Fungi & Systemic

Mycoses
 Why Care?

• Fungi are a leading cause of

nosocomial infections.
• Fungal infections are a major
problem in immune
suppressed people.
• Fungal infections are often
mistaken for bacterial
infections, with fatal
consequences.
Classification of Fungi

Domain Kingdom

Archea

Bacteria
Planta

Eukaria Animalia

Mycota
(Mycetae)
 Four major phyla of
Fungi

Chytridiomycota— sexual and asexual

spores motile, with posterior flagella

Zygomycota— sexual spores are thick walled

resting spores called zygospores

Ascomycota—spores borne internally in a

sac called an ascus

Basidiomycota—spores borne externally on a

club-shaped structure called a basidium

Deuteromycetes or fungi imperfecti, have no

known sexual state in their life cycle.
 Characteristics of fungi
A. eukaryotic, non- vascular organisms

B. reproduce by means of spores (conidia),

usually wind-disseminated

C. both sexual (meiotic) and asexual

(mitotic) spores may be produced, depending
on the species and conditions

D. typically not motile, although a few (e.g.

Chytrids) have a motile phase.

E. like plants, may have a stable haploid & diploid

states

F. vegetative body may be unicellular (yeasts)

or multicellular moulds composed of microscopic
threads called hyphae.

G. cell walls composed of mostly of chitin and

glucan.
 More Characteristics of
Fungi
H. fungi are heterotrophic ( “other feeding,”
must feed on preformed organic material),
not autotrophic ( “self feeding,” make their
own food by photosynthesis).

- Unlike animals (also heterotrophic), which

ingest then digest, fungi digest then ingest.
-Fungi produce exoenzymes to accomplish
this

I. Most fungi store their food as glycogen (like

animals). Plants store food as starch.

K. Fungal cell membranes have a unique sterol,

ergosterol, which replaces cholesterol
found in mammalian cell membranes

L. Tubule protein—production of a different

type in microtubules formed during nuclear
division.
 Fungal Morphology
Yeast Mould

Encapsulated yeast Hyphae (threads)

Cryptococcus neoformans making up a mycelium
 Dimorphism
Many pathogenic fungi are
dimorphic, forming moulds at
ambient temperatures but yeasts
at body temperature.
 Antifungal Agents
• Make use of biochemical differences
between “us” and “them”
• Target differences in membrane sterol
(ergosterol vs. cholesterol)
– Azoles
– Polyenes
– Allylamines
• Target cell wall biosynthesis (caspofungin)
• Target fungal tubulin (grisofulvin)
• Target fungal nucleoside metabolism.
(flucytosine)
• Antifungal agents often insoluble and/or
toxic.
• Susceptibility testing should be used if
available
 Antifungal Agents

Amphotericin
Member of polyene class of
antibiotics. Antifungal effect due
to interaction with sterols in
membrane, making membranes
leaky. Has high affinity for
ergosterol, but also binds to
cholesterol - severe side effects.

Azole antifungal agents

Have 5-membered organic rings that
contain either two or three nitrogen
molecules (the imidazoles and the
triazoles respectively).. Two important
triazoles are itraconazole and
fluconazole. The azole antifungal
agents inhibit cytochrome P450-
dependent enzymes involved in the
biosynthesis of cell membrane sterols.

5-fluorocytosine (5FC)
Fungi (but not humans) deaminate 5FC
to 5-fluorouracil which blocks RNA and
DNA synthesis.

Allylamines Highly hyrophobic

antifungal that accumulates in skin and
nails. Blocks ergosterol biosynthesis via
inhibition of squalene epoxidase
(terbinafine/Lamasyl)
Amphotericin Binds
Ergosterol
 Lab Diagnoses of Mycoses
• Clinical presentation
– History (risk factors)
– Physical Exam (lesions, devices)
• Histopathology
– Often sufficient
– Mould or Yeast?
– Septate hyphae?
• Culture of organism (days to
weeks)
– Problem, contaminating bacteria
• Serology
– Antibody or Antigen tests
• Molecular Biology
– RT-PCR
 Mycoses: diseases
cause by fungi
• Superficial
• Cutaneous
• Subcutaneous
• Systemic
• Opportunistic
 Superficial Mycoses
• Pityriasis versicolor--pigmented lesions on torso
• Tinea nigra--gray to black macular lesions often on palms
• Black piedra--dark gritty deposits on hair
• White piedra--soft whitish granules along hair shaft
• All are diagnosed by microscopy and are easily treated by
topical preparations.

Cutaneous Mycoses
Three genera of dermatophytes, Microsporum, Trichophyton, and
Epidermophyton cause infections of skin and its appendages.

Clinical Name Site Most frequent organism

Tinea capitis (epidemic) scalp Trichophyton tonsorus, Microsporum audouinii
Tinea capitis (non-
epidemic) scalp Microsporidium canis, Trichophyton verrucosum
Tinea favosa scalp, torso Trichophyton sp.
Tinea barbae beard Trichophyton rubrum, T. verrucosum
arms, legs
Tinea coporis torso T. rubrum, M. canis, T. mentagrophytes
T. rubrum, T. mentagrophytes, Epidermophyton
Tinea cruris crotch floccosum
Tinea pedis, manus feet hands T. rubrum, T. mentagrophytes
Tinea unguium nails T. rubrum, T. mentagrophytes, E. floccosum
Tinea imbricata torso T. concentricum
 Tinea corporis

Subcutaneous mycoses
Subcutaneous infections - over
35 species produce chronic
inflammatory disease of
subcutaneous tissues and
lymphatics. e.g. sporotrichosis -
ulcerated lesions at site of
inoculation followed by multiple
nodules - caused by a
dimorphic fungus:
Sporotrix schenckii.
 Systemic fungal infections are
uncommon
Natural immunity is high; physiologic barriers include:
1. Skin and mucus membranes
2. Tissue temperatureCfungi grow better at less than
37C
3. Redox potentialCin vivo conditions too reducing for
most fungi

Infection requires a large inoculum

and a susceptible host
1. infection often occurs in endemic areas
2. most infections are asymptomatic or self-limiting
3. in immune-compromised hosts, infections are more often
fatal (AIDS)

Systemic fungal disease is most often

associated with four organisms
1. Coccidioides immitis
2. Histoplasma capsulatum
3. Blastomyces dermatitidis
4. Paracoccidioides brasiliensis (S. America)
 Coccidioidomycosis
• Coccidiodes immitis is
considered to be the
most virulent of fungal
pathogens.
• Restricted to hot,
semi-arid areas of SW
USA and Mexico.
• Grows in the soil, but
inhalation of a single
spore can initiate
infection.
Conidia

In infected tissues, C.
immitis appears as a
mixture of endospores Spherules
and spherules.
 Coccidioidomycosis:
A. Encounter: Mycelium found in dry, dusty soil.
Contact by inhalation of arthroconidia
B. Spread: Most commonly an asymptomatic self
limited pulmonary disease, but may spread via
the blood to skin, soft tissues, bones, joints and
meninges.
C. Immune Response: T-cell mediated (Th-1): IL-
2, IFN-γ
D. Evasion of Defenses: Resistant to killing by
phagocytes
-- protein rich, hydrophobic outer wall
--alkaline halo associated with urease
E. Damage: secreted proteinases break down
collagen, elastin, hemoglobin, IgG & IgA
 Coccidioidomycosis:
E. Risk Factors
1. Ethnicity
2. Age: Extremes more susceptible
3. Sex: Males more susceptible
4. Pregnancy: 3rd trimester
5. Immunosuppression
F. Symptoms
1. Fever
2. Arthralgia
3. Erythema nodosum

G. Diagnosis
1. Exam: Suppurative or granulatomas inflammation
2. Histopathology: spherules or endospores seen in sputum, exudates
or tissue
3. Culture: —danger, highly infectious!
4. Serology: Complement fixation assay (in cerebrospinal fluid),
particle agglutination assay

H. Treatment
1. Often none.
2. Amphotericin B followed by an azole
 Histoplasmosis
(also called cave disease)

Caused by the dimorphic fungus Histoplasma capsulatum

Intracellular yeast at 37C Tuberculated macroconidia, grown at 25C

Histoplasmosis is characterized by intracellular growth of

the pathogen in macrophages and a granulomatous
reaction in tissue. These granulomatous foci may
reactivate and cause dissemination of fungi to other
tissues.
 Histoplasmosis

A. Encounter.
H. capsulatum grows in soil,
especially soil contaminated
by guano. Inhalation of
conidia from the
environment is source of
infection. This is more
likely in endemic areas. In
U.S. these include the
Atlantic Ocean to N. Dakota
(500,000 cases/year in
U.S.), except New England
& Florida. Most cases occur
in Ohio Valley and
Mississippi Valley)
 More Histoplasmosis
B. Spread
1. 90% of cases are asymptomatic, but in rare
cases flu like respiratory symptoms occur
2. Disseminated histoplasmosis occurs in 1:200
cases and is diagnosed frequently in patients with
AIDS living in the central U.S. Other risk factors:
being under 2 or receiving massive inoculum
3. In these cases, the organism spreads via blood
from the lung to involve bone marrow, adrenal
glands, heart valves and CNS
4. Spread can also be associated with underlying
lung disease (e.g., emphysema).

C. Immune Response
1. Cell-mediated responses are of primary
importance
2. Phagocytic activity of macrophage is considered
an important component of resistance to drugs.
3. Activated macrophage can kill yeast cells

D. Evasion of Defenses

1. Survival in macrophages—elevates pH
of phagosomes
2. Yeast cells absorb iron and calcium from
host
3. Alteration of cell surface
 Histoplasmosis
D. Damage
1. Lung--bronchial obstruction and
inflammatory sequelae
2. Disseminated histoplasmosis-fulminant
disease that may result in toxic shock
3. CNS-fatal if untreated.
4. Mediastinal fibrosis (rare)

E. Diagnosis
1. Direct histology and culture of blood or bone
marrow
2. Serological testing for antibody and histoplama
antigen in blood and urine.
3. Urine test: in HIV-infected patients with
disseminated histoplasmosis, histo. antigen
detection in urine is at least 90% sensitive.
 Even More Histoplasmosis

F. Treatment
• Amphotericin still mainstay of therapy vs.
disseminated and severe pulmonary
histoplasmosis.
• Ketoconasole or itraconasole is effective as
therapy for self-limited disease (used in AIDS).

Ocular Histoplasmosis
A small fraction of
individuals form scar tissue
in the retina many years
after the original
histoplasmosis infection.
Live organisms cannot be
recovered from these
specimens. The scarring
can obscure the macula and
lead to loss of central
vision. The first signs are
small “histo spots”.
 Gene Therapy Death 7/2007
Jolee Mohr, 36 enrolled in
clinical trial for gene therapy
for RA--AAV expressing
monoclonal Ab to TNFα.

Feb. 26, 2007: 1st shot—no

noticeable effect

July 2: Tired and cranky but

received 2nd shot (temp 99.6)

July 3, woke up feeling ill,

vomiting by PM (temp 101)

July 4, feverish and vomiting;

family physician “probably a
virus.”

Jolee Mohr, 36, died from July 7th, symptoms worsened

widespread histoplasmosis (temp 104.1). Went to ER-
accompanied by a hematoma that tests indicated liver damage
ruptured her organs, according and possible infection—sent
John Hart, a pathologist at the home under care of family
University of Chicago. At the time of doctor.
her death, she had disseminated
histoplasmosis in several organs of July 12: admitted to hospital.
her body. Signs of serious infection, but
tests for standard viruses or
Taking Humira bacteria were negative.

(adalimumab), a TNF-α July 18: Transferred to Univ. of

blocker to control RA Chicago Hospital

July 24: Dies from massive

bleeding and organ failure.
 Blastomycosis
Granulomatous mycotic
infection that
predominantly involves
lungs and skin; but can
spread to other organs.
Most prevalent in males
40-60 years of age and
children.

Blastomyces dermatitidis

Dimorphic organism
originates in the soil and
infection ensues by
inhalation of spores.
Converts to yeast in animal
hosts or at 37o in vitro.
 Blastomycosis
• Encounter: Most cases are in southern, central,
and southeastern USA. Infection is by inhalation
of spores.
• Spread: The pulmonary infection is either self
-limited or progressive. Dissemination often
occurs to the skin and to the bone - 80% of
patients have large skin lesions; a large number
also have granulomatous pulmonary lesions.
• Risk Factors: Occupational contact with soil;
owning a dog. Living in endemic area.
• Evasion of Defenses: Escapes phagocytosis by
neutrophils and monocytes by shedding its
surface antigen after infection
• Damage: Consequence of the immune
response to the organism—skin lesions
respiratory infiltrates.
• Diagnosis: based on clinical findings and
microscopic detection of organisms in tissue
specimens

Molly
 Blastomycosis
Immune response

1. Alveolar macrophage provide a first line of

defense.
2. T-cell stimulated PMNs kill Blastomyces cells by
oxidative mechanisms).
3. Conidia are more sensitive to killing by PMNs
because yeast are too big.
4. TH-1 response of primary importance

Treatment
1. Amphotericin B is the drug of choice for rapidly
progressive blastomycosis
2. Itraconazole or Fluconazole for less severe
cases
 Question: How did these soil
microorganisms evolve traits
that enable them to evade the
human immune system?
Hypothesis: Predation by soiled based
organisms such as amoeba and nematodes
selected for fungi that can: (1) survive in the
phagosome (2) escape from the predator.

Cassadeval,
Annu. Rev. Microbiol.
2008. 62:19–33
 Opportunistic Mycoses

Opportunistic mycoses are fungal infections that

do not normally cause disease in healthy people,
but do cause disease in people with weakened
immune defenses (immunocompromised
people). Weakened immune function may occur
due to inherited immunodeficiency diseases,
drugs that suppress the immune system (cancer
chemotherapy, corticosteroids, drugs to prevent
organ transplant rejection), radiation therapy,
infections (e.g., HIV), cancer, diabetes,
advanced age and malnutrition.

The most common infections are:

Aspergillosis
Candidiasis
Cryptococcosis
Pneumocystis carinii
Zygomycosis

(more from Dr. Wingard)

 Cryptococcus neoformans
• Encounter: Organism is ubiquitous and
infections occur worldwide C. neoformans
recovered in large amounts in pigeon poop.
Does not cause disease in birds. Primary site
of human infection is the lungs

• Spread: Cryptococcal meningitis is most

common disseminated manifestation. Can
spread to skin, bone and prostate.
 Cryptococcus neoformans
• Evasion of defenses: Yeast cells are resistant to
phagocytosis because of capsule. Melanin protects
against oxidative injury

• Immune response: Activated neutrophils have

an increased capacity to phagocytize C. neoformans.
Cell mediated immunity is our primary defense.
About 30% of cryptococcus infections occur in
patients with lymphoma (CNS). Major oportunistic
infection in patients with AIDS

• Diagnosis: Lumbar puncture and microscopic

examination of cerebrospinal fluid is diagnostic.
(India ink staining). Cyrptococcal antigens in
CSF and serum. Culture of organisms from
blood or CSF

• Treatment: Amphotericin B & 5FC. Followed by

oral fluconazole.
 Vancouver Island
Outbreak
• Largest Cryptococcus outbreak recorded
• Caused by C. gattii
• Infects immunocompetent and immunocomprimised
people
• First observed in Vancouver Island in 1999 but now
has spread to BC and Pacific Northwest
• Mainly caused by a single genotyope of C. gattii
(VGIIa)
• In U.S. subspecies identification is not routine (need
MLST)
• C. gattii is usually found in the tropics and subtropics
 C. gatti outbreak

Map of the Pacific Northwest, comprising parts of British

Columbia, Canada, and the states of Washington and Oregon in
the United States, showing human and veterinary Cryptococcus
gattii cases (including marine mammals) by place of residence
or detection, and locations of environmental isolation of C. gattii
during 1999–2008. cf. Datta et al. Emerg. Infect. Disease (2009)
 Aspergillosis

• Genus occurs
worldwide and contains
hundreds of species.
• These species
constitute the most
commonly found fungi
in any environment

Major portal of entry is the

respiratory tract.
Dissemination can occur
from the lungs and involve
other areas of the lung, the
brain, GI tract, and kidney.
CNS and nasal-orbital
cavities can also occur
without lung involvement.
Risk factors for invasive
disease are neutropenia
and high doses of adrenal
corticosteroids
 Aspergillosis
• Aspergillosis is the most common fatal infection seen in
patients with chronic granulomatous disease of childhood. 
• Patients with this condition are unable to form toxic oxygen
radicals after phagocytosis. 
• Progressive and disseminated disease can complicate
neoplastic diseases, especially acute leukemia, bone
marrow and organ transplantation (not necessarily AIDS).

In immunosuppressed
hosts: invasive pulmonary
infection, usually with
fever, cough, and chest
pain. May disseminate to
other organs, including
brain, skin and bone. In
immunocompetent hosts:
localized pulmonary
infection in persons with
underlying lung disease.
Also causes allergic
sinusitis and allergic
bronchopulmonary disease.

Agent: Aspergillus fumigatus, A. flavus.

 Candidiasis
C. albicans is a member of the indigenous microbial
flora of humans. 
1. Found in the gastrointestinal tract, upper
respiratory tract, buccal cavity, and vaginal
tract.
2. Growth is normally suppressed by other
microorganisms found in these areas.
3. Alterations of gastrointestinal flora by broad
spectrum antibiotics or mucosal injury can lead
to gastrointestinal tract invasion.
4. Skin and mucus membranes are normally an
effective barrier but damage by introduction of
catheters or intravascular devices can permit
Candida to enter the bloodstream.

In vitro (25o C):

mostly yeast;
In vivo (37o C):
Yeast, hyphae and
pseudohyphae

Note difference
from other fungi
 Candidiasis
Vaginal candidiasis is the
most common clinical
infection. Local factors
such as pH and glucose
concentration (under
hormonal control) are of
prime importance in the
occurrence of vaginal
candidiasis. In mouth:
normal saliva reduces
adhesion (lactoferrin is
also protective).
Candidal hyphae in mucosal
scraping

Immune Response
Hyphae are too big for phagocytosis but are
damaged by PMNs and by extracellular mechanisms
(myeloperoxidase and β-glucuronidase). Cytokine
activated lymphocytes can inhibit growth of C.
albicans.  Resistance to invasive infection by Candida
is mediated by phagocytes, complement and
antibody, though cell-mediated immunity plays a
major role. Patients with defects in phagocytosis
function and myeloperoxidase deficiency are at risk
for disseminated (even fatal) Candidiasis.
 Candidiasis

Thrush

Cutaneous

Risk factors for candidiasis

Post-operative status
Cytotoxic cancer
Chemotherapy
Antibiotic therapy
Burns
Drug abuse
Gastrointestinal damage.
 Chronic mucocutaneous
candidiasis
Chronic mucocutaneous
candidiasis (CMC) is the
label given to a group of
overlapping syndromes
that have in common a
clinical pattern of
persistent, severe, and
diffuse cutaneous
candidal infections.
These infections affect
the skin, nails and
mucous membranes.

CMC patients often have

defects in cell-mediated
immunity, but the defects
themselves vary widely.

CMC can be controlled by oral azole antibiotics.

 Environmental species kill
neutropenic patients.
Zygomycosis. Zygomycosis due to Rhizopus, Rhizomucor,
Absidia, Mucor species, or other members of the class of
Zygomycetes, also causes invasive sinopulmonary infections.

Category Features

Rhinocerebral The most frequent presentation

overall and classically affects
diabetics with ketoacidosis. Presents
with facial and/or eye pain. Common
complications include cavernous
sinus (rhinocererbral syndrome) and
internal carotid artery thrombosis.

Pulmonary It occurs most frequently among

neutropenic patients and presents
with nonspecific symptoms such as
fever, cough and dyspnea;
hemoptysis may occur with vascular
invasion.

Gastrointestinal Usually affects patients with severe

malnutrition; clinical picture mimics
intra-abdominal abscess. The
diagnosis is often made at autopsy.
Cutaneous Reported with minor trauma, insect
bites, no sterile dressing, wounds,
and burns. Necrotic lesions
progressively evolve from the
epidermis into dermis and even
muscle.
 Conclusions
• Most fungal infections affect our
surface not our contents
• A few dimorphic fungi can cause
systemic infections in otherwise
healthy people.
– Endemic areas
– Contact by inhalation
• Candida species inhabit our guts
and usually stay there, but, given
the right (wrong) conditions can
disseminate to infect almost any
organ.
– Important nosocomial infection
• In immune compromised people,
any fungus can be a deadly
pathogen