An Overview of Fungal Infections: Gary Garber

REVIEW ARTICLE Drugs 2001; 61 Suppl.
1: 1-12
0012-6667/01/0001-0001/$27.50/0
© Adis International Limited. All rights reserved.
An Overview of Fungal Infections

Gary Garber
Infectious Diseases Division, Ottawa Hospital, Ottawa, Ontario, Canada
Abstract The incidence of fungal infections is increasing at an alarming rate, presenting

an enormous challenge to healthcare professionals. This increase is directly
related to the growing population of immunocompromised individuals, resulting
from changes in medical practice such as the use of intensive chemotherapy and
immunosuppressive drugs. HIV and other diseases which cause immunosuppres-
sion have also contributed to this problem.
Superficial and subcutaneous fungal infections affect the skin, keratinous
tissues and mucous membranes. Included in this class are some of the most
frequently occurring skin diseases, affecting millions of people worldwide.
Although rarely life threatening, they can have debilitating effects on a person’s
quality of life and may in some circumstances spread to other individuals or
become invasive. Most superficial and subcutaneous fungal infections are easily
diagnosed and readily amenable to treatment.
Systemic fungal infections may be caused by either an opportunistic organism
that infects an at-risk host, or may be associated with a more invasive organism
that is endemic to a specific geographical area. Systemic infections can be life
threatening and are associated with high morbidity and mortality. Because diag-
nosis is difficult and the causative agent is often confirmed only at autopsy, the
exact incidence of systemic infections is difficult to determine. The most fre-
quently encountered pathogens are Candida albicans and Aspergillus spp. but
other fungi such as non-albicans Candida spp. are increasingly important.
Fungi exist in two basic forms: yeasts and intestinal tract and skin, which under certain con-
moulds. Yeasts are typically single, small, oval cells, ditions may proliferate and migrate into the sys-
whereas mould colonies consist of filamentous temic circulation, for example, when introduced
strands called hyphae. Some fungi are dimorphic, into the body via medical devices such as vascular
existing as either yeasts or moulds depending on catheters.
the external environment (e.g. temperature). Some fungi cause disease in otherwise healthy
Most fungi are ubiquitous, propagating success- individuals, but many species become pathogenic
fully in their natural environments with no need for only when the host is debilitated in some way, for
human or animal substrates. Some species, how- example, when the immune system is compro-
ever, are adventitious pathogens in humans, caus- mised. The number of individuals in this situation
ing superficial, subcutaneous or systemic infection. is increasing because of the complications of ad-
Most fungi causing systemic (or deep seated) infec- vanced HIV infection and developments in modern
tion do so by direct inhalation into the lung or by medicine, such as intensive chemotherapy and the
invasion of a wound site. Others, such as Candida use of immunosuppressive drugs.[1,2] Mortality
albicans, are commensal inhabitants of the gastro- among infected patients may be as high as 75 to
2 Garber
100%,[3] presenting a major challenge to healthcare a commensal yeast of the skin.[12] Some patients
professionals. with tinea versicolor are at risk of the infection
becoming invasive.[13]
1. Superficial Fungal Infections Nail infections, or onychomycoses, are thought
Superficial fungal infections occur in the outer- to account for approximately 33% of all fungal skin
most layers of the skin, nails, hair and mucous infections and 50% of all nail disorders (see fig.
membranes. In recent years, the incidence of these 1b).[14] Studies suggest that they affect between 2%
infections has risen steadily, mainly because of the and 13% of the population worldwide and up to
increasing number of immunocompromised 30% of groups at high risk, such as the elderly.[15]
patients and the growing popularity of health clubs The incidence of onychomycosis among people
and communal swimming pools, which facilitate with diabetes is particularly high; this group is
the spread of infection.[4] nearly 3 times as likely to be infected as healthy
individuals[16] and is at risk of developing serious
1.1 Infections of the Skin and sequelae if the infection is neglected. The dermato-
Keratinised Tissues phytes T. rubrum and T. mentagrophytes are the
principal causes of onychomycosis, accounting for
Superficial fungal infections include some of approximately 90% of toenail infections and 50%
the most frequently observed skin diseases, affect-
of fingernail infections, although non-dermato-
ing millions of people worldwide.[5] Dermato-
phyte yeasts (C. albicans and other non-albicans
phytes – specifically, Trichophyton spp., Micro-
Candida spp.) and moulds (Aspergillus spp., Fu-
sporum spp. and Epidermophyton spp. – are
sarium spp., Acremonium spp., Scopulariopsis spp.
responsible for most superficial fungal infections,
and Scytalidium spp.) appear to be causative patho-
although yeasts and some non-dermatophyte
gens in an increasing number of cases.[17-19]
moulds can also be causative agents.
Most fungal infections of the skin and kerati-
Dermatophytes infect the stratum corneum of
nised tissues are treatable and are readily diag-
the epidermis and keratinised tissues derived from
it, such as hair or nail. Fungal transmission occurs nosed through a combination of patient history,
through direct contact with infected people, ani- physical examination, and microscopy and culture
mals, soil or fomites. Specific dermatophyte infec- of skin or nail specimens. However, the causative
tions are named according to their location on the agent is not routinely identified.
body (see table I). Tinea pedis is the most prevalent In most patients, the symptoms are mild and not
fungal infection in the developed world and is usu- life threatening, but the impact on the patient’s
ally caused by Trichophyton rubrum or T. menta- quality of life can be severe.[20-23] In onychomy-
grophytes var. interdigitale.[6] Individuals with cosis, for example, toenail dystrophy may interfere
tinea pedis may be susceptible to secondary bacte- with walking, standing, exercise or proper shoe fit,
rial infection with, for example, group A strepto- and fingernail infection may limit daily activities
coccus.[7] Tinea capitis is another frequently oc- such as dressing or typing. Patients with unsightly
curring superficial disease, primarily affecting infected nails may also be embarrassed by the
children over the age of 6 months (fig. 1a).[8] Dur- condition, which, in turn, can affect their personal
ing the past 50 years, the predominant causative relationships and social lives by causing loss of
agent of this infection has changed from Micro- confidence and self-esteem.[23-25]
sporum audouinii to T. tonsurans,[9] which now ac- Superficial fungal infections, particularly of the
counts for as many as 96% of infections in the toenails and feet, can also act as a reservoir of or-
USA[10] and an increasing number of infections in ganisms, which could spread to other areas of the
the UK.[11] Tinea versicolor, an infection of the body or other individuals. Immunocompromised
stratum corneum, is caused by Malassezia furfur, patients, in particular, should be examined for early
© Adis International Limited. All rights reserved. Drugs 2001; 61 Suppl. 1

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REVIEW ARTICLE Drugs 2001; 61 Suppl.

© Adis International Limited. All rights reserved.

An Overview of Fungal Infections

Abstract The incidence of fungal infections is increasing at an alarming rate, presenting

© Adis International Limited. All rights reserved. Drugs 2001; 61 Suppl. 1

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