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Home , Endothrix, Hortaea werneckii, Lacazia, Piedraia hortae, Rhinosporidiosis

boards’ fodder Medical Mycology By Adriana Schmidt, MD, and Natalie M. Curcio, MD, MPH. (Updated July 2015*)

SUPERFICIAL ORGANISM CLINICAL HISTO/KOH TREATMENT MYCOSES* Pityriasis Malessezia furfur Hypo- or hyper-pigmented Spaghetti & meatballs: Antifungal shampoos and/or versicolor macules short hyphae + PO therapy (formerly Brown-black non-scaly Branching septate hyphae Topical imidazoles or palmaris Phaeoannellomyces werneckii) macules + budding yeast allylamines Black hortae Hard firm black Dark hyphae around concretions acrospores Cut off, PO , ovoides or inkin Soft loose white Blastoconidia, imidazoles, or triazoles (formely beigelii) concretions arthroconidia Fluorescent small KOH: spores on outside spore ectothrix: M. audouinii of the hair shaft; “Cats And Dogs M. distortum Wood’s lamp --> yellow Sometimes Fight T. schoenleinii fluorescence & Growl” M. ferrugineum+/- gypseum

Large spore spp. (T. tonsurans in North America; T. violaceum in KOH: spores within hair Topical antifungals; PO Europe, Asia, parts of Africa). shaft antifungals for T. manuum, T. rubrum > T. mentag. Majocchi’s granuloma: T. rubrum capitis, unguium

T. pedis Moccasin: T. rubrum, E. floccosum. Interdigital/vesicular: T. mentag

T. unguium Distal lateral, proximal and proximal white subungual: T. rubrum. White superficial: T. mentag. HIV: T. rubrum

SUBQ MYCOSES** ORGANISM TRANSMISSION CLINICAL HISTO/KOH TREATMENT Inoculation SubQ nodules; “Cigar bodies” or , KI, Inhalation lymphatic spread round yeast amphotericin B

Mycetoma Eumycotic: Penetrating wound in Triad: tumefaction, Grains + Eumycotic: excision, Pseudoallescheria foot (70%) > hand, draining sinuses, thick hyphae itraconazole boydii thorax, scalp grains (aggragates of (eumycotic) & Actino: trimetha/sulfa Actinomycotic: organisms) thin filaments Nocardia and (actinomycotic) Actinomadura Chromoblasto- Fonsacaea Direct inoculation to Verrucous or Pigmented “copper Excision, Cryotherapy, Pedrosoi, foot/LE; farmers granulomatous pennies” (medlar Itraconazole +/- flucytosine, (verrucous Cladophialophora plaque or or sclerotic bodies) CO2 laser Adriana N. Schmidt, dermatitis) carrionii (> 90%) nodule w/ central clearing; MD, Division of SCC in chronic Dermatology, loboi (formerly Water, soil, dolphins; Painless keloids, Thick-walled Excision (antifungals Vanderbilt (keloidal Loboa loboi) Brazil, Caribbean nodules, verrucous spherical ineffective) University Medical ) lesions on face/UE, ear organisms in “chain of coins”, Center Nashville, TN. not culturable

DIMORPHIC Fungi ORGANISM TRANSMISSION CLINICAL HISTO/KOH TREATMENT H.capsulatum var. Inhalation of spores 1° pulmonary: Tiny yeast forms Itraconazole (Darling’s capsulatum (US) from soil >>> 1° pneumonitis  within cytoplasm of Ampho B for severe Disease) inoc. arthritis & E.N macrophages; no in 10%; rare capsule skin lesions with dissemination Blastomycosis Blastomyces Inhalation of spores Well-demarcated Broad-based, Itraconazole Ampho B (Gilchrist’s dermatitidis from soil, and papules/pustules/ budding yeast Disease) primary cutaneous plaques (Gilchrist’s) Natalie M. Curcio, DIMORPHIC ORGANISM TRANSMISSION CLINICAL HISTO/KOH TREATMENT MD, MPH, Division FUNGI** of Dermatology, Paracoccidio- Paracoccidioides Inhalation of Systemic or “Mariner’s wheel” Itraconazole Vanderbilt University mycosis (S. brasiliensis spores from soil; 1° nasal/oral Ketaconazole Medical Center American Male agricultural mucosal ulcers or Ampho B Nashville, TN. Blastomycosis) workers verrucous Coccidiomycosis Inhalation of Facial pink Spherules Itraconazole; (San Joaquin immitis spores from soil papules, verrucous containing Ampho B or Valley Fever) nodules or SQ endospores Fluconazole abscesses; E.N. (meningitis) irectionsin D­Residency p. 1 • Fall 2008 boards’ fodder Medical Mycology By Adriana Schmidt, MD, and Natalie M. Curcio, MD, MPH. (Updated July 2015*)

OPPORTUNISTIC ORGANISM TRANSMISSION CLINICAL HISTO/KOH TREATMENT Cryptococcus C. neoformans var. Inhalation of spores Head and neck: Mucinous, encapsulated Fluconazole neoformans and or 1° cutaneous,↑ ulceration, cellulitis, yeast Ampho B C. gatti disseminated dz in molluscum-like +/- flucytosine (HIV) AIDS Penicilliosis Penicillium marneffei Inhalation of spores Molluscum-like skin Oval yeast w/cross walls; Itraconazole (dimorphic) from bamboo rats lesions parasitized macrophages Ampho B Excision

Fusariosis sp. Burn patients Septate hyphae Ampho B + 5FC Neutropenia 45° branching; “banana Voriconazole Trauma shaped macroconidia”

Aspergillosis 1° cutan.: A. flavus; Burn patients IV catheter, necrotic Septate hyphae 45° w/ Ampho B Disseminated: Transplant/GVHD nodules phialides + connidia in Voriconazole A. fumigatus Aflatoxins chains; Splendore-Hoeppli Itraconazole (nail Neutropenia phenomenon disease) Rhizopus Diabetes Ulceration, cellulitis, Wide angle 45-90° Excision Mucor DKA/burns and necrotic branching non- Ampho B Absidia Neutropenia abscesses; spetate broad Transplant sinuses, unilateral hyphae; Rhizopus  Malnutrition facial edema sporangia Phaeohypho- Alternaria Invasive disease SubQ cysts, Dematiaceous Excision mycosis in immunocom- ulcerated plaques, (black or pigmented) Itraconazole Phialophora promised; hemorrhagic dark yeast with Curvularia Cutaneous dz in pustules, necrotic pseudohypae-like Bipolaris immunocompetent papulonodules elements; Alternaria; hand grenade; Fontana-Masson + Rhinosporidium Direct inoculation Wart-like in nasal BIG raspberry-like Excision seeberi [protozoa] mucosa, eye, mouth spherules Dapsone, Ampho B injection

Protothecosis Prototheca Direct inoculation Various skin, Morula 8-20 µm (sphere of Ampho B wicherhamii after trauma Olecranon bursitis endospores) like Excision [Algae] “soccer ball”

*SUPERFICIAL MYCOSES= invade S. corneum, hair, nails **SUBCUTANEOUS MYCOSES= deeper penetration into dermis or subq. usually after trauma (inoculation) > inhalation. ***DIMORPHIC FUNGI= in nature and yeast in living tissue.

Abbreviations: WW: worldwide Vori: Voriconazole Top.: topical KI: potassium iodide

*Reviewed and updated July 2015 by: Alina Goldenberg, MD, Emily deGolian, MD, and Sharon Jacob, MD.

irectionsin www.aad.org/DIR Fall 2008 • p. 2 D­Residency