trichosporon
beigelli
 Laboratory diagnosis
• Presence of soft white
nodules on the hair

• Direct microscopy- KOH

prepration-
•
 Septate hyphae &
Arthroconidia
 DERMATOPHYTES
• Closely related group of filamentous fungi

• most common type of Superficial infection

• Dermatophytosis (Tinea or ring worm) – culture grows at

250 C

• Most common type of superficial mycosis seen in human

beings

Dermatomycosis – skin inf. Caused by any other fungi

like Candida, Aspergillus etc.

• Infect only – Superficial keratinised tissue

- Skin
- Hair
 GENERA
Trichophyton Microsporum Epidermophyton
Infect All (S,H,N) M never N E never H
Infect
- Hair - Hair - Skin
-Skin -Skin -Nails
-Nails
•25 species •22 species •Only one species
T rubrum M.gypseum Epidermophyton
T. mentagrophytes floccossum
 Trichophyton Microsporum Epidermophyton
Microconidia
Abundant Scanty Absent

Macroconodia
• Scanty •Predominant • abundant
• Cigar shaped • Spindle shaped • Pear shaped
• Thin walled •Large, Multicellular • Clusters
•Borne singly

SPIRAL Hyphae
Favic chandeliers / Antler tips
 Wood’s Lamp
• Fungi that fluoresce under Wood’s lamp:
– All Microsporum spp.
– Trichophyton schoenlenii
– Malassezia furfur
Other Clinical conditions:
Tinea capitis (fungal)
Pityriasis versicolor (fungal)
Erythrasma (bacterial: Corynebacterium minutissimum)
Tuberous sclerosis skin manifestations:
Ash leaf patches and Freckles
• Geophilic species  saprophytes in soil & cause infection in
man
• Example – Microsporum gypseum, M. nanum

• Zoophilic - primarily animal pathogen may also infect man

• e.g T. verucosum, T. mentagrophytes, M. canis

• Anthropophilic species – only human pathogens & are

transmitted indirectly via fallen hairs etc. (highly infectious)
• Example -
• T. rubrum,T. schoenleni, M. audouinii , E. floccosum
 II. Classification – Clinical classification
• Tinea capitis (head: scalp)
• T. corporis (body: non hairy skin)
• T. barbae (bearded areas) : neck ,face (barbers itch)
• T. faciei (non-bearded areas) : neck, face
• T. cruris (groin) (dhobi itch)
• T. pedis (plantar aspect foot, toes, interdigital), (athletes foot)
• T. incognito (altered morphology of any tinea due to steroid
use)
• T. imbricata
 Dermatophytids(“ID” reaction)
- Synonym
Mycid
Favid
Trichophytid
Epidermophytid

- Allergic reaction to fungal Ag

 away from site of infection by dermatophytes
 no isolation of fungus from ID
- Sterile vesicles
Causative agent:
Fungus isolation : from primary lesion
• Zoophillic spp.
• Geophillic spp.

Pathogenesis : Primary lesion  fungus


destruction of dermatophyte
Inflamation

Ag fractions  sensitize host  “ID”
Clinical features:
Signs & symptoms of primary lesion + vesicles

Epidemiology:
• occurs spontaneously
• present in 5-6% dermatophyte infections
• primarily seen in children 5-12 years
• provoked by treatment Inappropriate

Over energetic
Treatment of primary lesions Id’s disappear
in 2-3 wks
• Trichophyton species which is zoophilic?
a. t.tonsurans
Type Org
b. T.violaceum
c. T. schoenleneii Geophilic m.gypseum/m.nanum
d. T.mentagrophytes Zoophilic t.Verucosum/t.metagrophytes/m.canis
Arthrophilic t.rubrum/m.audounii/e.floccosum
 Woods lamp is used in
a. Tinea pedis
b. Pityriasis versicolar
c. Sporotrichosis
d. Vitilgo

• Not present in india

a. t.rubrum
b. T.mentagrophytes
c. Epidermophyton floccosum
d. Microsporum distortum
• Which of the following is difficult to isolate in
culture?
a. Candida
b. Dermatophytes
c. Cryptococcus
Require lipds/oils for growth
d. Coccidioidomycosis
e. Malassezia furfur

• A patient made a self diagnosis of athelete

foot (tinea pedis) and began using a product
shown on tv. The cond improved,but not
resolved completely.a skin scrapping was
sent to the lab for culture. The fungal culture Tricho Micro epidermo
yeilds slow growing colony, which produced
few small microconidia. Which id the Microconidia Many Scanty Absent
organism? Macroconidi Scanty Predominat Abundant
a. Trichosporon a Cigar Spindle Pear shaped
b. Microsoprum shaped shaped
c. Epidermophyton
d. trichophyton
 SUBCUTANEOUS MYCOSES

I. MYCETOMA
II. CHROMOBLASTOMYCOSIS
III. SPOROTRICHOSIS
IV. RHINOSPORIDIOSIS
V. SUBCUTANEOUS PHYCOMYCOSIS
 MYCETOMA
Chronic granulomatous localized infection
 skin / subcutaneous tissue
 fascia
 bone
•Means “tumor produced by fungi”
• Affects foot or the hand most often
Madura foot / Maduramycosis (Madurai 1842)
• Shoulders, buttocks, head or any site subject to trauma
• Common in tropics (specially S.India, T.Nadu)
• Male agricultural workers.
MYCETOMA – TRIAD FOR DIAGNOSIS

Tumefaction
Draining sinuses
Grains
Etiology and classification:
Eumycetoma – true fungi
Pseudomycotic mycetoma
Actinomycetoma- Actinomycetes, Nocardia
Botryomycosis- Bacteria
Mixed mycetoma- Two or more agents
PATHOGENESIS:
Traumatic inoculation of subcutaneous tissue

Compacted colonies
localised swollen lesion
multiple draining sinuses- Grains (must)
spread unusual
 MYCETOMA
A. EUMYCETES GRAINS
• Madurella mycetomatis Black
• Madurella grisea Black
• Exophilia jeanselmei Black
• Curvularia geniculata Black
• Aspergillus sp White
B. ACTINOMYCETOMA
• Nocardia asteroids
• Nocardia brasiliensis
• Nocardia caviae
yellowish white
• Actinomadura madurae
• Nocardiopsis dassonvillei
• Streptomyces somaliensis
• Actinomadura pelletieri PINK-RED
 Botryomycosis
The most common organism:
Staphylococcus aureus.
Other pathogens:
Pseudomonas aeruginosa
Escherichia coli, Serratia, and Proteus;
Coagulase-negative Staphylococci, Streptococci, and
Micrococci
Anaerobes such as Actinobacillus, Peptostreptococcus, and
Propionibacterium acnes
 DIAGNOSIS
Direct examination - pus or exudates
• Grains presence diagnostic
• Size, shape, consistency, colour of grains.
• Hyphae in Eumycetoma
• Microscopy -
• KOH preparation
– Gram staining & ZN staining with 1% H2SO4
– H & E Staining (Biopsy)
• In Actinomycetoma, the grains are composed of very thin
filaments (0.5m - 1m in diameter)

• With coccoid & bacillary elements

• Eumycetoma – hyphae are broad septate (2 – 6 m)

• Actinomycetomas may respond to Penicillin & sulphonamides &
other antibiotics
• Eumycetomas – are resistant & require surgical exploration often
including amputation. Rx Itraconazole
 CHROMOBLASTOMYCOSIS: (Verrucous
dermatitis, Chromomycosis)
•Chronic localized disease of the skin and S/C tissues
•Crusted warty lesions
•Resembles florets of cauliflower
•Usually involves limbs with brown walled globose bodies
(sclerotic bodies)/muriform cells/medlar bodies/Copper
penny bodies
ETIOLOGICAL AGENTS:
• Fonsecaea pedrosoi
• Fonsecaea compacta
• Phialophora verrucosa
• Exophiala dermatitidis
• Cladosporium carrioni
 LABORATORY DIAGNOSIS
• M/E: sclerotic bodies (yeast like
bodies with septae)
• Copper penny bodies

• Culture: SDA at 250 –300 C for 4

- 6 weeks

• Serology: not of much use

• TT: Sx / flucytoseine
 PHAEOHYPHOMYCOSIS
• However, it can involve CNS or other internal organs such
as liver, lungs or pancreases.

• The pigmented fungal elements show variety of

morphologies in tissue – they may be dark walled, short,
septate branched or unbranched or as spherical cells etc.

• e.g. Acrophialophora, Alternaria, Athrinium,

Cladophialophora, Cephaliophora, Cladorrhinum etc.
 PHAEOHYPHOMYCOSIS
• Nonspecific solitary subcutaneous lesion
• Opportunistic deep seated fungus infections (brain abcess) lung
infection
• Caused by dark pigmented fungus
• Diagnosis
made at the time of surgery
• Microscopy
 Distorted hyphal strands seen (pigmented)
 Sclerotic cells not seen (unlike
chromoblastomycosis)
Acrophialophora, Alternaria, Athrinium, Cladophialophora,
Cephaliophora, Cladorrhinum etc.
 RHINOSPORIDIOSIS
• Chronic granulomatus infection
of the mucocutaneous tissues-
large polyp or wart like lesions.
• Nose, Nasopharynx, and
conjunctiva
• Genitalia and other membranes
rare
• Caused by : Rhinosporidium
seeberi
• Mainly in India and Sri Lanka
• Through water

In India cases occur all over but endemic

foci exists in parts of Orissa, A P, Kerala,
Chennai & Raipur
 LABORATORY DIAGNOSIS
• MICROSCOPY: H & E

• Sporangia 350μm in diameter

• Thousands of endospores embeded

• In a stroma of connective tissues and

capillaries

• CAN’T BE CULTURED

•  Stains with mucicarmine.

• Treatment Radical surgery, dapsone

• Chronic pyogenous
SPOROTRICHOSIS
granulomatus infection of
the skin and s/c tissues

• Localized or lymphatic
spread
• After thorn picks/injuries
• Inf. due to implantation of
spores through injured skin.

• Commonly seen in gardeners.

• Lymphocutaneous MC form.
 LABORATORY DIAGNOSIS
• M/E: not of much use
• Culture: SDA, blood agar
• Dimorphic fungus
• Mould at 22 C
• Yeast phase in tissues and in culture at 37C
• Spherical and cigar shaped cells (Asteroid bodies)
• Yellow black granules are seen in
a. Mucormycosis
b. Mycetoma
c. Aspergillus
d. Rhinosporidiosis

• Color of granule produced in actinomycetes

a. Black
b. Yellow White>yelollw
c. Blue
d. White

• True about mycetome

a. Lymphatics involved
b. Antibiotics has no role
c. Commonly occurs in hands
d. Erodes bones
• Actinomycetema is caused by
ACTINOMYCETOMA (yellow-white)
a. Actinomyces • Nocardia asteroids
b. Madura mycosis • Nocardia brasiliensis
• Nocardia caviae
c. Norcardia • Actinomadura madurae
d. Streptomyces • Nocardiopsis dassonvillei
• Streptomyces somaliensis
• Actinomadura pelletieri (pink red)
 True about madura mycetoma
a. Fungal inf
b. Non painful nodular lesion
c. Discharging sinus
d. Bone involvement seen

• The granules dischrged in mycetoma contains

a. Bone specules
b. Fungal colonies
c. Pus cells
d. Inflammatory cells
• A farmer presents with multiple discharging sinus in leg not responding to antibiotics. Most likely
diagnosis is
a. Actinomycetoma
b. Nocardia
c. Sporothrix
d. Madurella

• Cause of botryomycosis
a. Staphylococcus albus
b. Pneumococcus
c. S.pyogenes
d. S.aureus
e. P.aeruginosa

• The cause of recurrent ulcer in sub-himalayan region is

a. Cladosporium
b. Sporothrix
c. Chromoblastomycosis
d. Mucor
• Cigar body is seen in
a. Cryptococcus
b. Histoplasmosis
c. Aspergillus
d. Sporotrichosis

• Sclerotic bodies are found in

a. Rhinosporidiosis
b. Histoplasmosis
c. Coccidioidomycosis
d. Chromoblastomycosis

• A gardener has multiple vesicles on hand and multiple eruptions along the lymphatics.
Most common fungus responsible is
a. Sporothrix
b. Cladosporium
c. Histoplasma
d. candida
• Best way to differentiate between eumycetoma and actinomycetoma
a. Duration of illness
Eumycetoma-serous
b. Severity of illness Actino- purulent
c. Clinical presentation
d. Nature of discharge

• True about rhinosporidium seebri

a. Fungi
b. Bacteria
c. Ketoconazole is given
d. Present in coastal area
• SYSTEMIC MYCOSIS –
• all dimorphic – to demonstrate thermal dimorphism
before confirming diagnosis
• 25 degree Celsius –mycelial form
• 37 degree –yeast form
 HISTOPLASMOSIS
• Darlings Disease, ohio valley ds
• Common endemic mycosis in pts with AIDS
• U.S.A, Africa, Australia, parts of East Asia,.

• Thermally Dimorphic
• 25ºC mold form
• 37ºC yeast form
• Environmental isolations - made from soil enriched with
excreta from chicken, starlings and bats.
• C/F  –
• Pulmonary – Acute
• - Chronic (Histoplasmoma) .

• 2. Cutaneous, S/C, Mucocut

• 3. Disseminated
• Primary lung infection - 95% of cases of histoplasmosis
are inapparent, subclinical or benign.

• 7% cases are mucocutaneous – m c form in INDIA

• Reactivation -disseminated infection , with involvement of

the reticuloendothelial system

• Fever, wt. loss, hepatosplenomegaly and lymphadenopathy

are the common clinical features
• All stages of this disease may mimic tuberculosis.
• Chest X Rays show (calcification)
 Lab diagnosis
• Clinical material:
Sputum and bronchial washings, pleural fluid and blood, bone
marrow,and tissue biopsies from various visceral organs.
• Direct Microscopy:
 Exudates and body fluids are examined using either 10% KOH and
calcofluor white mounts
 Tissue sections are stained using PAS digest, Grocott's
methenamine silver (GMS) or Gram stain.
 Histopathology is one of the most important ways of diagnosis.
Positive direct microscopy demonstrating characteristic tiny oval
yeast cells (2-4micom) with narrow based budding yeast cells
from any specimen should be considered significant.
GMS stained tissue section showing yeast form
Laboratory Diagnosis

Culture:
• Thermally Dimorphic
 25ºC mold form
 37ºC yeast form

• Blood agar
• SDA : Mycelial phase ( at 22oC)
colonies:
 White, cottony mycelia
 Large ( 8-20µm), thick-walled sperical
spores with tubercle like projections-
tuberculate macroconidia (characteristic)
 Laboratory Diagnosis:
• Serology

 Ag detection in serum and urine- helpful in early diagnosis ( false positives

may occur).

 Immunodiffusion for the detection of antibody is useful in the diagnosis

however, detection of ANTIBODIES in immunosuppressed patients is
difficult, with 20-50% of patients testing negative.

• Skin test – Histoplasmin skin test (An allergen is injected just below
the cleaned skin surface. The injection site is checked at 24 hours and
at 48 hours for signs of a reaction. Occasionally, the reaction may not
appear until the fourth day.)
 BLASTOMYCOSIS
 Formerly known as North American blastomycosis. Chicago Disease
Few case reports from India
 Etiology- Blastomyces dermatitidis (dimorphic fungus)
 Suppurative & granulomatus Cutaneous lesions
Commonly causes self limited or localized pulmonary
lesions
 Chronic disseminated ds in immunocompromised pts – lungs, Other
tissues ( skin & bone)

Mode of infection: Inhalation (conidia)- Lungs (asymptomatic focal/ diffuse

consolidation)
- Cutaneous  papule – nodule - ulcer
 Laboratory Diagnosis:
• Samples -Sputum, BAL, lung Bx, Skin Bx
• Direct microscopy - KOH / calcofluor
white , PAS digest, Grocott's methenamine
silver (GMS) or Gram stain

• Tissue : Thick walled yeast cells

producing buds on a broad base
• Figure of 8 morphology

• Culture: Culture is confirmatory.

• Mycelial form at 25 deg C (on LCB
Mount)
• Fungus is also seen surrounded by a refractile, eosinophilic halo
called splendore – Hoeppli or asteroid body d/t immune
complex deposition around organism.

• For skin test  Ag derived from mycelial phase

•
• For serol test  Ag derived from yeast phase

• Treatment – Oral ketoconazole

 COCCIDIOIDOMYCOSIS
• Self-limited influenza like fever (VALLEY FEVER or
DESERT RHEUMATISM)
• MC deep mycosis in USA
• Endemic in S., N. & Central USA & Mexico.
• Not reported from India

Caused by: Coccidioides immitis (dimorphic fungus)

• Mode of infection: Inhalation (arthroconidia)

• Respiratory infection : Asymptomatic in most cases

• Ds not transmitted from man to man.
• Coccidiodal granuloma in < 1% cases (highly
fatal)
 Laboratory Diagnosis

• Tissue phase : Spherule

with a thick doubly refractile
wall filled with endospores
• Mycelial phase:
Pseudohyphae fragmenting
into arthrospores
• Treatment : Amphotericin B /
KNZ / Flucon / Itraconazole.
• In soil & in culture (at room
temp) grow as mould with
barrel shaped arthroconidia.
• No sexual stage
 PARACOCCIDIOIDOMYCOSIS
Chronic granulomatous infection of lungs, mucosa,
skin and lymphatic system

Formerly known as South American blastomycosis (Central

America to Argentina)

Caused by: Paracoccidioides brasiliensis

Mode of infection: Inhalation

More in males as estrogen bind and prevent mycelia-yeast
conversion in females.
• At 37 degree  multipolar budding (mickey mouse appearance)

– Characterized by primary pulmonary infection that may spread by hematogenous routes

systemically.

– Microscopical examination of tissues, sputum, biopsies show numerous yeast + cells with
multiple bud.

• C/F- Mucocut, Lymphatic (Bull neck). Visceral (pulmonary)

 Laboratory Diagnosis:

• Tissue at 37oC : Yeasts with multipolar budding

– Multiple budding yeast cells- also k/a Mariner’s wheel, Pilot’s wheel,
Mickey Mouse
• Skin test- i.d, Ag is gp43
• Room temp : Mycelial phase
Penicillium
marneffi/ Talaromyces marneffei,
• Brick red pigment on SDA - opportunistic fungi

• (S) to nystatin.

• Isolated from Bamboo rat feces

• Dimorphic fungi

• Seen in S.E. Asia, in India Manipur and NE

states
• Infects RES, Lung  systemic mycosis in AIDS
• Morphology  Sausage shaped cells with
transverse septa which divide by binary fission.
• Darling disease is caused by
a. Histoplasma
b. Candida
c. Cryptococcus
d. Rhizopus

• Most common deep mycosis in india

a. Histoplasmosis
b. Blastomycosis
c. Coccidiomycosis
d. Cryptococcus

• True about histoplasmosis

a. Person to person transmission
b. In early stage,indistiguiable from tb
c. Culture is not diagnostic
d. Mycelial forms are infective form
• Endemic fungal infections are
a. Cryptococcus
b. Aspergillosis
c. Cioccidioides immitis
d. Histoplasma
e. Blastomyces

• True about histoplasma capsulatum

a. Dimorphic
b. Cause moniliasis
c. Capsulated
d. Cause vally fever
• OPPORTUNISTIC MYCOSES
 Opportunistic Mycoses
• Most important fungal pathogens:
Aspergillus
Candida
Cryptococcus
Pneumocystis
Rhizopus
Mucor
Absidia
 CANDIDIASIS
• Diseases affecting skin
mucosa
skin appendages
rarely internal organ
• Normally present as normal flora of skin,
mucosa, GIT flora
• >81 species
 CANDIDIASIS
• Imp pathogenic species :
• C albicans (70-90%)
• C tropicalis
• C pseudotropicalis
• C krusei
• C glabrata
• C lusitaniae
• C haemulonii
 Risk factors for candidiasis
• Diabetes mellitus most • Urinary Catheters
common factor • I/V catheters & drug abuse
• Pregnancy
• AIDS Candida albicans is the
• Neutropenia & cellular most common pathogenic
immunodef species.
• Not Immunoglobulin deficiency Non albicans Candida are
• Broad spectrum antibiotics being increasingly isolated.
• Corticosteroid therapy
• O.C. Pill (all types)
• 3rd degree burn
 CULTURE

• SDA
• Blood agar: creamy white smooth colonies
• Chrome agar
Green: C.dublinesis
Blue: C. tropicalis
Pink: C. krusei
 SPECIES IDENTIFICATION
• Fermentation and Assimilation of sugars
• Chlamydospore production (Corn Meal Agar)

• Morphology of hyphae presence of pseudohyphae indicate

colonization

• GERM TUBE TEST: Reynolds Braude Phenomenon: Positive

C.albicans
C.dublinesis
C. africana
C. stellatoidea
Germ Tube Test Chlamydospore formation
 Spectrum of Candidiasis
Mucocutaneous Systemic Chronic Candidal
• Oral thrush • Cystitis, pyelitis, renal granuloma
• Oesophageal thrush papillary necrosis
• Oesophagitis • Pneumonia
• Vulvovaginal thrush • Endophthalmitis
• Diarrhoea • Osteomyelitis
• Arthritis
• Endocarditis
(previously damaged
or prosthetic valve)
• Meningitis (in
Immunocomp)
• C.albicans is responsible for about half of all cases
of candidemia in hospitalized patients & is most
common cause of mucosal candidiasis.
 Some other Candidal spp.
C. dublinesis
• Germ tube +
• Seen in HIV patients
• Resistance to fluconazole
• Chlamydiospores + on corn meal media
C. krusei
• Fluconazole Resistance
C. lusitaniae
• Amphotericin B resistance
• Raynaud braude phenomenon is seen in
a. Candida albicans
b. Candida psitasi
c. Histoplasma
d. Cryptococcus

• Most common fungal infection in immunocompetent persons

a. Candida
b. Cryptococcus
c. Mucor
d. Aspergillosis

• A vitreous aspirate from a case of metastatic endopthalmitis on culture yeilds gram positive round to oval cells, 12-14µm in size.
Lab finding shows growth in cornmeal agar at 20 deg, microscopy shows hyphae and growth in human serum at 37deg shows
budding yeast. The org is
a. Candida albicans
b. Histoplasmosis
c. Blastomycosis
d. coccidioidomycosis
• MC fungal infcetion in febrile neutropenia
a. Aspergillus niger
b. Candida
c. Mucormycosis
d. A.fumigatus

• Which of the following spreads through care givers hands to neonates?

a. c.albicans
b. C.tropicalis
c. C.glabrata
d. C.parapsiloisis
 CRYPTOCOCCOSIS
Encapsulated yeast (Gram positive) Polysachharide
Capsule can be demonstrated by India Ink and Nigrosin
3 varieties
C. neoformans species complex is now divided into 2
species:
C. neoformans and C. gattii
C. neoformans var. grubii- Serotype A
C. neoformans var. neoformans- Serotype D
 C. neoformans reservoirs is pigeons droppings
 C gatii reservoirs is Eucalyptus tree (red gum)
• Based on capsular agglutination reaction detected by cross-
absorbed rabbit polyclonal antisera,

C. neoformans divided into 5 serotypes:

A, D, AD, B and C
It is the initial AIDS defining illness in approx. 2% pts. And generally occurs in
pts with CD4 counts of < 200/µl

MC cause of meningitis in AIDS pt.

Pathogenesis
Mode of infection: Inhalation / Skin / Mucosa
Clinical presentation:
Pulmonary infection:
Mild, Self-limiting, No calcification transitory and mild character
Primary site of infection

CNS Disease : Most Frequent presentation

 Pathogenesis
Virulence factors
• Polysaccharide capsule – not immunogenic,
No anti capsular ab formed. (anti capsular ab not
protective)

• Phenyloxidase enzyme responsible for production

of melanin when grown on niger seed agar or L –
dopa agar

• Ability to grow at 370C is also virulence factor

 C. neoformans complex
• Grows at 37º C
• Hydrolyse urea

• Produce brown colonies on niger seed agar

/ Bird seed Agar / Phenol oxidase positive
/ produce melanin
• Produce disease in mice
• Diazonium Blue B test Positive
• Inositol assimilation Positive
CNS Disease : Most Frequent involved
–Meningitis
–Meningoencephalitis
–Cryptococcoma

Cryptococcal Meningitis :
Most common clinical form (85% cases)
Commonly seen in patients with abnormalities of T- Lymphocyte function
10% AIDS patients
2nd – LUNG
Skin can also be affected
Least common- Kidney

The clinical signs are mostly insidious and very rarely

dramatic. Headache, mental changes, moderate fever
 LABORATORY DIAGNOSIS:

Clinical material

Cerebrospinal fluid (CSF)

Biopsy tissue (brain, liver)

Sputum, bronchial washings

Pus, blood and urine can be collected depending on

the site of infection or the organ system involved.

Lumbar puncture is the single most useful diagnostic

test.
 Direct Microscopy
• Unstained, wet preparation of
CSF with India ink or Nigrosin
• Capsular antigen rapid
detection

Tissue sections :
 PAS
 Mucicarmine stain for capsule

• Capsulated, budding yeast

cells (4 -20µm) surrounded by
Mucopolysacchride capsule
• Which of the following is only yeast?
a. Candida
b. Mucor
c. Rhizopus
d. Cryptococcus

• Budding is seen in
a. Cryptococcus and candida
b. Candida and rhizopus
c. Rhizopus and mucor
d. Candida and aspergilus

• The capsule of cryptococcus neoformans in csf sample is best seen by

a. Gram stain
b. Indian ink
c. Giemsa stain
d. Methanamine silver

• Most common organism causing acute meningitis in AIDS?

a. Pneumococcus
b. S.agalactae
c. Cryptococcus neoformans
d. Listeria monocytogenes
• Cryptococcus can be seen easily by
a. Alberts stain
b. Indian ink
c. Grams stain
d. Zn stain

• Neurotropic fungus among the following

a. Trichophyton
b. Cryptococcus
c. Histoplasma
d. Aspergillosis
e. Candida

• Latex agglutination study of the antigen in csf helps in the diagnosis of

a. Cryptococcus
b. Candidiasis
c. Aspergillosis
d. Histoplasmosis
 ASPERGILLOSIS
Aspergillus fumigatus is the most common cause of
aspergillosis, found in >90%. followed by A. niger

 Ubiquitous in the environment, growing on dead leaves, stored

grain, compost piles, hay, and other decaying vegetation.

• In immunosupressive therapy & in AIDS pts severe form of

aspergillosis invasive disease occurs
 1.Disease in a Normal Host

Toxicosis/ Allergic Superficial/ Invasive

mycotoxicosis manifestations noninvasive infection
infections
1.Ingestion of 1.Allergic asthma 1.Cutaneous
mycotoxins 2.Allergic rhinitis 1.Single organ
infection 2.Multiple
3.Allergic sinusitis 2.Otomycosis organ/
4.Extrinsic allergic
2.Ingestion of 3.Sinusitis disseminated
alveolitis
other 4.Saprophytic
5.Hypersensitivity BPA
metabolites pneumonitis 5.Tracheo-
6.ABPA bronchitis
 Risk factors for invasive aspergillosis
Classic factors Non-neutropenic factors

Acquired neutrophil defect COPD

Neoplastic disease with persistent Chronic and acute liver disease
neutropenia Intracranial surgery
High dose of corticosteroids Reactive airway disease
Immunosuppressants Rheumatoid arthritis
Bone marrow/ solid organ ICU stay
transplants
Aplastic anaemia/myelodysplastic Newly recognized factors
syndrome/myelofibrosis i.v drug abuse
AIDS – only when CD4 < 50 cells Diabetes mellitus
Primary defect of neutrophils Burn wound
Chronic granulomatous disease Application of tapes/ECG leads
ABPA/asthma
 MCQ most common
• Mc form of human infections by aspegillus- Otomycosis

• Mc cause of fungal corneal ulcer – Aspergillus followed by Fusarium followed by

Phaeoid / melanized fungi

• Mc cause of paranasal sinus mycoses- Aspergillus

 CLINICAL MANIFESTATIONS
 ABPA (allergic bronchopulmonary aspergillosis) Type I & III HS reaction.
 C/F  Coughing out of mucous plugs.
 Fungus ball – usually develops in preexisting cavities such as tuberculosis
.It is only colonization without invasion

 Invasive aspergillosis  Disseminated disease in severely

immunocompromised,diabetics, neutropenic patients  Pulmonary nodules

 Endocarditis in immunocom patients, patients undergoing open heart

surgery.

 Paranasal granuloma
 Aspergilloma

Invasive
aspergilllosis ABPA
(IPA or CNA )
 ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS

It is a long term allergic response to

Aspergillus that is characterized by transient
pulmonary infiltrate due to atelactasis.

Incidence
Asthma 1-2% Cystic fibrosis 10-15%

Clinical presentation
• Symptoms of asthma
• Episodic wheezing
• Expectoration of sputum containing brown plugs
• Pleuritic chest pain and fever
• Chest radiography - “ring sign” and “tram line” sign
 Diagnostic criteria of ABPA
( Greenberger PA )

Major criteria
• Asthma
• Immediate skin reactivity to Aspergillus
• Total serum IgE >1000 IU/mL
• Increased serum IgE and IgG to Aspergillus fumigatus
• Central bronchiectasis

Minor criteria
• Pulmonary infiltrates
• Peripheral blood eosinophillia >1000/mm3
• Precipitating antibodies to A. fumigatus
LABORATORY DIAGNOSIS:
• Clinical material:
 Sputum, bronchial washings and tracheal
aspirates
 Tissue biopsies;Blood
• Direct Microscopy:
 Sputum, washings and aspirates- 10%
KOH and/or Gram stained smears are
prepared
 Tissue sections or sputum smears are
stained with H&E, GMS and PAS digest.
 Demo of HYALINE, DICHOTOMOUSLY
BRANCHED SEPTATE HYPHAE (Antler horn
appearance)..
 Supporting Clinical Symptoms
 Biopsy and EVIDENCE OF TISSUE
INVASION is of particular importance.
• A 25 yr old female complains of recurrent rhinitis, nasal discharge and b/l nasal blockage
since 2 yrs. She has a history of asthma and allergy. o/e multiple ethmoidal polyps are noted
with mucosal thickening and impacted secretions in both the nasal cavities. Biopsy is taken
and the material is cultured which shown the growth of many hyphae and pseudohyphae with
dichotomous branching typically at 45. the most likely organism is
a. Aspergillus fumigatus
b. Rhizopus
c. Mucor
d. Candida

• In HIV infected indivudual gram stain of lung aspirate shows yeast like morphology. All of
the following might be present except
a. Candida tropicalis
b. Cryptococcus neoformans
c. Penicillium marneffi
d. Aspergillus fumigatus
• In a patient, corneal scrapping shows narrow angle septate hyphae, whioch of the following is most
likely diagnosis?
a. Mucor
b. Aspergillus
c. Histoplasma
d. Candida

• Common fungus causing corneal ulcer

a. Mucor
b. Sporothrix
c. Aspergillus
d. Fusarium

• Most common aspergillus infection in human

a. Aspergillus niger
b. A.flavus
c. A.nidulans
d. A.fumigatus
 ZYGOMYCOSES/ MUCORMYCOSES
• Pathologically mucormycosis is characterized
by vascular invasion because they have
predilection for elastic lamina of large &
small arteries thus causing thrombosis
hemorrage & infarction & necrosis of tissue

• All pts have serious underlying condition such

as d.m., i\c, burns & trauma
– Characterized by broad aseptate, ribbon like
hyphae
• Rhizopus – has rhizoids & sporangiophores
that arise in groups directly above rhizoids
• Mucor – Does not possess rhizoids shows
branching
• Absidia – Has rhizoids and sporangiophores
that arise from the aerial mycelium in between
the rhizoids
Zygomycosis may lead to
• Rhinocerebral zygomycosis (In debilitated
patients, Diabetic Ketoacidosis) (bread
mould)
• Pulmonary zygomycosis
• Gastrointestinal zygomycosis
• Cutaneous (Burns)
• Disseminated
Predisposing factors for mucormycosis –
– Uncontrolled DM
– Organ transplant
– Haemat malignancy
– Patients on desferoxamine
• A diabetic patient suffers from a soft tissue infection and microbiological examination reveals the
infection been caused by with fungi with aseptate and broad hyphae. Which of the following is
responsible for the infection?\
a. Candida
b. Aspergillus
c. Penicillium
d. Mucor

• Which of the following is aseptate fungus?

a. Aspergillus
b. Candida
c. Nocardia
d. Rhizopus

• True about mucormycosis

a. Nose is a common site
b. DM is a predisposing factor
c. Common in india
d. all
• Mucormycosis ,true is
a. Lymph invasion
b. Septate hyphae
c. Angioinvasion
d. Long term desferroxamine therapy is a predisposing factor
e. May lead to blindness

• Orbital mucormycosis is a complication of

a. AIDS
b. Steroid
c. Cushings disease
d. DM
 PNEUMOCYSTINOSIS
• Pneumocystis jiroveci is not a pathogen in healthy humans. In
people with a weak immune system, it can cause Pneumocystis
carinii pneumonia (PCP) and in some cases extrapulmonary spread.

 Subjects with CD4 counts below 200 / µL and who are not
receiving preventive therapy are nine times more likely to
develop PCP
Controversial class ? parasite ? fungi
– Taxonomical classification into fungus due to :
–RNA, mitrochondrial protein and major enzyme
–Presence of  1,3 glucan in cell wall.
 CLINICAL MANIFESTATIONS:
• Fever (79-100%),
• Mild and dry cough (59-91%),
• Dyspnea (29-95%),
• Cyanosis
• Sputum production (23-30%).
In patients infected with HIV, the disease
course tends to have:
 A more subtle presentation
 Longer prodrome
 Milder symptoms ( absence of positive symptoms
even in the presence of respiratory faliure)
On a chest examination
 Crackles/crepts
 Signs of focal lung consolidation
 Acute bronchospasm
 Pneumatoceles, and Pneumothorax rarely
On Chest X Ray
 Diffuse alveolar or interstitial pulmonary infiltrates
are the classic findings
 Occasionally patchy asymetric infiltrates are seen
 No abnormalities can also be detected
Gradual spreading of perihilar haziness with granular components or formation of
indistinct nodules.(diffuse mottling) - bilateral alveolar or interstitial pulmonary infiltrates
with characterisitic ‘ground-glass’ appearance, which is classic finding of PCP.
 LABORATORY DIAGNOSIS:
• Clinical specimens
Induced sputum ( using 3% hypertonic saline)[55-95%]
Bronchioalveolar lavage fluid [79- 98%]
Bronchial or lung biopsy [94-100%]
BAL fluids are considered better than induced sputum
samples, but since the load is higher in HIV patients induced sputum
samples give comparable results
• Direct microscopy
Direct Fluorescent Antibody (DFA) test
Giemsa staining
Gomori Methenamine Silver Staining (GMSS)
Toludine blue O
 DEFINITIVE DIAGNOSIS OF PCP IS ESTABLISHED BY DEMONSTRATION OF
P. CARINII IN THE SUSPECTED SAMPLE
Cysts of Pneumocystis
jiroveci in lung tissue,
Giemsa stain method
See intracellular yeasts
GM Silver stain
 Immunohistochemistry
staining of P. jiroveci in
infected lung

Indirect & Direct immunofluorescence using monoclonal antibodies that target Pneumocystis jirovecii.
( images from BAL)
Currently, the “Gold standard” technique for diagnosis of P.jirovecii involves immunofluorescent staining of
BAL Fluid with sensitivity and specificity values of about 95%.
• Pn. Carinii infection occurs in HIV infected patient at CD4 count
< 200 / l
– Common in HIV patients

– Causes interstitial plasma cell pneumonia IN i/c BUT CAN INFECT

CHILDREN TOO.

– Life cycle  trophozoite, sporozoite and cyst which contains 8

sporozoite.
– Typical granular, foamy, honeycombed material seen by H&E stain of
tissue
– Can’t be grown on fungal culture media

Treatment  DOC is trimethoprim + sulfamethoxazole

– Alt. – TMP + Dapsone
– Clindamycin + Primaquine; Atovaquone
– Parentral Pentamidine
– Antiprotozoal (pentamidine) can also be used
 Amphotericin B resistance
Those fungi which are notorious to be Ampho B resistant are:
• Aspergillus terreus
• Aspergillus nidulans
• Candida lusitaniae
• Candida rugosa
• Paecillomyces sp.
• Pseudallescheria boydii
• Fusarium solani
• False about p.jeroveci
a. Seen only in immuocompromised
b. Frequently associated with CMV
c. May be associated with pneumatocele
d. Diagnosed with sputum microscopy

• Which of the following is a fungus?

a. Klebsiella
b. Clostridia
c. Pneumocystitis
d. Listeria

• Fungal toxin causing liver cancer

a. Aflatoxin
b. Fumonisin
c. Trichothesin
d. Histoplasmin

• DOC for p.jerovecii

a. Cotrimoxazole
b. Penicillin
c. AMB
d. clotrimazole
• a patient of acute leukemia is admitted with febrile neutropenia. On day
4 of being treated with braod spectrum antibiotics, his fever increases.
Xray chest shows b/l fluffy infiltrates. Which of the following is the best
next step?
a. Add antiviral
b. Antifungal
c. Cotrimoxazole
d. Chemotherapy

• A young man aged 30 yrs, present with difficulty in vision in the left eye
for last 10 days. He is immunocompetent, a farmer by occupation,
comes from a rural community and gives a history of trauma to his left
eye with vegetative matter 10-15 days back. o/e there is an ulcerative
lesion in the cornea, whose base has raised soft creamy infiltrate. Ulcer
margin is feathery and hyphae present. o/e branching aseptate hyphae
were noted. There were few sattelite lesions also. Corneal scrapping
shows sickle shaped macroconidia. What should be the diagnosis?
a. Fusarium
b. Aspergillus
c. Mucormycosis
d. dermatophyte