Mycology

– basis of diagnosis
 mycology
mycoses
fungemia
exo-antigen
fungal antigenemia
biomarker
pre-emptive
therapy
 Fungi
FUNGI BACTERIA
nucleus eukaryotes prokaryotes

cell membrane sterols (ergosterol) -

cell wall chitin, mannan, glucan, murein, teichoic acid,
chitosan proteins

oxygen almost all strict aerobes facultative and obligate

aerobes and anaerobes,

- heterotrophs requiring organic carbon source for growth ( biotrophic, saprophyte)

- extracellular enzymes

- host defense: cell-mediated immunity (role of antibodies is minor) -> neutrophil

phagocytosis and killing
 Antifungal agents- mode of action

- Polyenes (amphotericinB, nystatines, pimarcin)

- Azoles (ketokonazole, itraconazole, fluconazole, vericonazole, posaconazole)
- Echinocandins (caspofungin, mikafungin, anidulafungin )
- Nucleoside analogs(antimetabolites): (5 fluorocytosine)
- Allylamines: (tebinafine)
 Fungal
morphotypes

Unicellular form (Yeast) Yeasts

spherical or ellipsoid fungal cells
reproduce by budding

Mycelial form : moulds, dermathophytes

Molds
hyphal or mycelial form of growth
branching filaments (filamentous)
.

Fungal morphotypes

Unicellular form (Yeast)

 FUNGUS FAMILY

YEAST MOLDs & dermatophytes

Candida, Cryptococcus,
Malessezia, Geotrichum,
Dymorphic fungi Aspergillus, Penicillium,
Blastomyces, Coccidioides, Mucor, Rhizopus, Fusarium,
Trichosporon, Rodotorula
Histoplasma, Paracoccidioides Cladosporium,
etc.
or Scopulariopsis

Dimorphic fungi – have two growth

forms: molds & yeast, which develope
under different growth conitions
 SPORULATION

sexual by asexual by
sexual spores: asexual spores
common
- ascospores
- zygospores
non common

CONIDIOSPORES SPORANGIOSPORES ARTROSPORES

borne externally borne in a sac or ascus fragmentation
on on of
AERIAL HYPHA AERIAL HYPHA VEGETATIVE
HYPHA

size of fungal spores ranges from 2–3 m (Cladosporium , Aspergillus,Penicillium) up to

160 m (Helminthosporium)
 clinically important fungi

Yeasts filamentous fungi

Basidiomycetes

Glucan + Glucan - Glucan + Glucan -

Cryptococcus Mucormycetes
Candida Trichosporon formerly: zygomycete
Geotrichum Rhodotorula Ascomycetes
Sacharomyces Malassezia
Rhizopus
Mucor
Rhizomucor
Hyphomycetes Pheohyphomycete Lichtheimia
Cunninghamella
Aspergillus Dermatophytes Alternaria Apophysomyces
Acremonium Culvularia
Penicillium Trichophyton
Epidermophyton Phialophora
Paecilomyces Cladophialophora
Scedosporium Microsporum
Bipolaris
Scopulariopsis Exophiala
Fusarium Rhinocladiella
 Pathogenicity factors

- Adhesion

- Change of antigenic surface structure

- Dimorphism
- extracellular fungal products:
- enzymes : proteinases, phospholipases
- mycotoxins
 Mycoses
1. superficial affect outermost layers

2. cutaneous affect deeper layers (dermatophytes)

3. subcutaneous subcutaneous tissue,

connective tissue, muscle, fascia
4. systemic
A) systemic primary – dimorphi fungi
B) systemic opportunistic (exogenous/endogenous NF)

5. allergic mycoses affects lungs or sinuses

 1. Superficial mycoses
 pityriasis versicolor (Malassezia furfur)
 tinea nigra (Hortea werneckii)
 black piedra (Piedraia hortae)
 white piedra (genous Trichosporon)

Infections of the STRATUM CORNEUM or hair shaft

 Malassezia furfur – lipophilic yeast
Considered part of microbial flora previously
known as Pityrosporum ovale

Pityriasis versicolor
chronic infection
occur as macular patches of discolored skin
inflamation, scaling, irritation are minimal
lesins fluoresce under Wood’s lamp

opportunistic fungemia in patients

receiving total parenteral nutrition
(contamination of the lipid emulsion)

folliculitis – rarely
contributor to dandruff and seborrheic dermatitis
 TINEA NIGRA – Hortaea werneckii
appear as a dark discoloration often on the palm

PIEDRA - endemic in tropical countries

Black piedra -Piedra hortae: nodular infection of the hair shaft
White piedra - Trichosporon spp.: large, soft, yellowish nodules on the hair

https://mycology.adelaide.edu.au/mycoses/superficial/
Cutaneous mycoses - dermatophytoses

fungi that infect only the superficial keratinized tissue (nails, skin, hair)
unable to grow in 37C
unable to grow in the presence of serum = no systemic spread

genera:

- Trichophyton
- Epidermophyton
- Microsporum

identification, based on morphological

criteria (macroconidia and microconidia)
 skin, nails, hair

All 3 organisms infect attack skin BUT…

-> Microsporum does not infect nails

-> Epidermophyton does not infect hair
 Dermatophytes

antropophilic zoophilic or geophilic

- relatively mild and chronic - more acute inflammatory inf.

infections in human - tend to resolve more quickly
- may be difficult to eradicate
 Onychomycosis =
fungal infections of the nail

Dermatophytes Candida nondermatophytic molds

>80% 10% 6%

Dermatophytids - an allergic reaction to the fungus = fungus-free skin lesions

Ringworm infection may cause skin lesions in a part of the body that is remote from
the actual infection. Such lesions are called "dsermatophytid The lesions themselves
are fungus-free, and normally disappear upon treatment of the actual infection
 Dermatophyte nail mycosis - risk factors

- weighting of the nail (jogging, tennis, badminton, climbing, marches)

- beauty treatments (pedicure, manicure)
- occupation requiring wearing footwear industry
- underlying diseases (diabetes, Cushing's syndrome, hypothyroidism, AIDS, cancer)

- it occurs in adults, especially the elderly. Rare in children

- nail infections are usually secondary to athlete's foot
- shoes are often „incubator” for fungi
 Prevention tinea pedis and unguium

- Decontaminated footwear and textiles

- "15 minutes"

- eliminate "the effect of the plastic bag"

- examination of the patient's family

- cure "pet" - zoofilne dermatophytes

SUBCUTANEOUS MYCOSES

acquired through traumatic lacerations or

puncture wounds to enter

usually confined to tropics and subtropics with

exception of Sporotrichosis

common among those who work with soil and

vegetation and have little protective clothing
http://cmapspublic3.ihmc.us/rid=1GNQT38TZ-1V40FR1-HMZ/Subcutaneous%20Mycoses.cmap
 Sporothrix scheneckii

Dimprphic: mycelial in nature, yeast in tissue

Raised skin lesions with proximal spread along
lymphatic channels
Causative agent of sporotrichosis ("rose gardener's disease")
-Cutaneous sporotrichosis
-Extracutaneous sporotrichoses
-Central nervous system sporotrichosis
Risk groups: gardeners, forestry workers, miners, laboratory workers,
veterynarians
Transmission : traumatically introduced into the skin typically by a thorn
 primary systemic mycoses – dimorphi fungi

blastomycosis
- mycelial in nature, yeast in tissue
coccidiomycosis
- all of primary systemic fungal
pathogens are agents of respiratory
histoplasmosis
infections
Endemic paracoccidioidomycosis
 Possible clinical courses of mycosis by dimorphic fungi

inhalation

colonisation

infection

Asymptomatic pneumonia Acute symptomatic pneumonia

healing

Chronic lung disease Chronic progressive lung disease

Endogenous
reactivation

Extrapulmonary dissemination
dimorphi fungi disease endemic area virulence

Blastomyces blastomycosis Ohio-;Misissippi River Valley Modification of cell wall composition

dermatidis (escape recognition by macrophages)

Coccidioides immitis coccidiomycosis deserts of Mexico regions, generate an alkaline

Central and South America microenvironment that helps to
survive intracellulary within the
phagosome
Histoplasma histoplasmosis Latin America, parts of Asia, survive and proliferate within
capsulatum Middle East, eastern half of USA phagosome ( unknown mechanism )

Paracoccidioides Paracoccidioidomycosi Central and South America Hormonal influences on infection

brasiliensis s Estrogen inhibits transition from
conidia to the yeast form this fungi
 Opportunisctic systemic mycoses

 Candidiasis ( Candida albicans, Candida spp.)

 Cryptococcosis (Cryptococcus neoformans)
 Aspergillosis (Aspergillus fumigatus, Aspergillus spp.)
 Mucormycosis (Rhizopus, Mucor, Absidia)
 Hyalohyphomycosis (Fusarium, Scopulariopsis, Beauveria)
 Pheohyphomycosis (Cladosporium, Bipolaris, Curvularia)
clinical groups and predisposing factors
for invasive candidiasis

- broad-spectrum antibiotic therapy

- corticosteroid therapy
- pregency
- oral contraceptive use
- systemic disease ( diabetes mellitis etc.)

- neutropenia (especially >7 days)

- hematological & solid tumor malignancy

- postsurgical intensive care patients

- prolonged intravenous catheterization
- parental nutrition
- severe burns
- neonates
 Clinical manifestations of Candida infections:

Causative agents:
Candida albicans
Candida parapsilosis
Candida glabrata
Candida tropicalis

Oral candidiasis (including thrush, glossitis, stomatitis)

Candida vulvovaginitis
Cutaneous candidiasis(including diaper candidiasis, paronychia, onychomycosis)
Candiduria
Candidemia and disseminated candidiasis
 Candida albicans virulence factors

- enzymes (proteinases,phospholipases)
- composition of the cell surface/ hydrophobicity
- ability to undergo the yeast-to-hypha transformation
(regulated by both pH and temperature)
- thigmotropism
 Cryptococcus neoformans
C. neoformans var neoformans
reservoir: bird droppings
host predisposition: immunocompromissed

C .neoformans var gatti

reservoir: eucalyptus trees
host predisposition: mostly healthy people
endemic in Australia, Papua New Guinea, parts of Africa, the
Mediterranean region, India, south-east Asia, Mexico, Brazil, Paraguay
and Southern California
 Cryptococcus
Cryptococcosis : neoformans
 pulmonary infections
 CNS infections (cryptococcal meningoencephalitis)
 rare infect other body sides
 cryptococcosis is an AIDS- defining illness in patients with HIV

virulence:
 polysacharide capsule
 phenoloxidase (enzyme that converts hydroxybenzoic substances to melanin;
protect against oxidative host defense)
 ability to grow in 37 °C
 Aspergillus A.fumigatus
A. flavus
A. niger
A. terreus
have a global distribution
small spore size
 thermo-tolerance allowing growth at human body temperature
resistance to oxidative killing
produce metabolites and enzymes with proteolytic and
immunosuppressive activity
 Aspergillus spp. infections

-Invasive pulmonary aspergillosis

- aspergilloma (fungus ball )
-disseminated aspergillosis
- allergic bronchopulmonary aspergillosis
- Farmer’s lung
- aspergillus sinusitis

Well-know risk factor for invasive aspergillosis:

 macrophage function reduced

 phagocytosis or cellular killing reduced

 Clinical Current diagnostic methods

Infection = manifestation
Empirical/targeted therapy

Biological
infection
Pathological changes

INFECTION
INFECTION

Targeted prophylaxis/
Pre-emptive therapy

PCR
Antigen detection
 Diagnosis of invasive Aspergillosis

Galactomannan (GM)
- polysaccharide component of the cell wall
- highly immunogenic antigen
- exo-antigen that can be detected in serum, BAL or CSF
- monitoring of GM during antifungal therapy allows progression of
treatment to be measured

(1→3)-β-D-glucan
- exo-antigen
-present in molds, yeast, bacteria, plants
- may also be used in diagnosis of candidiasis or fusariosis
- absent in Cryptococcus species, zygomycetes and humans
-- may be used as a complementary test to GM
 Invasive Candidiasis

Based on detection of antigen:

> β-glucan
> Mannan
Mannan
-polysaccharide component of the cell wall of Candida spp.
-highly immunogenic antigen
-immunologically more active then β-glucan
-positive results may be obtained 2-15 days before positive blood cultures
-negative results of the tests do not exclude infection

Invasive Cryptococcosis
Only based on detection of capsular polysaccharide
(glucuronoxylomannan) antigen
detection in serum, BAL or CSF
 Invasive fungal infections

biomarker Best detection speciment disease

method
(1→3)-β-D-glucan Enzimetic fungitell Blood serum Invasive
Candidiasis
Fusariosis
Aspergillosis
Mannan/ anty- EIA Blood serum Specific for Candidiasis
mannan 2x - = no IFI

galactomannan EIA Blood serum Invasive Aspergillosis

BAL ! + in 50% fusariosis
CSF ! Cross reaction with
Geotrichum
glucuronoxylomannan EIA Blood serum Invasive
Latex aglutination CSF Cryptococcosis
urine
 Mycotoxins & mycotoxicoses

– secondary metabolites produced by fungi

– impair the immune system
- neurotoxic, mutagenic, carcinogenic and teratogenic effects.
- toxic effects depends on the type of mycotoxin, the duration and
dose of exposure and the age, health and nutritional status
of the individual affected

aflatoxin (Aspergillus flavus and A. parasiticus)

ergot alkaloids (Claviceps spp., A. fumigatus and Penicillium chermesinum)
ochratoxins (A. ochraceus , A. alliaceus , A.terreus , P. niger and P. viridicatum)

Chronic exposure to mycotoxins causes

immunosuppression of varying extent.
 Fungal Allergy
- majority of allergy-causing molds belong to the divisions of ascomycota or basidiomycota
(Alternaria , Aspergillus, Bipolaris , Cladosporium , Curvularia ,Penicillium)

- outdoor spore concentration ranges from 230 to10 6 spores/m 3

- immunological mechanisms underlying mold allergies are hypersensitivity reactions of

types I, II, III and IV

Clinical Manifestations of fungal allergy:

Allergic Rhinitis
Allergic Asthma
Atopic Dermatitis
Allergic Bronchopulmonary Mycoses
Allergic Sinusitis
 Hypersensitivity Pneumonitis
 Pneumocystis jiroveci ( formally P. carinii)
1. Pneumocystis pneumonia (PCP)
- AIDS defining illnes
- probably transmission from person to person
- CD4 level = predicting risk factor for develope PCP
CD4 count of <200 cells/mm3 (90% AIDS patient develope PCP)
SYMPTOMS:
- shortness of breath (especially with exeration)
- nonproductive cough
- fever

2. Extrapulmonar infections are rare (may infect any area of body)

occur in <3%of patients P. jiroveci does not contain ergosterol and
has not been cultured
polyenes (amphotericinB, nystatines, pimarcin)
Mechanism of Formation
Formationofofcomplexes
complexeswith withergosterol
ergosterolininfungal
fungalcell
cell
action membranes,
membranes,resulting
resultingininmembrane
membranedemage
demageand andleakage
leakage

Spectrum yests
yests+ +molds
molds(also
(alsoMucormycetes
Mucormycetes )+
 
) +dimorphic
dimorphicfungi
fungi
of activity
yeasts: hialopyphomycetes:
yeasts: hialopyphomycetes:
Trichosporon spp - A. tereus
Trichosporon spp - A. tereus
- Fusarium spp.
- Fusarium spp.
- Scedosporium apiosperum
- Scedosporium apiosperum

Rare
Rare; ;
if->
if->may
maybebepresent
presentininCandida
Candidaspp.
spp.

most
most efective
efectivedrug
drugforfor
severe
severe
other cidial
cidial
insoluble
insoluble in in
water
water
nephrotoxicity
nephrotoxicity (new
(new formulations
formulationswith
withliposomes)
liposomes)
widely
widely distributed
distributedin in
tissues,
tissues,
poor
poor
in in
body
body fluids
fluids
half-life
half-life>15>15days
days 
drug of choice
 azoles (ketokonazole, itraconazole, fluconazole, vericonazole, posaconazole)

Mechanism of
action

Spectrum Antifungal spectrum different for each agent

Antifungal spectrum different for each agent
of activity
Aspergillus spp. - resistant to fluconazole
C.Aspergillus spp. - resistant
krusei - resistant to fluconazole
to fluconazole
C. krusei
50% - resistant
C. glabrata to fluconazole
intermediate for fluconazole
50% C. glabrata intermediate for fluconazole

overproduction of enzyme (demethylasis of lanosterol)

overproduction of enzyme (demethylasis of lanosterol)
efflux pomps
efflux pomps
less permeability for antifungal agent
less permeability for antifungal agent

other static : Candida spp.

static : Candida spp.
cidial : II generation of triazoles for Aspergillus
cidial : II generation of triasole for Aspergillus
Supplanted AmB in less severe mycoses because are less toxic & can
be administered orally
 azoles

IMIDAZOLES TRIAZOLES

Ketoconazole I generation:
Miconazole Fluconazole
Clotrimazole Itraconazole

II generation:
usually localized fungal infections
Voriconazole
(topical agents)
Pozaconasol
exc. ketoconazole-> oral
izawuconazol
administration for systemic inf.
 echinocandins ( caspofungin, micafungin, anidulafungin)

Mechanism of Perturb the sinthesis of -glucan

action

Spectrum Candida spp., Aspergillus, spp. dimorphic fungi

of activity

Mucormycetes, Cryptococcus spp., Trichosporon spp.

C. parapsilosis (high MIC)
Fusarium (!)

C. glabrata - MDR

other cidial – Candida

static – Aspergillus -> MEC (minimal effective concentration)
Echinocandins not for UTI
poor penetration for CNS
 antimetabolites (5- fluorocytosine)
Mechanism of
action Interferes with DNA synthesis

- Candida spp.
Spectrum - Cryptococcus spp.
of activity - some of pheohyphomycetes

because resistance develops quickly flucytosine in never used

alone

penetrate well into all tissues, including CSF

other dose-related bone marrow suppression and hepatotoxicity, hair loss
 synergistic effect:
Candida : AmB + 5’FC
Cryptococcus: Fluconasol + 5’FC