UNIT 2: CLINICAL AND DIAGNOSTIC MYCOLOGY

 Morphology
 Guide to the Identification of Fungi in Culture
 Detailed info such as pathogenicity, rate of growth, colony morphology, enlarged drawing of microscopic appearance,
photomicrograph, and references for additional information.

SUPERFICIAL FUNGI
Hortea werneckii
Obsoleted names: Phaeoannellomyces werneckii, Exophiala werneckii, Cladosporium werneckii
Epidemiology:
 Reservoir: humid tropical and temperate areas, soil, trees, decaying vegetation
and sewage
 Causative agent: Tinea nigra (Tinea nigra palmaris, Keratomycosis nigricans)
 Lesions: flat and smooth, not scaly, irregularly shaped brown to black spots
(Ag(NO3)2 stains.
o Palmar and plantar lesions (stratum corneum) may resemble melanoma
o Multiple brownish-black macule from a bilateral Tinea nigra of palm
Specimen: skin scrapings from dark pigmented lesions
Macroculture: [SDA + cycloheximide, antibacterial (ie, chloramphenicol)]
 Fad rate growth: slowly withing 21d (maturation)
 Colony and morphology: surface is at first light colored, moist, shiny, and yeastlike but soo becomes olive black.
Grayish green hyphae may form at the periphery, and the center may lose its shine and become olive due to thin layer
of mycelium (2nd-3rd week). Reverse: black.
Wood lamp: No fluorescence
Microscopic Morphology:
 Very early phase: pale or dark brown, yeastlike cells
 Mature forms: one or two celled (3-5 x 7-10um) – annelids, round at one end while tapered
an elongated with striations at the other end where conidia are formed
 Each conidium functions as annelide & produce new conidia
 Chlamydoconidia may develop with age
 Note the moist yeast like, olive-black colonies, and the development of filamentous
colonies (thin layer of mycelium)

Malassezia furfur (Pityrosporum furfur, Pityrosporum ovale pro parte)

Epidemiology:
 Reservoir: domestic animals, bird
 CA: Pityriasis versicolor (Tinea versicolor)
 Site of Infection: stratum corneim, organisms can readily seen in skin scrapings
 Lesions: scaly (furfuraceous infection), discrete or concresecent hypo-pigmented or hyperkeratotic patches on the neck, torso
and limbs
 Lipophilic (exogenous lipid) organism with ff predisposing factors, poor nutrition, excessive sweating, and pregnancy.
Specimen: Skin scraping from discolored area, blood (tissue)
Macroculture: SDA + Olive (vegetable) oil + antibacterial
  CULTURE IS NOT ESSENTIAL for ID unless, finding of direct microscopic exam are atypical or unless
full species ID is needed
 M. furfur culture on Littman oxgall agar are overlaid with oil
 Culture needed, scrapings may be inoculated on Leeming-Notman medium which uses whole milk as a
major lipid source; or on Dixon agar.
Wood’s lamp: yellow to light green fluorescence
Microscopic morphology:
 10% KOH, observable branching filaments and of variable lengths intermingled with clusters of small,
unicellular, oval and round, budding yeast cells that resembles spaghetti and meatball appearance
 Yeast show presence of collarette between mother and daughter cells (budding is phialidic and unipolar),
4um-8um in size

Piedraia hortae
Epidemiology:
 Resrvoir: hot & wet tropical areas  Asia, S. America, Africa
 CA: black piedra
 Site of infection: eyebrows, eyelashes, and scalp
 Fungal infection: scalp hair, less commonly: beard/mustache & rarely: axillary/pubic hair
 Forms nodules that serves as ascostromata cont. locals that harbor asci and ascopores.
 Characterized by: presence of discrete, hard, gritty, dark brown to black nodules adhering firmly to the hair shaft
Specimen: hair collected by clipping or pucking
Macroculture: SDA + thiamine (increase mycelial production)
 Rate of growth: slow, mature in 21d
 Colony morphology: small, adherent, compact, somewhat raised, and dark greenish brown black and may be glabrous or
covered with very short aerial hypha
 Reddish brown, diffusible pigment may form
 Reverse: black
Microscopic Morphology
 Hyphae are closely septet, dark, and thick walled
o Vary in diameter with many intercalary chlamydoconidia-like cells
 Asci may be produce in culture. Walls of asci is readily dissolve, releasing single-celled curved Ascospores taper at the ends
to form “whiplike” extensions.
 Ascospores are more likely to be seen on direct
microscopic examination of the specimen than on
culture.
Trichosporon beigelii
Obsoleted name: Trichosporon curateum
Epidemiology:
 Reservoir: soil, lake water, temperate & tropical areas
 CA: white piedra
 Site of Infection: facial, axillary, groin, pubic hair
 Fungal infection: hair shaft charact. by the presence of soft white, yellowish beige, or greenish nodules found chiefly on
facial, axillary, and less commonly on scalp, eyebrows, lashes
 Trichosporon ovoides: scalp hair, white piedra
 Trichosporon inkin & T. asahii: most cases of public white piedra
 Nodules may be discrete or more often coalescent, forming an irregular transparent sheath
Specimen: Hair
Macroculture: SDA + thiamine (increase mycelial production)
 Colony morphology: appear as white to creamy  observed within 5 days, young colonies may appear waxy or pasty
 Mature colonies: cerebriform
Microscopic Morphology:
 Intertwined hyaline septate hyphae
 Hyphae breaking up into oval or rectangular
arthroconidia (2-4um diameter)
 Occasional blastoconidia
 Bacteria that may surround the nodule as a zooglea (jelly-
like mass)

CUTANEOUS FUNGI

DERMATOPHYTOSES DERMATOMYCOSES
Syn: Plants of the skin, Tinea, Ringworm  Fungal infection: caused by a group of organism other
 Fungal infection: invades keratinized portion of the hair, than dermatophytes involving the skin only
skin, and nails  keratin as the nitrogen source  Invasion of the cutaneous tissues by other fungi
 Primary dermatophytoses: infection involving skin, nails
and hairs
 Secondary dermatophytoses: other sites, systemic

Classification of Dermatophytes by Morphology

Classification of Dermatophytes by Origin

CLASSIFICATION OF DERMATOPHYTES BY INFECTION

Tinea corporis
 Body or trunk, neck and shoulder
 Erythematous circular lesions, scaly patch with sharply demarcated margins
resulting in abnormal-looking patch of the skin at the hub of the week or ring
 Transmitted via direct contact with an infected person, by formites, or by
autoinoculation
 Diagnose by examination of a direct preparation of the skin scales
 Relapse occurs especially if T. rubrum is the agent
Tinea cruris
 Proximal medial thighs, perineum, buttocks
 Ringworm of the groin  “jock itch”

Tinea pedis
 Feet athlete’s foot
 All forms are pruritic (itchy)
 Lesions vary from chronic intertriginous form between skin folds with “peeling”
maceration, fissuring of the skin to a from in which fluid filled vesicle and bullae
are seen
 T. rumbrum  cause chronic infection
 E. floccosum  acute infection that spontaneously resolve
Tinea manuum
 Palms and between fingers
 Most cases are from patients who have tinea pedis since infections are caused
by the same dermatophyte
 Tinea barbae
 Exclusively on bearded areas of face and neck
 Superficial form  resembles tine corporis
 Pustular form  assoc with zoophilic dermatophytes
o Folliculitis is the inflammation of hair follicles
 Boggy tumefactions, a Marion appears as an inflamed, thickened, pus-filled area
& sometimes accompanied by fever
 Develop to alopecia and permanent scarring
Tinea unguium
 Nails
 Superficial form  whitish patches on the surface of the nail contain fungus
without nail distortion
 Subungual form  deep layers of the skin is invaded. Nail becomes brittle and
thickened and is freq discolored.
 Debris from dungus & from tissue destruction accumulate in the nail, causing
distortion and cracking.

Tinea capitis
 Hair of the scalp, eyebrows, eyelashes
 Non-inflammatory or inflammatory with scarring and alopecia

Tinea imbricata
 Specialized form of tinea corporis
 Ringlike growth in overlapping circles

CLASSIFICATION OF HAIR INFECTION

ENDOTHRIX ECTOTHRIX FAVIC (FAVUS) TYPE
Infects inner portion of the ear Other portion of the hair Creates parallel lesions with the hair shaft
 Arthroconidia form by  Hyphae fragments from into  Clinical entity characterized by the
fragmentation of the hyphae arthroconidia that accumulate occurrence of dense masses of
within the hair shaft around the hair shaft and form mycelium & epithelial debris 
 Preence of conidia weakens a mosaic sheath (pattern of yellowish, cup-chaped crusts called
hair so that it loses its luster arthroconidia resembling a tile scutula
that become brittle, and mosaic)  Dev  hair follicles and destroy
breaks off above the surface  Hair becomes grayish, dull and them, w/ scarring and alopecia.
of the scalp discolored, eventually hair  Hair shaft is filled with long
 As it continuous to grow, becomes brittle and breaks off filamentous arthroconidia; empty
conidia in the shafts of the hair  CA: air-filled areas are left in the hair
stubs appear black dots leaving o M. audouinii, when hyphae degenerate into fat
grayish patch  gray patch o T. mentagrophytes, droplets
 CA: o T. verrucosum  Lesions have “mousy odor”
o T. tonsurans,  CA: T. schoenleinii
o T. violaceum
 CUTANEOUS FUNGI (CAUSATIVE AGENTS)
Epidermophyton floccosum
THE ONLY HUMAN PATHOGEN IN THIS GENUS.
 Surface is brownish yellow to olive gray or khaki w/ suede like surface, raised
and folded in the center, flat periphery & submerged fringe of growth
 Macroconidia: smooth thin-walled that often produce clusters growing directly
from hyphae
o Numerous chlamydospores are formed in older cultures. Microconidia
is not formed.

Epidemiology Worldwide, among host or humid tropical areas

 Anthropophilic
Laboratory Diagnosis Specimen:
 Nail scrapings (material from the tips of the nail)
 Skin cravings
Direct microscopy via KOH with or without BLUE OR BLACK DYES,
CALCOFLUOR WHITE
Culture:
 25-30 ºC pref temperature
 Modified SDA, modified SDA with antimicrobials
MACROSCOPIC EXAMINATION:
 Modified SDA: 6-12 days at 25-30 ºC
 Obverse shows mustard yellow or khaki
 White, downy; scanty colony
 Velvety of powdery depending on the quantity of macroconidia produced
 Center shows folded with radiations to a thin flattened fringed periphery
 Reverse: yellow-brown or yellow orange
MICROSCOPIC EXAMINATION:
 Hyphae: 3-4um thin
o Hyaline septate and branched
 Macroconidia occur singly or in small clusters of two or three on the same
conidiosphore
o Clavate conidia  likened to snowshoes, paddles, or beaver’s tail
Microsporum audouinii
FORMERLY CAUSED EPIDEMICS OF RINGWORM OF THE SCALP IN CHILDREN
AND RARELY IN ADULTS.

 Flat to velvety, thin, pale salmon to pale

brownish reverse
 Rare deformed macroconidia, often with
break, constricted mid region & at least trace
granulation;
o Drop shaped microconidia and aerial
arthroconidia may be present
o Pectinate branching
o Apiculate terminal chlamydospores often seen
Epidemiology Worldwide  Africa, Europe, US
 Anthropophilic
Laboratory diagnosis Specimen: Hair and skin scrappings
Direct Microscopy: KOH or CFW
Culture: 25-30 ºC in Modified SDA with antimicrobials
Dermatophyte testing medium (DTM) may be used as a screening
Potato dextrose agar or Potato flakes agar (PFA)  to initiate production of
conidia with the addition of yeast extract
MACROSCOPIC EXAMINATION:
  Modified SDA: rapid, intermediate, or slow grower
o Initial colonies  7-10 days – flat, white colonies
o Mature colonies  3 weeks to mature
 Obverse: white, downy; scanty colony, velvety or powdery depending on the
quantity of macroconidia produced
 Reversed: reddish brown pigment
 PDA: 2 weeks
o Reverse: salmon pink orange brown
MICROSCOPIC EXAMINATION:
 Hyaline  3-4 μm
o septate and branched •
 Vegetative hyphae: terminal and intercalary, pectinate bodies and racquet
hyphae.
 Macroconidia: Distorted cylinders or spindles with thick walls (15 x 80μm);
o 5-7 cells per macroconidium; arranged- individual (rare).
 Microconidia: clavate or ovoid (2 x3 μm);
o arranged- solitary.
DIFFERENTIAL TEST:
 Polished cooked rice and hair perforation test results is negative for both test.
 Does not grow at all on the rice grains or it grows poorly and produces a
pigment.
Microsporum canis var. canis
ECTOTHRIX TYPE OF INFECTION RESULTING TO GRAY PATCH TINEA CAPITIS.
 Flat to velvety, thin, pale to
yellow, with yellow (rarely pale)
reverse
 Macroconidia: thick walled,
roughened and beaked
 Microconidia: drop shaped
Epidemiology  Worldwide
 Geophilic and Zoophilic
Laboratory Diagnosis Specimen: skin scrapings or hair.
 Positive for fluorescence test (yellow to green)
Direct microscopy: KOH and(or) CFW
Culture: 25-30ºC in modified SDA with antimicrobials and
DTM can be used for screening
PDA, PFA and modified Cornmeal (CM) can be used to enhance pigmentation.
Production of macroconidia is enhanced by the addition of yeast extract.
MACROSCOPIC EXAMINATION
 Rapid growers on modified SDA (4-6 days).
 Obverse, buff colored with a feathery periphery; cottony and granular
depending on the macroconidia produced.
 Reverse, flat with radial grooves, white to yellow and cottony; bright yellow
pigment.
MICROSCOPIC EXAMINATION
 Hyaline (width: 4-6 μm), septate and branched
 Macroconidia: (11 x 72μm); spindle shaped with asymmetrical beaked apex
and thick rough walls; 6-15 cells per macroconidium; arranged individually.
 Microconidia: clavate (3 x5 μm); arranged- solitary (sparse).
DIFFERENTIAL TEST
 Positive on hair perforation test.
 Yellow pigment on polished rice test.
 Microsporum gypseum
TINEA CAPITIS AND TINEA CORPORIS.
 Granular, sandy in color, or
occasionally light cinnamon or
rosy buff
o Reverse: usually pale to
brownish
 Macroconidia: abundant, thin
walled, fusoid (tapered at both ends) roughened with up to 6 septa
 Microconidia: drop shaped mostly formed along sparsely branced hyphae.
Epidemiology  Worldwide
 Geophilic
Laboratory diagnosis Specimen: skin scrapings or hair.
Rarely fluoresce on fluorescence test (yellow to green)
Direct microscopy: KOH and(or) CFW
Culture: 25-30ºC in modified SDA with antimicrobials and DTM can be used for
screening.
PDA, PFA can be used to enhance pigmentation.
MACROSCOPIC EXAMINATION
 Rapid growers on modified SDA (5-6 days).
 Flat granular as numerous macroconidia are produced.
 Obverse and reverse on SDA show tan to cinnamon-pink to brown.
 Reverse (PDA) show brown to modified cinnamon-pink.

MICROSCOPIC EXAMINATION
 Hyaline (width: 4-6 μm), septate and branched
 Macroconidia: (11 x 42μm); ellipsoidal to fusiform with rough thick walls; 2-6
cells per macroconidium; arranged individually and in clusters.
 Microconidia: clavate (3 x5 μm); arranged- sessile and solitary.

DIFFERENTIAL TEST
 Positive both on hair perforation test and polished rice test.
 Grows well on sterile rice grains, producing yellow pigment and characteristic
conidia.
Granular to Trichophyton mentagrophytes
powdery, CAUSATIVE AGENT:
yellow-  Tinea manuum
cream to  Tinea cruris
buff  Tinea corporis
surface,  Tinea pedis
pale to red  Tinea capitis
brown reverse.  Tinea barbae
 Tinea unguium
Macroconidia: uncommon, club-shaped, smooth
Microconidia: nearly spherical, abundant, mostly produced in dense tufts; spiral
appendages present

Note:
 T. mentagrophytes var. mentagrophytes  zoophilic
 T. mentagrophytes var. interdigitale  anthropophilic
Clinical Findings  T. manuum, T. cruris, T. corporis, T. Pedis, T. Capitis, T. barbae, and T.
unguium
o invades the nail plate.
 T. mentagrophytes var. mentagrophytes (zoophilic strain)
 o causes severe inflammatory reactions that are relatively short in
duration.
 T. mentagrophytes var. interdigitale (anthropophilic)
o less inflammatory (T. pedis).
Epidemiology  Worldwide
 Antrophilic and zoophilic
 Geophilic, usually found in soil contaminated with animal debris
Laboratory Diagnosis Specimen: skin scrapings or hair (ectothrix)
Direct microscopy: KOH and (or) CFW
Culture: 25-30ºC in modified SDA with antimicrobials.
Grows also at 37ºC. DTM can be used for screening.
PDA, PFA slants and (or) CMA with 1% dextrose can be used.
MACROSCOPIC EXAMINATION (modified SDA 6-8 days)
Type I colonies T. mentagrophytes var. mentagrophytes
 Obverse: flat granular, creamy, yellow, to tan to reddish brown.
 Reverse, buff, yellow-brown or reddish brown
 Concentric rings or growth can sometimes be seen in the topography of
the colony.
Type II colonies T. mentagrophytes var. interdigitale
 Obverse, flat and downy, cream to light yellow with white feathery fringes
that may become pink.
 Reverse, light yellow to yellow orange.
 Other features may be lack of dark pigment on PDA or CMA with 1%
dextrose
MICROSCOPIC EXAMINATION
 Hyaline (width: 3-5 μm), septate and branched
 Macroconidia: (6 x 35μm); abundant type I colonies than type II. Clavate to
cigar shaped with smooth thin walls, 3-6 cells arranged in solitary. Rat tail
conidia may form.
 Microconidia is (3-5 μm). Abundant in type I colonies, arthroconidia (commonly
in skin specimen). The type I colonies show globose and unicellular (en
grappe), while type II colonies show clavate or pyriform in shape.
 Other structures include chlamydoconidia, favic chandelier (reindeer antlers)
DIFFERENTIAL TEST
 Positive on hair perforation test.
 Growth in Trichophyton agar— the growth is not enhanced by inositol and
thiamine.
 Urease test is positive for <4 days colonies, tests that are positive beyond 4
days are no longer significant.
Cottony to Trichophyton rubrum
velvety, CAUSATIVE AGENT:
white to  Tinea manuum
reddish  Tinea corporis
surface,  Tine pedis
typically  Tinea capitis
wine red  Rare: ecothrix and endothrix
reverse Macroconidia: seldom seen, pencil shaped
but yello variants occasional, red Microconidia: drop shaped, abundant scanty or not formed; lateral hyphal projections
color poorly formed in presence of often present
common bacterial contamination

Epidemiology  Worldwide
 Anthrophilic and Zoophilic (rare)
 Geophilic, usually found in soil contaminated w/ animal debris
Laboratory diagnosis Specimen: skin scrappings or hair (ectothrix)
Direct microscopy: KOH and/or CFW with KOH
Culture: 25-30ºC in modified SDA with antimicrobials.
DTM can be used for screening
PDA, or PFA can be used
CMA may be used when T. rubrum is suspected to enhance the production
of conidia for pigmentation studies
MACROSCOPIC EXAMINATION – modified SDA (10-14 days  slow growers)
Type I colonies: T. pedis
 Obverse: white, downy to fluffy
 Reverse: yellow – blood red
 Concentric rings or growth can sometime be seen in the topography of
the colony
Type II colonies: T. corporis and T. capitis
 Obverse: tan, yellow or red tinged, granular due to production of
macroconidia; rugose folds
 Reverse: colorless, tan or yellow to brown, eventually, deep wine-red
color
 Other features in PDA or CMA with 1% to 2% dextrose (1-2 weeks
incubation)
o Obverse: velvety texture
o Reverse: white, pink to red at the periphery
MICROSCOPIC EXAMINATION
 Hyaline: 3-5um
o Septate and branched
 Macroconidia: sparse or absent in type I colonies; abundant in type II
o Narrow cylinders with thin, smooth walls (5x22um)
o 3-8 cells per macroconidium
o Arranged singly, or in small groups, directly on hyphae
 Microconidia: 2um; sparse type in type I colonies and more numerous in type II
o Thin clavate or tear drop shapes
o Arranged en thryses (sleeve-like arrangement around hyphae) or en
grappe
o Other structures include chlamydoconidia, flavic chandelier
(reindeer anthers)
DIFFERENTIAL TEST
 Positive on hair perforation test
 Growth in Trichophyton agar – the growth is not enhanced by inositol and
thiamine
 Urease test: positive for <4 days colonies, tests that are positive beyond 4
days are no longer significant

Trichophyton schoenleinii
CAUSATIVE AGENT:
 Tinea manuum
 Tinea corporis
 Tinea pedis
 Tinea capitis
 Rare: ectothrix and endothrix
Convoluted (glabrous) texture, No conidia seen. Favic chandeliers or nailhead
heaped or folded topography. Slightly hyphae are present.
velvety whitish colony.

Clinical findings  Tinea favor or favus  infection in the scalp characterized by the formation of
scutulae
  Lesions: charact by mouse-like odor
 Tinea corporis, tinea barbae, and tinea unguium
Epidemiology  Worldwide
 Endemic in Europe, Africa, and Asia
Laboratory diagnosis Specimen: skin scrapings, stubs of hair, nail scrapings.
Direct microscopy: KOH (10% with DMSO), and CFW.
Culture: 25-37ºC in modified SDA with antimicrobials.
DTM can be used for screening.
Boiled rice grain medium: should be inoculated when growth occurs in the
primary cultures to enhance production of macroconidia.
MACROSCOPIC EXAMINATION (modified SDA 2-3 weeks— slow growers)
 Obverse, small, white to tan with a glabrous texture and heaped or folded
topography. Prolonged incubation may produced velvety texture.
 Reverse, colorless to light yellow. • Colonies may become brittle and may crack
or split the medium, a characteristic mousy odor typically develops in the
culture.
MICROSCOPIC EXAMINATION
 Hyaline (width: 3-5 μm), septate and branched
 Macroconidia: not applicable or rarely seen.
 Microconidia is (varying sizes) clavate, favic chandeliers, arranged in sessile
and solitary.
DIFFERENTIAL TEST
 Positive on hair perforation test.
 Growth in Trichophyton agar— the growth is not enhanced by inositol and
thiamine.
 Urease test is positive for >11 days, slow production.