MEDICAL MYCOLOGY

Arthur F. Di Salvo, MD
Reno, Nevada
 Medical Mycology Outline
HOUR SUBJECT

1. Introduction, Actinomycetes
2. Yeasts, Dermatophytes
3. Filamentous Fungi, Dimorphic Fungi
4. Dimorphic Fungi
5. Opportunistic Fungi
 OBJECTIVES
– To impart sufficient basic science of the
medically important fungi to assist you in
diagnosing mycotic diseases.
– To impart sufficient clinical knowledge
to raise your index of suspicion for
mycotic diseases.
•What is SAID is not HEARD

•What is HEARD is not UNDERSTOOD

•What is UNDERSTOOD is not RETAINED

•What is RETAINED is not IMPLEMENTED

• ASK QUESTIONS ANYTIME
INTRODUCTION
Fairy Ring
Mushrooms
What is Mycology?
 Mycology is the study of
• Beer
• Wine
• Bread
• Cheese
• Gourmet mushrooms
• Environmental toxins
• Biodegradation
• Disease
 BIOREMEDIATION

• Oil spills
• Cyanide in mining operations
• Dioxins and pesticides
• Produce organic acids, sugars
• Other commercial products
A. Classification
 What is a Fungus ?

• Eukaryotic – a true nucleus

• Do not contain chlorophyll
• Have cell walls
• Produce filamentous structures
• Produce spores
 Species of Fungi

• 100,000 – 200,000 species

• About 300 pathogenic for man

 Kingdom Fungi
Eukaryocytes

•Ascomycota
•Basidiomycota
•Zygomycota
•Mitosporic Fungi
(Fungi Imperfecti)
KINGDOM CHARACTERISTIC EXAMPLE

     

Monera Prokaryocyte Bacteria

Actinomyces

Protista Eukaryocyte Protozoa

Fungi Eukaryocyte * Fungi

Plants Eukaryocyte Plants

Moss

Animals Eukaryocyte * Arthropods

Mammals

Man
KINGDOM CHARACTERISTIC EXAMPLE

     

Monera Prokaryocyte Bacteria

Actinomyces

Protista Eukaryocyte Protozoa

Fungi Eukaryocyte * Fungi

Plants Eukaryocyte Plants

Moss

Animals Eukaryocyte * Arthropods

Mammals

Man
SIZE COMPARISON OF PATHOGENS

Cocci 0.8 u
Bacilli 4-6 u
Spirochetes 8 - 10 u
Viruses 0.08 u
Protozoa 15 u
Nematodes 10 mm
Fungi 10 – 15 u
 Actinomyces
(True Bacteria)
• Tradition
• Clinical infection resembles mycoses
• Actinomyces grow on mycotic media
• Actinomyces grow slowly (24-48 h)
• Gross colonies resemble fungi
– (rough,heaped, short aerial filaments)
• Resemble mycelia microscopically, with branched
mycelia in tissue and smears.
HANDOUT

Page 2
What is Medical Mycology ?
 MYCOTIC DISEASES
(Four Types)
1. Hypersensitivity
– Allergy
2. Mycotoxicosis
– Production of toxin
3. Mycetismus (mushroom poisoning)
– Pre-formed toxin
4. Infection
 Hypersensitivity

• FARMER’S LUNG – Moldy hay

• MALT WORKER’S DISEASE – Moldy barley
• CHEESE WASHER’S LUNG – Moldy cheese
• WOOD TRIMMER’S DISEASE – Moldy wood
 PATHOGENIC FUNGI
• NORMAL HOST

• Systemic pathogens - 25 species

• Cutaneous pathogens - 33 species
• Subcutaneous pathogens - 10 species

• IMMUNOCOMPROMISED HOST
Opportunistic fungi - 300 species
 PARASITIC STATE
1. Increased metabolic state
2. Modified metabolic pathways
3. Modified cell wall structure
– Carbohydrate content
– Lipid structure
– RNA aggregates
 PATHOGENICITY OF FUNGI
1. Thermotolerance

2. Ability to survive in tissue environment

3. Ability to withstand host defenses

 REVIVED INTEREST IN MYCOLOGY

1. Increased frequency of mycotic diseases

2. Increased awareness by physicians
3. Better trained laboratory personnel
4. More invasive procedures used on patients
5. Increased use of immunosuppressive drugs
6. Increase in immunosuppressive disease
7. Better laboratory diagnostic tools
B. MORPHOLOGY
 MORPHOLGY
• Yeasts
• Hyphae (filamentous fungi, mycelium)
– Septate
– Coenocytic (non-septate)
• Dimorphic
– Yeast
– Mycelium
Dimorphic Fungi
• Yeast Form
• Parasitic form
• Tissue form
• Cultured at 37 C
• Mycelial Form
• Saprophytic form
• Cultured at 25 C
 SPORES
• SEXUAL
• ASEXUAL
– Arthrospore
– Blastospore
– Chamydospore
– Conidia
• Microconidia
• Macroconidia
By their fruits ye shall know them

Mathew 7:20
EPIDEMIOLOGY

PAGE 3
C. EPIDEMIOLOGY
MOST MYCOTIC AGENTS

ARE SOIL SAPRPHYTES

 ECOLOGICAL ASSOCIATION
PATHOGEN HUMAN SOIL
_________________________________________
Blastomyces dermatitidis 1898 1964
Cryptococcus neoformans 1894 1951
Coccidioides immitis 1900 1932
Histoplasma capsulatum 1934 1949
Mycotic Diseases Are NOT
Contagious
ESTABLISHMENT OF INFECTION WITH A MYCOTIC
AGENT DEPENDS ON

1. Inoculum size

2. Resistance of the host

 THE CLINICIAN MUST DISTINGUISH
BETWEEN:

• COLONIZATION

• FUNGEMIA

• INFECTION
 PORTAL OF ENTRY
MOUTH
RESPIRATORY TRACT
EYE
•SKIN
•HAIR
•NAILS
•RESPIRATORY TRACT
•GASTROINTESTINAL SKIN
TRACT
•URINARY TRACT

UROGENITAL TRACT

ANUS
 COLONIZATION
MOUTH
RESPIRATORY TRACT
EYE

Multiplication of
an organism at a
given site
without harm to SKIN

the host

UROGENITAL TRACT

ANUS
 INFECTION
MOUTH
RESPIRATORY TRACT
EYE

Invasion and
multiplication of
organisms in
body tissue SKIN

resulting in
local cellular
injury.
UROGENITAL TRACT

ANUS
GEOGRAPHIC DISTRIBUTION

The present ease and frequency of world-wide

travel make it more likely that physicians in the
United States will be confronted with a variety
of unfamiliar mycoses acquired in distant parts
of the country or of the world.
 Endemic Mycoses

Those fungus infections with a limited

geographic distribution. They are all
caused by dimorphic fungi
 PATIENT HISTORY

• Medical
• Travel
• Occupation
• Avocation
D. DIAGNOSIS
 Diagnosis

1. Wet Mount
2. Skin test
3. Serology
4. Fluorescent antibody
5. Biopsy and histopathology
6. Culture
7. DNA probes
 Diagnosis

1. Wet Mount
2. Skin test
3. Serology
4. Fluorescent antibody
5. Biopsy and histopathology
6. Culture
7. DNA probes
 DIRECT MICROSCOPIC
OBSERVATION

• 10 % KOH

• Gentle Heat
KOH Wet Mount
 Diagnosis

1. Wet Mount
2. Skin test
3. Serology
4. Fluorescent antibody
5. Biopsy and histopathology
6. Culture
7. DNA probes
 SKIN TESTING
(DERMAL HYPERSENSTIVITY)

Use is limited to :

– Determine cellular defense mechanisms

– Epidemiologic studies
 Diagnosis

1. Wet Mount
2. Skin test
3. Serology
4. Fluorescent antibody
5. Biopsy and histopathology
6. Culture
7. DNA probes
FUNGI ARE POOR ANTIGENS
 FUNGAL SEROLOGY
ANTIBODIES
• Latex Agglutination IgM

• Immunodiffusion IgG

• Complement Fixation IgG

Most serological tests for fungi measure
antibody. Newer tests to measure
antigen are now being developed

ANTIGEN DETECTION PRESENTLY

AVAILABLE
 Cryptococcosis
 Histoplasmosis
 Aspergillosis
 Diagnosis

1. Wet Mount
2. Skin test
3. Serology
4. Fluorescent antibody
5. Biopsy and histopathology
6. Culture
7. DNA probes
 DIRECT FLUORESCENT ANTIBODY
CAN BE APPLIED TO

1. HISTOLOGIC SECTIONS
2. CULTURE

• Viable organisms
• Non-viable organisms
 Diagnosis

1. Wet Mount
2. Skin test
3. Serology
4. Fluorescent antibody
5. Biopsy and histopathology
6. Culture
7. DNA probe
 INFLAMMATORY REACTION
• Normal host
– Pyogenic
– Granulomatous
• Immunodeficient host
– Necrosis
Polymorphic Nuclear Leukocytes
Giant Cell
GMS
 Diagnosis

1. Wet Mount
2. Skin test
3. Serology
4. Fluorescent antibody
5. Biopsy and histopathology
6. Culture
7. DNA probes
 ISOLATION MEDIA

SABOURAUD DEXTROSE AGAR

(pH ~ 5.6)
•Plain
•With antibiotics
•With cycloheximide
 INCUBATION TEMPERATURE

• 37 C - Body temperature

• 25 C - Room temperature
 Diagnosis

1. Wet Mount
2. Skin test
3. Serology
4. Fluorescent antibody
5. Biopsy and histopathology
6. Culture
7. DNA probes
 DNA Probes

• Rapid (1-2 Hours)

• Species specific
• Expensive
E. TREATMENT
 THERAPY

Because they are eukaryotic, fungi are

biochemically similar to the human host.
Therefore it is difficult to develop
chemotherapeutic agents that will destroy the
invading fungus without harming the patient.
 A BASIC TENET OF PATHOLGY :

A CAUSE OF IRREVERSIBLE CELL INJURY IS

CELL MEMBRANE DAMAGE.
 IN FUNGAL THERAPY

We attempt to induce cell injury by causing the

cell membrane of the fungus to become
permeable.
 PROBLEM

Finding an agent that will selectively injure fungal

cell walls without damaging the host cell.
 ALL EUKARYOTIC CELLS
CONTAIN STEROLS

•Mammalian cells – cholesterol

•Fungal cells - ergosterol
 Ergosterol Synthesis
Acetyl-CoA
Acetoacetyl-CoA
HMG-CoA
Mevalonic Acid
Squalene
Allylamines
Squalene-2,3-Epoxide
Lanosterol
Azoles
Morpholines
Polyenes Ergosterol
JB
 PRIMARY ANTI-FUNGAL
AGENTS
1. Polyene derivatives
– Amphotericin B
– Nystatin
2. Azoles
– Ketoconazole
– Fluconazole
– Itraconazole
– Voriconazole
– Posaconazole
 AMPHOTERICIN B
Mechanism of Action
• Amphotericin B binds to sterols
• Ergosterol is a constituent of the fungal cell wall
• AMB has a greater avidity for ergosterol than for
the cholesterol in the human cell wall
• Binding to the fungal cell wall alters the
permeability and the intracellular contents leak
 AMPHOTERICIN B
Disadvantages
• Intravenous administration
• Thrombophlebitis
• Nephrotoxic
• Fever
• Chills
• Anemia
• Long term administration
 Azoles

There are a few rare serious side effects

from Itraconazole and Fluconazole
 PRIMARY ANTI-FUNGAL
AGENTS
3. Griseofulvin
4. 5-fluorocytosine (5-FC)
5. Allylamines
-Terbinafine (Lamasil)
6. Echinocandins
- Caspofungin
 Griseofulvin

A slow acting drug used for skin and nail

infections. It accumulates in the stratum
corneum and prevent hyphal penetration
through these layers
5-fluorocytosine
(5-FC)
Interferes With RNA Synthesis
 MECHANISMS OF ACTION
• Polyenes • Ergosterol in cell
membrane
• Azoles • Interfere with ergosterol
synthesis
• Griseofulvin • Forms a barrier to fungal
growth

• 5 - FC
• Inhibits RNA synthesis
F. Clinical Classification of Mycoses

•Cutaneous
•Subcutaneous
•Systemic
•Opportunistic
Cutaneous Mycoses

Skin, hair and nails

Rarely invade deeper tissue

Dermatophytes
 Subcutaneous Mycoses

• Confined to subcutaneous tissue and rarely spread

systemically. The causative agents are soil
organisms introduced into the extremities by
trauma
 Systemic Mycoses

• Involve skin and deep viscera

• May become widely disseminated

• Predilection for specific organs

 OPPORTUNISTIC FUNGI

Ubiquitous saprophytes and occasional

pathogens that invade the tissues of those
patients who have:
• Predisposing diseases:
Diabetes, cancer, leukemia, etc.
• Predisposing conditions:
Agammaglobulinemia, steroid or antibiotic
therapy.
Medical Mycology Iceberg
THE ESSENTIAL ELEMENT OF
DIAGNOSIS IS:

A HIGH INDEX OF SUSPICION !

 End of
Introduction