NAME RESERVOIR

Malassezia furfur N aturally found on the skin surfaces of

AN-AN many animals, including humans.
AP-AP

Isolated in 18% of infants and 90-100%

of adults.

DERMATOPHYTES Depending on the particular species

Microsporum Soil (geophilic)

Trichopyton Animals (zoophilic)
Epidermophyton floccosum Human (anthropophilic)

Infections due to zoophilic or geophilic

dermatophytes may produce a more
intense inflammatory response than
those caused by anthropophilic
microbes
Sporothrix schenkii Found on rose thorns
Coccidioides immitis Desert areas of the southwestern
United States and northern Mexico

Respiratory transmission

Histoplasma capsulatum Mississippi valley

Present in bird and bat droppings

Respiratory transmission

Blastomyces dermatitidis
Cryptococcus neoformans Pigeon droppings

Candida albicans Normal flora of the skin, mouth and

gastrointrointestinal tract

Aspergillius fumigatus Ubiquitous

Aspergillus may cause a broad

spectrum of disease in the human host,
ranging from hypersensitivity reactions
to direct angioinvasion. Aspergillus
primarily affects the lungs, causing the
Aspergillius flavus following four main syndromes:
• Allergic bronchopulmonary
aspergillosis (ABPA)
Aspergillius niger • Chronic necrotizing Aspergillus
pneumonia (or chronic necrotizing
pulmonary aspergillosis [CNPA])
• Aspergilloma
• Invasive aspergillosis

Rhizopus Saprophytic molds

Rhizomucor
 Saprophytic molds

Mucor
Pneumocystis jirovecii Unicellular fungi found in the
respiratory tracts of many mammals
and humans
 MORPHOLOGY CLINICAL SYNDROME
“Spaghetti and meat balls” Tinea/Pityriasis versicolor - a common, benign,
Dimorphic, lipophilic fungi superficial cutaneous fungal infection usually
characterized by hypopigmented or hyperpigmented
macules and patches on the chest and the back. In
patients with a predisposition, tinea versicolor may
chronically recur. The fungal infection is localized to
the stratum corneum.

Dermatophytosis
Tinea corporis (body): “ringworm”
Tinea cruRis (groin): “jock itch”
Tinea pedis (feet): “athlete’s foot”
Tinea capitis (scalp)
Tinea unguium (nail): Onychomycosis

Suppurating subcutaneous nodules that progress

proximally along lymphatic channels
(lymphocutaneous sporotrichosis)
Dimorphic: Coccidiodomycosis
Mycelial forms with spores at Asymtomatic (in most persons)
25ºC Pneumonia
Yeast forms at 37ºC Disseminated: can affect the lungs, skin , bones and
meninges

Dimorphic : Histoplasmosis

Mycelial forms with spores at Asymptomatic (in most persons)

25oC
Yeast forms at 37oC Pneumonia: lessions calcify, which can be seen on
chest X-ray (may look similar to PTB)
Disseminated: can occur in almost any organ,
especially in lung, spleen, or liver

Dimorphic: Blastomycosis

Mycelial forms with spores at Asymptomatic (uncommon)

25oC
Yeast forms at 37oC Pneumonia: lesion rarely calcifies
Dessiminated (most common): present with weight
loss, night sweats, lung involvement and skin ulcers

Cutaneuos: skin ulcer

Blastomycosis is usually localized to the lungs and
may present with:

A self-limited flulike illness with fever, chills, myalgia,

headache, and a nonproductive cough
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
Polysaccharide capsule Cryptococcus

Yeast form only (Not dimorphic) Subacute or chronic meningitis

Pneumonia: usually self-limited and asymptomatic

Skin lesions: look like acne

Pseudohyphae and yeast Candidiasis in a normal host

Oral thrush
Vulvovaginal candidiasis
Cutaneous
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
Branching septated hyphae Aspergillosis
(acute angles, 45O) Allergic bronchopulmonary aspergillosis (IgE
mediated): asthma type asthma type reaction with
shortness of breath and high fever

Asperigilloma (Fungus ball): associated with

hemoptysis (blood cough)

Invasive aspergillosis: necrotizing pneumonia. May

disseminate to other organs in immunocompromised
patients

Aflatoxin consumption (produced by Aspergillus

flavus ) can cause liver damage and live cancer
Broad, non-septated, branching Mucormycosis
hyphae (right angles, 90o) Rhinocerebral (associated with diabetes): starts on
nasal mucosa and invades the sinus and orbit
Broad, non-septated, branching
hyphae (right angles, 90o)

Pulmonary mucormycosis
The organism is found in 3 PJP – Pneumocystis jirovecii pneumonia occurs when
distinct morphologic stages, as both cellular immunity and humoral immunity are
follows: defective.
The trophozoite (trophic form),
in which it often exists in clusters Once inhaled, the trophic form of Pneumocystis
The sporozoite (precystic form) organisms attach to the alveoli. Multiple host
The cyst, which contains several immune defects allow for uncontrolled replication of
intracystic bodies (spores) Pneumocystis organisms and development of illness.
Activated alveolar macrophages without CD4+ cells
are unable to eradicate Pneumocystis organisms.
Increased alveolar-capillary permeability is visible on
electron microscopy.
 TREATMENT DIAGNOSIS
Dandruff shampoo (containing Potassium hydroxide (KOH) prep: reveals short,
selenium sulfide) curved, unbranched hyphae with spherical yeast
cells ( look like “spaghetti and meatballs”)

Topical imidazole Malassezia is extremely difficult to propagate in

laboratory culture and is culturable only in
media enriched with C12- to C14-sized fatty
acids.
Topical imidazole KOH: branched hyphae
Oral griseofuivin is used for tinea Wood’s lamp: ceratin species of Microsporum
unguium and tinea capitis will fluoresce under ultraviolet light
Oral terbinafine A fungal culture, which is often used as an
adjunct to KOH for diagnosis, is more specific
than KOH for detecting a dermatophyte
infection. Therefore, if the clinical suspicion is
high yet the KOH result is negative, a fungal
culture should be obtained.
If the above clinical evaluations are inconclusive,
a polymerase chain reaction (PCR) assay for
fungal deoxyribonucleic acid (DNA)
identification can be used.

Itraconazole Dimorphic
Fluconazole Culture at 25ºC will grow branching hyphae
Oral potassium iodide Culture at 37ºC will grow yeast cells

Definitive diagnosis of sporotrichosis at any site

requires the isolation of S schenckii in a
specimen culture from a normally sterile body
site.
The organism can be recovered with fungal
culture from sputum, pus, subcutaneous tissue
biopsy, synovial fluid, synovial biopsy, bone
drainage or biopsy, and cerebrospinal fluid
(CSF).
Amphotericin B Biopsy of affected tissue: lung biopsy, skin
Itraconazole biopsy, etc.
Fluconazole Silver stain or KOH prep
Culture on Sabouraud’s agar
Serology
Skin test
Itraconazole Lung biopsy

Amphotericin B (in Silver stain specimen

immunocompromised patients
Culture on Sabouraud’s agar will reveal hyphae
at 25oC and yeast at 37oC
Serology

Skin test (test for exposure only)

Urine antigen test
Itraconazole Biopsy of affected tissue: lung biopsy, skin
biopsy, etc.
Ketoconazole Silver stain specimen

Amphotericin B Culture on Sabouraud’s agar

Serology

Skin test (test for exposure only)

Sputum specimens processed with 10%
potassium hydroxide, cytology smears, or a
fungal stain
Enzyme immunoassay (EIA) techniques on
sputum, tissue, or bronchoscopic specimens
Amphotericin B and flucytosine India-ink stain of cerebrospinal fluid (CSF):
(is superior to amphotericin B observe encapsulated yeast
alone) Cryptococcal antigen test of CSF: detects
polysaccharide antigens
Fungal culture

The choice of antifungal agent KOH stain of specimen

depends on the area involved Silver stain of specimen
and its severity. Blood culture: growth must be respected
Blood assay for beta-D-glucan

Allergic bronchopulmonary Allergic brochopulmonary aspergillosis:

aspergillosis -> treat with High level of IgE (IgE level > 1000 IU/dL)
corticosteroids Sputum culture
Wheezing patient and chest X-ray with fleeting
infiltrates
Increased level of eosinophils
Skin test: immediate hypersensitivity reaction
Aspergilloma: removal via Aspergilloma: diagnose with chest X-ray or CT
thoracic surgery scan

Invasive aspergillosis: treat with Invasive aspergillosis: sputum examination and

voriconazole, possibly culture
caspofungin. (very high
mortality)

Amphotericin B and surgery Biopsy

Black nasal discharge
Amphotericin B and surgery

TMP-SMX A lactic dehydrogenase (LDH) study is performed

as part of the initial workup.[24] LDH levels are
usually elevated (>220 U/L) in patients with P
jiroveci pneumonia (PJP). They are elevated in
90% of patients with PJP who are infected with
HIV. The study has a high sensitivity (78%-
100%); its specificity is much lower because
other disease processes can result in an
elevated LDH level. [Clin Invest Med. 1992 Aug.
15(4):309-17.

Quantitative PCR for pneumocystis may become

useful in distinguishing between colonization
and active infection, but these assays are not
yet available for routine clinical use.
 NOTES ANATOMIC LOCATION
SUPERFICIAL (SKIN)

Secretes the enzyme keratinase, CUTANEOUS

which digests keratin

For atypical presentations of

tinea corporis, further evaluation
for HIV infection and/or an
immunocompromised state
should be considered.

Primary pulmonary infection SUBCUTANEOUS

(pulmonary sporotrichosis) is
rare, as is direct inoculation into
tendons, bursae, or joints.
Osteoarticular sporotrichosis is
caused by direct inoculation or
hematogenous seeding.

In rare cases, disseminated S

schenckii infection
(disseminated sporotrichosis)
occurs, characterized by
disseminated cutaneous lesions
and involvement of multiple
visceral organs; this occurs most
commonly in persons with AIDS.
Common oppurtunisitc infection SYSTEMIC
in AIDS patients from the
southwest United States
SPHERULES WITH ENDOSPORES

Can survive intracellularly within SYSTEMIC

macrophages

YEASTS WITHIN MACROPHAGES

BROAD-BASED BUD SYSTEMIC

Most cases occur in SYSTEMIC
immunocompromised person

MCC of meningoencephalitis in
HIV

YEAST WITH A HALO

YEAST WITH PSEUDOHYPHAE CUTANEOUS or SYSTEMIC
(normal host, or opportunistic)

Rarely found in individuals who OPPORTUNISTIC

are immunocompetent

The FDA has approved an

intravenous formulation of the
triazole antifungal posaconazole
(Noxafil), which is indicated for
the prophylaxis of invasive
Aspergillus and Candida
infections in severely
immunocompromised adults
who are at high risk of
developing these infections.

Aflatoxins contaminate peanuts,

grains, and rice
The disease is rapidly fatal OPPORTUNISTIC
The disease is rapidly fatal OPPORTUNISTIC

The taxonomic classification of

the Pneumocystis genus was
debated for some time. It was
initially mistaken for a
trypanosome and then later for a
protozoan. In the 1980s,
biochemical analysis of the
nucleic acid composition of
Pneumocystis rRNA and
mitochondrial DNA identified the
organism as a unicellular fungus
rather than a protozoan.
Subsequent genomic sequence
analysis of multiple genes
including elongation factor 3, a
component of fungi protein
synthesis not found in protozoa,