NNAAMMEE RREESSEERRVVOOIIRR MMOORRPPHHOOLLOOGGYY CCLLIINNIICCAALSSYY NNDDRROOMMEE TTRREEAATTMMEENNTT DDIIAAGGNNOOSSIISS NNOOTTEESS AANNAATTOOMMIICLLOO CCAATTIIOONN furfur NN aturally found on the skin s urfaces of “Spaghetti and meat balls” Tinea/Pityriasis versicolor - a common, benign, Dandruff shampoo (containing Potassium hydroxide (KOH) prep: reveals short, SUPERFICIAL (SKIN) AN-AN AN-AN many animals, including humans. Dimorphic, lipophilic fungi superficial cutaneous fungal infection usually selenium sulfide) curved, unbranched hyphae with spherical AP-AP 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, 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.acids. DDeeppeennddiinngoon tthh eppaa rrttiiccuullaarsspp eecciieess Topical imidazole KKOOHH:bbrr aanncchheedhhyy pphhaaee Secretes the enzyme keratinase, CUTANEOUS (body): “ringworm” Oral griseofuivin is used for tinea Wood’s lamp: ceratin species of which digests keratin (groin): “jock itch” unguium and will fluoresce under ultraviolet light Microsporum Soil (geophilic) Tinea pedis (feet): “athlete’s foot” Oral A fungal culture, which is often used as anan For atypical presentations of Trichopyton Animals (zoophilic) Tinea capitis (scalp) adjunct to KOH for diagnosis, is more specific tinea corporis, further floccosum Human (anthropophilic) Tinea unguium (nail): than KOH for detecting a 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 areare 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 FFoouunndoo nrr oossett hhoorrnnss SSuuppppuurraattiinngss uubbccuuttaanneeoouusnn oodduulleestt hhaatpp rrooggrreessss Dimorphic Primary pulmonary infection SUBCUTANEOUS proximally along lymphatic channels Fluconazole Culture at 25ºC will grow branching hyphae (pulmonary ) 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 sit ee Osteoarticular sporotrichosis is requires the isolation ofS schenckii in aa in caused by direct inoculation or specimen culture from a normally s terile body hematogenous seeding. site.site. The organism can be recovered with fungal In rare cases, disseminated SS 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).(CSF). disseminated cutaneous lesions and involvement of multiple visceral organs; this occurs most commonly in persons with AIDS.

Coccidioides immitis Desert areas of the s outhwestern 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 25ºC25ºC 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 Mississippi valley Dimorphic:: I Ittrraaccoonnaazzoollee LLuunngbb iiooppssyy CCaanss uurrvviivveiinn ttrraacceelllluullaarrllyww iitthhiinn SYSTEMIC macrophages PresPresent in bibiin rd aard nd baband t drdrt oppingoppingss MyceMycelial forms with sporespores atats A sAsyymmppttoommaattiic ((iin mmoosst ppeerrs osonnss)) A mAmpphhoot eterriicciin B ((iinn Silver stain specimen 2525ooCC immunocompromised patients Respiratory transmission Yeast forms at 37ooCC Pneumonia: lessions calcify, which can be seen on Culture on Sabouraud’s agar will reveal hyphae WITHIN MACROPHAGES chest X-ray (may look similar to PTB) at 2525at ooC and yeast at 37ooCC 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: I tItrra caco nona zazo lolee B iBio popsys yofo fa fafffeec tcteed t itis sssu eue: l ulungn gb ibio pops ysy, s kski nin BROAD-BASED BUD SYSTEMIC biopsy, etc. Mycelial forms with spores at AAssyymmppttoommaattiic(( uunnccoommmmoonn)) KKeettooccoonnaazzoollee SSiillvveerss ttaaiinss ppeecciimmeenn 2525ooCC Yeast forms at 37ooCC PPnneeuummoonniiaa: ll: ees isioon rrn aarreelly ccy aallcciiffiieess A mAmpphhoot eterriicciin BBn Culture on Sabouraud’s agar Dessiminated (most common): present with weightweight Serology loss, night sweats, lung involvement and skin ulcers

CCuuttaanneeuuooss:ss kkiinuu llcceerr SSkkiintt eesst((tt eesstffoo ree xxppoossuurreoo nnllyy)) 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 sputumsputum 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,fever, shortness of breath, tachypnea, hypoxemia, and finally hemodynamic collapse PPiiggeeoonddrr ooppppiinnggss Polysaccharide capsule Cryptococcus AAmmpphhootteerriicciinBaa nn dfflluu ccyyttoossiinnee India-ink stain of cerebrospinal fluid (CSF): Most cases occur in SYSTEMIC (is superior to amphotericin B observe encapsulated yeast immunocompromised person YYeeaasstff oorrmoo nnlly(( NNootdd iimmoorrpphhiicc)) SSuubbaaccuutteoo rcc hhrroonniicmm eenniinnggiittiiss alone)alone) CCrryyppttooccooccccaalaa nnttiiggeentt eesstoo fCC SSFF:dd eetteeccttss polysaccharide antigens Pneumonia: usually self-limited and asymptomatic FFuunnggaalcc uullttuurree MMCCCoo fmm eenniinnggooeenncceepphhaalliittiisii nn HIVHIV Skin lesions: look like acne YEAST WITH A HALO Normal flora of the skin, mouth and PPsseeuuddoohhyypphhaaeaa nndyy eeaasstt in a normal host TThhecc hhooiicceoo faa nnttiiffuunnggaalaa ggeenntt KOH stain of specimen YEAST WITH PSEUDOHYPHAE CUTANEOUS or SYSTEMIC gastrointrointestinal tract OOrraaltthh rruusshh depends on the area involved SSiillvveerssttaa iinoof sspp eecciimmeenn (normal host, or opportunistic) VVuullvvoovvaaggiinnaalcc aannddiiddiiaassiiss and its severity. BBlloooodcc uullttuurree:gg rroowwtthmm uusstbb err eessppeecctteedd CCuuttaanneeoouuss BBlloooodaass ssaayffoo rbbee ttaa--DD--gglluuccaann 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 Allergic bronchopulmonary Allergic brochopulmonary aspergillosis: Rarely found in individuals who OPPORTUNISTIC (acute angles, 45OO)) Allergic bronchopulmonary aspergillosis (IgE (IgE aspergillosis -> treat with High level of IgE (IgE level > 1000 IU/dL) are immunocompetent 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 ( ball): associated with Aspergilloma: removal via Aspergilloma: diagnose with chest X-ray or CT the prophylaxis of invasive syndromes: hemoptysis (blood cough) thoracic surgery scanscan Aspergillus and Candida • Allergic bronchopulmonary infections in s everelyeverely 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 , 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 flavus ) can cause liver damage and live cancer grains, and rice Rhizopus SSaapprroopphhyyttiic mmoollddss BBrrooaadd, nnoonn--sseeppttaatteedd, bbrraanncchhiinngg AAmmpphhootteerriicciinB aa nndss uurrggeerryy BiopsyBiopsy TThhedd iisseeaasseiis rr aappiiddllyff aattaall OOPPPPOORRTTUUNNIISSTTIICC Rhizomucor hyphae (right angles, 90oo)) Rhinocerebral (associated with diabetes): starts on Black nasal discharge nasal mucosa and invades the sinus and orbit Mucor Mucor Pulmonary mucormycosis Unicellular fungi found in the The organism is found in 3 PJP ––PJP Pneumocystis jirovecii pneumonia occurs when TTMMPP--SSMMXX A lactic dehydrogenase (LDH) study is TThhettaa xxoonnoommiicccll aassssiiffiiccaattiioonooff 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 thethe 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 whowho trypanosome and then later for organisms attach to the alveoli. Multiple host immune clusters are infected with HIV. The study has a highhigh 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 areare 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.use.