NAME RESERVOIR MORPHOLOGY CLINICAL SYNDROME TREATMENT DIAGNOSIS NOTESANATOMIC LOCATION Malassezia furfur N aturally found on the skin surfaces of “Spaghetti and meat balls” Tinea/Pityriasis versicolor - a common, benign, Dandruff shampoo (containing Potassium hydroxide (KOH) prep: reveals short, SUPERFICIAL (SKIN) AN-AN many animals, including humans. Dimorphic, lipophilic fungi superficial cutaneous fungal infection usually selenium sulfide) curved, unbranched hyphae with spherical yeast AP-AP characterized by hypopigmented or hyperpigmented cells ( look like “spaghetti and meatballs”) macules and patches on the chest and the back. In Isolated in 18% of infants and 90-100% patients with a predisposition, tinea versicolor may Topical imidazole Malassezia is extremely difficult to propagate of adults. chronically recur. The fungal infection is localized to in laboratory culture and is culturable only in the stratum corneum. media enriched with C12- to C14-sized fatty acids. DERMATOPHYTES Depending on the particular species Dermatophytosis Topical imidazole KOH: branched hyphae Secretes the enzyme keratinase, CUTANEOUS Tinea corporis (body): “ringworm” Oral griseofuivin is used for tinea Wood’s lamp: ceratin species of Microsporum which digests keratin Tinea cruRis (groin): “jock itch” unguium and tinea capitis will fluoresce under ultraviolet light Microsporum Soil (geophilic) Tinea pedis (feet): “athlete’s foot” Oral terbinafine A fungal culture, which is often used as an For atypical presentations of Trichopyton Animals (zoophilic) Tinea capitis (scalp) adjunct to KOH for diagnosis, is more specific tinea corporis, further Epidermophyton floccosum Human (anthropophilic) Tinea unguium (nail): Onychomycosis than KOH for detecting a dermatophyte evaluation for HIV infection infection. Therefore, if the clinical suspicion is and/or an immunocompromised high yet the KOH result is negative, a fungal state should be considered. culture should be obtained. Infections due to zoophilic or geophilic If the above clinical evaluations are dermatophytes may produce a more inconclusive, a polymerase chain reaction (PCR) intense inflammatory response than assay for fungal deoxyribonucleic acid (DNA) those caused by anthropophilic identification can be used. microbes Sporothrix schenkii Found on rose thorns Suppurating subcutaneous nodules that progress Itraconazole Dimorphic Primary pulmonary infection SUBCUTANEOUS proximally along lymphatic channels Fluconazole Culture at 25ºC will grow branching hyphae (pulmonary sporotrichosis) is (lymphocutaneous sporotrichosis) Oral potassium iodide Culture at 37ºC will grow yeast cells rare, as is direct inoculation into tendons, bursae, or joints. Definitive diagnosis of sporotrichosis at any site Osteoarticular sporotrichosis is requires the isolation of S schenckii in a caused by direct inoculation or specimen culture from a normally sterile body hematogenous seeding. site. The organism can be recovered with fungal In rare cases, disseminated S culture from sputum, pus, subcutaneous tissue schenckii infection biopsy, synovial fluid, synovial biopsy, bone (disseminated sporotrichosis) drainage or biopsy, and cerebrospinal fluid occurs, characterized by (CSF). disseminated cutaneous lesions and involvement of multiple visceral organs; this occurs most commonly in persons with AIDS. Coccidioides immitis Desert areas of the southwestern Dimorphic: Coccidiodomycosis Amphotericin B Biopsy of affected tissue: lung biopsy, skin Common oppurtunisitc infection SYSTEMIC United States and northern Mexico Mycelial forms with spores at Asymtomatic (in most persons) Itraconazole biopsy, etc. in AIDS patients from the 25ºC Pneumonia Fluconazole Silver stain or KOH prep southwest United States Respiratory transmission Yeast forms at 37ºC Disseminated: can affect the lungs, skin , bones and Culture on Sabouraud’s agar SPHERULES WITH ENDOSPORES meninges Serology Skin test Histoplasma capsulatum Mississippi valley Dimorphic : Histoplasmosis Itraconazole Lung biopsy Can survive intracellularly within SYSTEMIC macrophages Present in bird and bat droppings Mycelial forms with spores at Asymptomatic (in most persons) Amphotericin B (in Silver stain specimen 25oC immunocompromised patients Respiratory transmission Yeast forms at 37oC Pneumonia: lessions calcify, which can be seen on Culture on Sabouraud’s agar will reveal hyphae YEASTS WITHIN MACROPHAGES chest X-ray (may look similar to PTB) at 25oC and yeast at 37oC Disseminated: can occur in almost any organ, Serology especially in lung, spleen, or liver Skin test (test for exposure only) Urine antigen test Blastomyces dermatitidis Dimorphic: Blastomycosis Itraconazole Biopsy of affected tissue: lung biopsy, skin BROAD-BASED BUD SYSTEMIC biopsy, etc. Mycelial forms with spores at Asymptomatic (uncommon) Ketoconazole Silver stain specimen 25oC Yeast forms at 37oC Pneumonia: lesion rarely calcifies Amphotericin B Culture on Sabouraud’s agar Dessiminated (most common): present with weight Serology loss, night sweats, lung involvement and skin ulcers Cutaneuos: skin ulcer Skin test (test for exposure only) Blastomyces dermatitidis BROAD-BASED BUD SYSTEMIC Blastomycosis is usually localized to the lungs and Sputum specimens processed with 10% may present with: potassium hydroxide, cytology smears, or a fungal stain A self-limited flulike illness with fever, chills, myalgia, Enzyme immunoassay (EIA) techniques on headache, and a nonproductive cough sputum, tissue, or bronchoscopic specimens An acute illness resembling bacterial pneumonia, with high fever, chills, a productive cough, and pleuritic chest pain; mucopurulent or purulent sputum Chronic illness, with low-grade fever, a productive cough, fatigue, night sweats, and weight loss Rapidly progressive, and severe disease, eg, multilobar pneumonia or ARDS, with fever, shortness of breath, tachypnea, hypoxemia, and finally hemodynamic collapse Cryptococcus neoformans Pigeon droppings Polysaccharide capsule Cryptococcus Amphotericin B and flucytosine India-ink stain of cerebrospinal fluid (CSF): Most cases occur in SYSTEMIC (is superior to amphotericin B observe encapsulated yeast immunocompromised person Yeast form only (Not dimorphic) Subacute or chronic meningitis alone) Cryptococcal antigen test of CSF: detects polysaccharide antigens Pneumonia: usually self-limited and asymptomatic Fungal culture MCC of meningoencephalitis in HIV Skin lesions: look like acne YEAST WITH A HALO Candida albicans Normal flora of the skin, mouth and Pseudohyphae and yeast Candidiasis in a normal host The choice of antifungal agent KOH stain of specimen YEAST WITH PSEUDOHYPHAE CUTANEOUS or SYSTEMIC gastrointrointestinal tract Oral thrush depends on the area involved Silver stain of specimen (normal host, or opportunistic) Vulvovaginal candidiasis and its severity. Blood culture: growth must be respected Cutaneous Blood assay for beta-D-glucan Diaper rash Rash in the skin folds of obese individuals Candidiasis in an immunocompromised host Thrush, vaginitis and/or cutaneous, plus: Esophageal Disseminated candidiasis: acquired by very sick hospitalized patients, resulting in multi-organ system failure Chronic mucocutaneous candidiasis Aspergillius fumigatus Ubiquitous Branching septated hyphae Aspergillosis Allergic bronchopulmonary Allergic brochopulmonary aspergillosis: Rarely found in individuals who OPPORTUNISTIC (acute angles, 45O) Allergic bronchopulmonary aspergillosis (IgE aspergillosis -> treat with High level of IgE (IgE level > 1000 IU/dL) are immunocompetent Aspergillus may cause a broad mediated): asthma type asthma type reaction with corticosteroids Sputum culture spectrum of disease in the human shortness of breath and high fever Wheezing patient and chest X-ray with fleeting The FDA has approved an host, ranging from hypersensitivity infiltrates intravenous formulation of the reactions to direct angioinvasion. Increased level of eosinophils triazole antifungal posaconazole Aspergillus primarily affects the lungs, Skin test: immediate hypersensitivity reaction (Noxafil), which is indicated for Aspergillius flavus causing the following four main Asperigilloma (Fungus ball): associated with Aspergilloma: removal via Aspergilloma: diagnose with chest X-ray or CT the prophylaxis of invasive syndromes: hemoptysis (blood cough) thoracic surgery scan Aspergillus and Candida • Allergic bronchopulmonary infections in severely Aspergillius niger aspergillosis (ABPA) Invasive aspergillosis: necrotizing pneumonia. May Invasive aspergillosis: treat with Invasive aspergillosis: sputum examination immunocompromised adults • Chronic necrotizing Aspergillus disseminate to other organs in voriconazole, possibly and culture who are at high risk of pneumonia (or chronic necrotizing immunocompromised patients caspofungin. (very high developing these infections. pulmonary aspergillosis [CNPA]) mortality) • Aspergilloma Aflatoxin consumption (produced by Aspergillus Aflatoxins contaminate peanuts, • Invasive aspergillosis flavus ) can cause liver damage and live cancer grains, and rice Rhizopus Saprophytic molds Broad, non-septated, branching Mucormycosis Amphotericin B and surgery Biopsy The disease is rapidly fatal OPPORTUNISTIC Rhizomucor hyphae (right angles, 90o) Rhinocerebral (associated with diabetes): starts on Black nasal discharge nasal mucosa and invades the sinus and orbit Mucor Pulmonary mucormycosis Pneumocystis jirovecii Unicellular fungi found in the The organism is found in 3 PJP – Pneumocystis jirovecii pneumonia occurs when TMP-SMX A lactic dehydrogenase (LDH) study is The taxonomic classification of respiratory tracts of many mammals distinct morphologic stages, as both cellular immunity and humoral immunity are performed as part of the initial workup.[24] LDH the Pneumocystis genus was and humans follows: defective. levels are usually elevated (>220 U/L) in debated for some time. It was The trophozoite (trophic form), patients with P jiroveci pneumonia (PJP). They initially mistaken for a Once inhaled, the trophic form of Pneumocystis in which it often exists in are elevated in 90% of patients with PJP who trypanosome and then later for organisms attach to the alveoli. Multiple host immune clusters are infected with HIV. The study has a high a protozoan. In the 1980s, defects allow for uncontrolled replication of The sporozoite (precystic form) Pneumocystis organisms and development of illness. sensitivity (78%-100%); its specificity is much biochemical analysis of the The cyst, which contains several Activated alveolar macrophages without CD4+ cells are lower because other disease processes can nucleic acid composition of intracystic bodies (spores) unable to eradicate Pneumocystis organisms. Increased result in an elevated LDH level. [Clin Invest Med. Pneumocystis rRNA and alveolar-capillary permeability is visible on electron 1992 Aug. 15(4):309-17. mitochondrial DNA identified microscopy. the organism as a unicellular fungus rather than a protozoan. Quantitative PCR for pneumocystis may Subsequent genomic sequence become useful in distinguishing between analysis of multiple genes colonization and active infection, but these including elongation factor 3, a assays are not yet available for routine clinical component of fungi protein use. synthesis not found in protozoa,