[MT 301] Medical Mycology

Sultan Kudarat State University Subcutaneous Mycoses

Subcutaneous Mycoses: Fungal ▪ The subcutaneous mycoses include a wide spectrum of fungal infections characterized by the development of lesions, usually
infections affecting the muscles, fascia and at sites of trauma where the organism is implanted in the tissue.
bone: ▪ The infections initially involve the deeper layers of the dermis, subcutaneous tissue, or bone. Most infections have a chronic and
insidious growth pattern, eventually extending into the epidermis, and are expressed clinically as lesions on the skin surface.
*Fascia: sheet or band of connective tissue
covering or binding together parts of the Several features are common about this group of infections, including the following:
body, for example, 1. The patient can usually associate some form of trauma occurring at the sites of infection (like splinter a thorn, the implantation
muscles or organs of other foreign bodies or a bite).
2. The infections occur on parts of the body that are most prone to be traumatized (like the feet, legs, hands and arms)
3. The etiologic agents are usually organism commonly found in soil or on decaying vegetation.
4. Several bacterial infections mimic the subcutaneous fungal infections. For this reason it is extremely important that the etiologic
agent be established. Since most bacterial infections can be managed with antibiotics.
5. Subcutaneous mycoses are difficult to treat and surgical intervention ( Excision or amputation) is frequently employed.

a. Sporotrichosis:
Causative agent Clinical Manifestations
▪ Sporothrix schenckii a. Fixed cutaneous sporotrichosis: Primary lesions develop at the site of implantation of the fungus, usually at more exposed sites
mainly the limbs, hands and fingers. Lesions often start out as a painless nodule which soon become palpable and ulcerate often
Description discharging a serous or purulent fluid. Importantly, lesions remain localised around the initial site of implantation and do not spread
o Sporotrichosis is primarily a along the lymphangitic channels. Isolates from these lesions usually grow well at 35C, but not at 37C.
chronic mycotic infection of the
b. Lymphocutaneous sporotrichosis: Primary lesions develop at the site of implantation of the fungus, but secondary lesions also
cutaneous or subcutaneous
appear along the lymphangitic channels, which follow the same indolent course as the primary lesion ie, they start out as painless
tissues and adjacent lymphatics
nodules which soon become palpable and ulcerate. No systemic symptoms are present. Isolates from these lesions usually grow
characterized by nodular lesions
well at both 35C and 37C.
which may suppurate and
ulcerate. Infections are caused c. Pulmonary sporotrichosis: This is a rare entity usually caused by the inhalation of conidia but cases of haematogenous
by the traumatic implantation of dissemination have been reported. Symptoms are nonspecific and include cough, sputum production, fever, weight loss and
the fungus into the skin, or very upper-lobe lesion. Haemoptysis may occur and it can be massive and fatal. The natural course of the lung lesion is gradual
rarely, by inhalation into the lungs. progression to death.
Secondary spread to articular
d. Osteoarticular sporotrichosis: Most patients also have cutaneous lesions and present with stiffness and pain in a large joint, usually
surfaces, bone and muscle is not
the knee, elbow, ankle or wrist. Osteomyelitis seldom occurs without arthritis; the lesions usually confined to the long bones near
infrequent, and the infection may
affected joints.
also occasionally involve the
central nervous system, lungs or e. Other rare forms of sporotrichoisis include endophthalmitis, chorioretinitis and meningitis.
genitourinary tract.

Laboratory Diagnosis
Clinical Material Direct Microscopy Culture Serology and Identification
A tissue biopsy is the best Tissue sections should be stained using PAS digest, Clinical specimens should be inoculated onto Serological tests are of limited value
specimen. Grocott's methenamine silver (GMS) or Gram primary isolation media, like Sabouraud's dextrose in the diagnosis of Sporotrichosis.
stain.Sporothrix schenckii is a dimorphic fungus and this agar and Brain heart infusion agar supplemented
is the typical yeast-like form seen in tissue. with 5% sheep blood. Identification: Hyphomycete
characterized by thermal
Interpretation: Look for small narrow base budding yeast Interpretation: A positive culture from a biopsy dimorphism and clusters of ovoid,
cells (2-5um). Note they are often present in very low should be considered significant. denticulate conidia produced
numbers and may be difficult to find. PAS and GMS sympodially on short conidiophores.
stains are essential.
Rqd2 ONTANILLAS, BSMT-3 Instructor: Mandy A. Delfin, RMT, AMT, MSMT
[MT 301] Medical Mycology
Sultan Kudarat State University Subcutaneous Mycoses
b. Chromoblastomycosis:
Causative agents Clinical Manifestations
o include various dematiaceous hyphomycetes associated ▪ Lesions of chromoblastomycosis are most often found on exposed parts of the body
with decaying vegetation or soil, especially Phialophora and usually start a small scaly papules or nodules which are painless but may be
verrucosa, Fonsecaea pedrosoi, F. compacta and itchy.
Cladophialophora carrionii
▪ Satellite lesions may gradually arise and as the disease develops rash-like areas
Description enlarge and become raised irregular plaques that are often scaly or verrucose. In
o A mycotic infection of the cutaneous and subcutaneous long standing infections, lesions may become tumorous and even cauliflower-like in
tissues characterised by the development in tissue of appearance. Other prominent features include epithelial hyperplasia, fibrosis and
dematiaceous (brown-pigmented), planate-dividing, microabscess formation in the epidermis.
rounded sclerotic bodies.
▪ Chromoblastomycosis must be distinguished from other cutaneous fungal infections
o Infections are caused by the traumatic implantation of fungal such as blastomycosis, lobomycosis, paracoccidioidomycosis and sporotrichosis. It
elements into the skin and are chronic, slowly progressive and may also mimic protothecosis, leishmaniasis, verrucose tuberculosis, certain leprous
localised. lesions and syphilis. Mycological and histopathological investigations are essential
to confirm the diagnosis.
o Tissue proliferation usually occurs around the area of
inoculation producing crusted, verrucose, wart-like lesions.
Worldwide distribution but more common in bare footed
populations living in tropical regions.

Laboratory Diagnosis
Clinical Material Direct Microscopy Culture Serology and Identification
Skin scrapings and/or (a) Skin scrapings should be examined using 10% Clinical specimens should be inoculated There are currently no
biopsy. KOH and Parker ink or calcofluor white mounts; (b) onto primary isolation media, like commercially available
Tissue sections should be stained using H&E, PAS Sabouraud's dextrose agar. serological procedures for the
digest, and Grocott's methenamine silver (GMS). diagnosis of
Interpretation: chromoblastomycosis.
Interpretation: The dematiaceous hyphomycetes involved
The presence in tissue of brown pigmented, are well recognised as environmental fungi, Identification:
planate-dividing, rounded sclerotic bodies from a therefore a positive culture from a non-sterile Culture characteristics and
patient with supporting clinical symptoms should specimen, such as sputum or skin, needs to microscopic morphology are
be considered significant. Remember direct be supported by clinical history and direct important, especially conidial
microscopy or histopathology does not offer a microscopic evidence in order to be morphology, the arrangement
specific identification of the causative agent. considered significant. Culture identification of conidia on the conidiogenous
Note: direct microscopy of tissue is necessary to is the only reliable means of distinguishing cell and the morphology of the
differentiate between chromoblastomycosis and these fungi. conidiogenous cell. Cellotape
phaeohyphomycosis where the tissue flag and/or slide culture
morphology of the causative organism is mycelial. preparations are
recommended.

Rqd2 ONTANILLAS, BSMT-3 Instructor: Mandy A. Delfin, RMT, AMT, MSMT

[MT 301] Medical Mycology
Sultan Kudarat State University Subcutaneous Mycoses
c. Phaeohyphomycosis:
Causative agent Clinical Manifestations
▪ The etiological agents include various Clinical forms of phaeohyphomycosis range from localized superficial infections of the stratum corneum (tinea nigra) to
dematiaceous hyphomycetes especially subcutaneous cysts (phaeomycotic cyst) to invasion of the brain.
species of Exophiala, Phialophora, Wangiella, Ideally, individual disease states involving an invasive fungal infection by a dematiaceous hyphomycete should be
Bipolaris, Exserohilum, Cladophialophora , designated by a specific description of the pathology and the causative fungal genus or species (where known); for example
Phaeoannellomyces, Aureobasidium, "pathology A" caused by "fungus X".
Cladosporium, Curvularia and Alternaria.
Ajello (1986) listed 71 species from 39 genera as a. Subcutaneous phaeohyphomycosis:
causative agents of phaeohyphomycosis o Subcutaneous infections occur worldwide, usually following the traumatic implantation of fungal elements from
contaminated soil, thorns or wood splinters. Exophiala jeanselmei and Wangiella dermatitidisare the most
Description common agents and cystic lesions occur most often in adults. Occasionally, overlying verrucous lesions are
o A mycotic infection of humans and lower formed, especially in the immunosuppressed patient.
animals caused by a number of dematiaceous
(brown-pigmented) fungi where the tissue b. Paranasal sinus phaeohyphomycosis:
morphology of the causative organism is o Sinusitis caused by dematiaceous fungi, especially species of Bipolaris, Exserohilum, Curvularia and Alternaria is
mycelial. increasingly being reported, especially in patients with a history of allergic rhinitis or immunosuppression.
o This separates it from other clinical types of
disease involving brown-pigmented fungi c. Cerebral phaeohyphomycosis:
where the tissue morphology of the organism is o Cerebral phaeohyphomycosis is a rare infection, occurring mostly in immunosuppressed patients following the
a grain (mycotic mycetoma) or sclerotic body inhalation of conidia. However, cerebral infections caused by Cladophialophora bantianahave been reported
(chromoblastomycosis). in a number of patients without any obvious predisposing factors. This fungus is neurotropic and dissemination
to sites other than the CNS is rare.

Laboratory Diagnosis
Clinical Material Direct Microscopy Culture Serology and Identification
Skin scrapings and/or a. Skin scrapings, sputum, bronchial washings and aspirates should be Clinical specimens should be prepared as There are currently no commercially
biopsy; sputum and examined using 10% KOH and Parker ink or calcofluor white mounts outlined in the chapter 2 and inoculated available serological procedures for
bronchial washings; b. Exudates and body fluids should be centrifuged and the sediment onto primary isolation media, like the diagnosis of any of the infections
cerebrospinal fluid, pleural examined using either 10% KOH and Parker ink or calcofluor white Sabouraud's dextrose agar. classified under the term
fluid and blood; tissue mounts phaeohyphomycosis.
biopsies from various c. Tissue sections should be stained using H&E, PAS digest, and Interpretation: The dematiaceous
visceral organs and Grocott's methenamine silver (GMS). hyphomycetes involved are well Identification: Culture characteristics
indwelling catheter tips. recognized as common environmental and microscopic morphology are
Interpretation: The presence of brown pigmented, branching septate airborne contaminants, therefore a positive important, especially conidial
hyphae in any specimen, from a patient with supporting clinical culture from a non-sterile specimen, such as morphology, the arrangement of
symptoms should be considered significant. Biopsy and evidence of sputum or skin, needs to be supported by conidia on the conidiogenous cell
tissue invasion is of particular importance. Remember direct direct microscopic evidence in order to be and the morphology of the
microscopy or histopathology does not offer a specific identification considered significant. A supporting clinical conidiogenous cell. Cellotape flag
of the causative agent. history in patients with appropriate and/or slide culture preparations are
predisposing conditions, is also helpful. recommended.
Note: direct microscopy of tissue is necessary to differentiate Culture identification is the only reliable
between chromoblastomycosis which is characterized by the means of distinguishing these fungi.
presence in tissue of brown pigmented, planate-dividing, rounded
sclerotic bodies and phaeohyphomycosis where the tissue
morphology of the causative organism is mycelial.

Rqd2 ONTANILLAS, BSMT-3 Instructor: Mandy A. Delfin, RMT, AMT, MSMT

[MT 301] Medical Mycology
Sultan Kudarat State University Subcutaneous Mycoses
d. Mycetoma:
Causative agents Clinical Manifestations
▪ Acremonium sp., Aspergillus nidulans, Madurella grisea, ▪ Mycetoma is a chronic, suppurative infection of the subcutaneous tissue and
Madurella mycetomatis, Scedosporium apiospermum contiguous bone. The clinical features are fairly uniform, regardless of the organism
involved.
Description
o A mycotic infection of humans and animals caused by a ▪ The feet are the most common site for infection and account for at least two-thirds of
number of different fungi and actinomycetes characterized cases. Other sites include the lower legs, hands, head, neck, chest, shoulder and arms.
by draining sinuses, granules and tumefaction.
▪ Most cases start out as a small hard painless nodule, which over time begins to soften
o The disease results from the traumatic implantation of the on the surface and ulcerate to discharge a viscous, purulent fluid containing grains.
aetiologic agent and usually involves the cutaneous and
subcutaneous tissue, fascia and bone of the foot or hand. ▪ The infection slowly spreads to adjacent tissue, including bone, often causing
considerable deformity. Sinuses continue to discharge serosanguinous fluid
o Sinuses discharge serosanguinous fluid containing the containing the granules, which vary in size, colour and degree of hardness,
granules which vary in size, colour and degree of hardness, depending on the aetiologic species. These grains are the hallmark of mycetoma.
depending on the aetiologic species, and are the hallmark
of mycetoma. World-wide distribution but most common in
bare-footed populations living in tropical or subtropical
regions.

Laboratory Diagnosis
Clinical Material Direct Microscopy Culture Serology and Identification
Tissue biopsy or excised sinus, Serosanguinous fluid containing the granules should be Clinical specimens should be
serosanguinous fluid containing examined using either 10% KOH and Parker ink or inoculated onto primary isolation
the granules which vary in size, calcofluor white mounts, and tissue sections should be media, like Sabouraud's dextrose
colour and degree of hardness, stained using H&E, PAS digest, and Grocott's agar.
depending on the aetiologic methenamine silver (GMS).
species.
Interpretation: The presence of white to yellow or black
pigmented grains, from a patient with supporting clinical
symptoms should be considered significant. Biopsy and
evidence of tissue invasion is of particular importance.
Remember direct microscopy or histopathology does not
offer a specific identification of the causative agent.

Rqd2 ONTANILLAS, BSMT-3 Instructor: Mandy A. Delfin, RMT, AMT, MSMT

[MT 301] Medical Mycology
Sultan Kudarat State University Subcutaneous Mycoses
e. Zygomycosis:
Description Clinical Manifestations
Zygomycosis in the debilitated patient is the most acute and fulminate fungal infection known. The disease typically involves the rhino-facial-
The term zygomycosis describes cranial area, lungs, gastrointestinal tract, skin, or less commonly other organ systems.
in the broadest sense any It is often associated with acidotic diabetes, starvation, severe burns, intravenous drug abuse, and other diseases such as leukemia and
infection due to a member of the lymphoma, immunosuppressive therapy, or the use of cytotoxins and corticosteroids, therapy with desferrioxamine (an iron chelating agent for
Zygomycetes. These are primitive, the treatment of iron overload) and other major trauma.
fast growing, terrestrial, largely The infecting fungi have a predilection for invading vessels of the arterial system, causing embolization and subsequent necrosis of surrounding
saprophytic fungi with a tissue. A rapid diagnosis is extremely important if management and therapy are to be successful.
cosmopolitan distribution. To a. Rhinocerebral zygomycosis: Predisposing factors include uncontrolled diabetes mellitus or acidosis, steroid induced hyperglycemia,
date, some 665 species have especially in patients with leukemia and lymphoma, renal transplant and concomitant treatment with corticosteroids and azathioprine.
been described although Infections usually begin in the paranasal sinuses following the inhalation of sporangiospores and may involve the orbit, palate, face,
infections in humans and animals nose or brain.
are generally rare. b. Pulmonary zygomycosis: Predisposing conditions include haematological malignancies, lymphoma and leukemia, or severe
neutropenia, treatment with cytotoxins and corticosteroids, desferrioxamine therapy; diabetes and organ transplantation. Infections
Medically important orders and result by inhalation of sporangiospores into the bronchioles and alveoli, leading to pulmonary infraction and necrosis with cavitation.
genera include: c. Gastrointestinal zygomycosis: A rare entity, usually associated with severe malnutrition, particularly in children, and gastrointestinal
diseases which disrupt the integrity of the mucosa. Primary infections probable result following the ingestion of fungal elements and
a. Mucorales, causing usually present as necrotic ulcers.
subcutaneous and d. Cutaneous zygomycosis: Local traumatic implantation of fungal elements through the skin, especially in patients with extensive burns,
systemic zygomycosis diabetes or steroid induced hyperglycemia and trauma. Lesions vary considerably in morphology but include plaques, pustules,
(Mucormycosis) - ulcerations, deep abscesses and ragged necrotic patches.
Rhizopus, Absidia, e. Disseminated zygomycosis: May originate from any of the above, especially in severely debilitated patients with haematological
Rhizomucor, Mucor, malignancies, burns, diabetes or uraemia.
Cunninghamella, f. Central Nervous System alone: Intravenous drug abuse. Traumatic implantation leading to brain abscess.
Saksenaea, g. Infections caused by entomophthoraceous fungi:
Apophysomyces, o Zygomycosis due to entomophthoraceous fungi is caused by species of two genera, Basidiobolus and Conidiobolus. Infections
Cokeromyces and are chronic, slowly progressive and generally restricted to the subcutaneous tissue in otherwise healthy individuals.
Mortierella. o Other characteristics that separate these infections from those caused by mucoraceous fungi are a lack of vascular invasion or
infarction and the production of a prolific chronic inflammatory response, often with eosinophils and Splendore-Hoeppli
phenomena around the hyphae.
b. Entomophthorales, • Zygomycosis caused by B. ranarum
causing subcutaneous - Is a chronic inflammatory or granulomatous disease generally restricted to the subcutaneous tissue of the limbs, chest,
zygomycosis back or buttocks, primarily occurring in children and with a predominance in males.
(Entomophthoromycosis) - Initially, lesions appear as subcutaneous nodules which develop into massive, firm, indurated, painless swellings which are
- Conidiobolus and freely movable over the underlying muscle, but are attached to the skin which may become hyperpigmented but not
Basidiobolus. ulcerated.
• Zygomycosis caused by Conidiobolus sp.
- Is a chronic inflammatory or granulomatous disease that is typically restricted to the nasal submucosa and characterised
by polyps or palpable restricted subcutaneous masses.
- Infections usually begin with unilateral involvement of the nasal mucosa. Symptoms include nasal obstruction, drainage
and sinus pain. Subcutaneous nodules develop in the nasal and perinasal regions and progressive generalised facial
swelling may occur.
- Infections also occur in horses usually producing extensive nasal polyps and other animals. Conidiobolus coronatus is also
a recognised pathogen of termites, other insects and spiders.

Rqd2 ONTANILLAS, BSMT-3 Instructor: Mandy A. Delfin, RMT, AMT, MSMT

[MT 301] Medical Mycology
Sultan Kudarat State University Subcutaneous Mycoses
Laboratory Diagnosis
Clinical Material Direct Microscopy Culture Serology and Identification
Skin scrapings from cutaneous lesions; a. Scrapings, sputum and Inoculate specimens onto primary There are currently no commercially available
sputum and needle biopsies from exudates should be examined isolation media, like Sabouraud's serological procedures for the diagnosis of
pulmonary lesions; nasal discharges, using 10% KOH & Parker ink or dextrose agar. Most zygomycetes zygomycosis. Although some laboratories have
scrapings and aspirates from sinuses in Calcofluor mounts; and are sensitive to cycloheximide developed ELISA tests for the detection of antibodies
patients with rhinocerebral lesions; (actidione) and this agent should to Zygomycetes.
and biopsy tissue from patients with b. Tissue sections should be not be used in culture media. Look
gastrointestinal and/or disseminated stained with H&E and GMS. for fast growing, white to grey or Identification:
disease. Examine specimens for broad, brownish, downy colonies. Zygomycetes are usually fast growing fungi
infrequently septate, characterised by primitive coenocytic (mostly
Warning: thinwalled hyphae, which Interpretation: aseptate) hyphae. Asexual spores include
Zygomycetous fungi have primitive often show focal bulbous Despite being recognised as chlamydoconidia, conidia and sporangiospores
coenocytic hyphae that will often be dilations and irregular common laboratory contaminants, contained in sporangia borne on simple or
damaged and become non-viable branching. zygomycetes are infrequently branched sporangiophores.
during the biopsy procedure isolated in the clinical laboratory.
(especially scrapings and aspirates), Interpretation: As a rule, a Therefore, in patients with any of Sexual reproduction is isogamous producing a thick-
or by the chopping up or tissue positive direct microscopy, the above predisposing conditions, walled sexual resting spore called a zygospore.
grinding process in the laboratory. especially from a sterile site, especially diabetes or
should be considered immunosuppression and/or clinical Most isolates are heterothallic i.e. zygospores are
This is why zygomycetous fungi that significant, even if the symptoms, the isolation of any absent, therefore identification is based primarily on
are clearly visible in direct microscopic laboratory is unable to culture zygomycete fungus should be sporangial morphology.
or histopathological mounts are often the fungus. regarded as potentially significant.
difficult to grow in culture from clinical Obviously, in patients without This includes the arrangement and number of
specimens. If on clinical and/or predisposing conditions, the sporangiospores, shape, colour, presence or
radiological evidence zygomycosis is isolation of a zygomycete from a absence of columellae and apophyses, as well as
suspected then try to avoid excessive non-sterile site, such as skin or the arrangement of the sporangiophores and the
tissue damage when collecting the sputum, must be interpreted with presence or absence of rhizoids.
specimen and in the laboratory gently caution, especially in the absence
tease the tissue apart and inoculate it of direct microscopy. Growth temperature studies (25,37,45C) can also be
directly onto the isolation media. helpful. Tease mounts are best, use a drop of 95%
alcohol as a wetting agent to reduce air bubbles.
If you are not sure hold the specimen Laboratory identification of some zygomycetous
in saline or BHI broth until the results of fungi, especially Apophysomyces elegans and
the direct microscopy or frozen Saksenaea vasiformis may be difficult or delayed
histology sections are known. If because of the mould's failure to sporulate on the
zygomycetous hyphae are present primary isolation media or on subsequent subculture
proceed as above, otherwise onto potato dextrose agar.
homogenised the specimen and plate
out. Sporulation may be stimulated by the use of nutrient
deficient media, like cornmeal-glucose-sucrose-
yeast extract agar, Czapek Dox agar, or by using the
agar block method on water agar.

Rqd2 ONTANILLAS, BSMT-3 Instructor: Mandy A. Delfin, RMT, AMT, MSMT

[MT 301] Medical Mycology
Sultan Kudarat State University Subcutaneous Mycoses
f. Lobomycosis:
Causative agent Clinical Manifestations
▪ Loboa loboi ▪ The initial infection is thought to be caused by traumatic implantation such as an arthropod
sting, snake bite, sting-ray sting, or wound acquired while cutting vegetation. The lesions
Description begin as small, hard nodules resembling keloids and may spread slowly in the dermis and
o Lobomycosis is a chronic, localised, subepidermal continue to develop over a period of many years. Older lesions become verrucoid and may
infection characterised by the presence of keloidal, ulcerate.
verrucoid, nodular lesions or sometimes by
vegetating crusty plaques and tumours. The lesions ▪ The disease may be transfered to other areas of of the skin by further trauma or
contain masses of spheroidal, yeast-like organisms autoinoculation. Thus the areas of involvement may become quite extensive.
tentatively referred to as Loboa loboi. There is no
systemic spread. ▪ Lesions are usually found on the arms, legs, face or ears.

o The disease has been found in humans and dolphins ▪ 90% of cases are men, mostly in farmers and other high risk groups exposed to various harsh
and is restricted to the Amazon Valley in Brasil. conditions as well as aquatic habitats.

Laboratory Diagnosis
Clinical Material Direct Microscopy Culture Serology and Identification
Tissue sample obtained by a. Tissue can be macerated and The aetiologic agent known as There are currently no serological tests
curettage or surgical biopsy. mounted in 10% KOH and Parker ink or "Loboa loboi" remains to be available.
calcofluor white mounts cultured.
b. Tissue sections should be stained using Identification: Clinical features,
PAS digest, Grocott's methenamine geographic location and microscopic
silver (GMS) or Gram stains. morphology are important.

Interpretation: The presence of chains of darkly

pigmented, spheroidal, yeast-like organisms
tentatively referred to, as Loboa loboi is typical
for lobomycosis.

Rqd2 ONTANILLAS, BSMT-3 Instructor: Mandy A. Delfin, RMT, AMT, MSMT