The Pocket Guide to Fungal Infection Second Edition Malcolm D. Richardson PhD, FIBiol, FRCPath Mycology Unit Department of Bacteriology and Immunology University of Helsinki Helsinki, Finland Elizabeth M. Johnson PhD Mycology Reference Laboratory Health Protection Agency Bristol, United Kingdom The Pocket Guide to Fungal Infection Second Edition To families and friends The Pocket Guide to Fungal Infection Second Edition Malcolm D. Richardson PhD, FIBiol, FRCPath Mycology Unit Department of Bacteriology and Immunology University of Helsinki Helsinki, Finland Elizabeth M. Johnson PhD Mycology Reference Laboratory Health Protection Agency Bristol, United Kingdom © 2005 Malcolm D. Richardson, Elizabeth M. Johnson Published by Blackwell Publishing Ltd Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia The right of the Authors to be identified as the Authors of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. First edition published 2000 Reprinted 2000, 2002 Second Edition 2005 Library of Congress Cataloging-in-Publication Data Richardson, M. D. The pocket guide to fungal infection / Malcolm D. Richardson, Elizabeth M. Johnson. — 2nd ed. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-1-4051-2218-4 ISBN-10: 1-4051-2218-8 1. Mycoses—Handbooks, manuals, etc. I. Johnson, Elizabeth M., Ph.D. II. Title. [DNLM: 1. Mycoses—Handbooks. WC 39 R524p 2005] RC117.R474 2005 616.9′69—dc22 2005004901 ISBN-13: 978-1-4051-2218-4 ISBN-10: 1-4051-2218-8 A catalogue record for this title is available from the British Library Set in 8/11.5 pt Frutiger by Graphicraft Limited, Hong Kong Printed and bound by Replika Press PVT Ltd, Harayana, India. Commissioning Editor: Maria Khan Development Editor: Claire Bonnett Production Controller: Kate Charman For further information on Blackwell Publishing, visit our website: http://www.blackwellpublishing.com The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has been manufactured from pulp processed using acid-free and elementary chlorine-free practices. Furthermore, the publisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards. Contents Contents Introduction to the second edition, 1 Introduction to the first edition, 2 Acknowledgements, 3 Dermatophytosis Tinea capitis, 4 Tinea corporis, 8 Tinea cruris, 12 Tinea pedis, 16 Tinea manuum, 18 Tinea unguium, 20 Mucosal and cutaneous infections Oral candidosis, 24 Vaginal candidosis, 28 Cutaneous candidosis, 32 Malassezia infections, 36 Mould infections of nails, 42 Keratomycosis, 46 Otomycosis, 50 Opportunistic fungal infections Aspergillosis, 52 Pneumocystis carinii pneumonia, 60 Deep candidosis, 62 Cryptococcosis, 70 Mucormycosis, 76 Systemic mycoses Blastomycosis, 84 Coccidioidomycosis, 88 Histoplasmosis, 94 Paracoccidioidomycosis, 100 Subcutaneous mycoses Chromoblastomycosis, 104 Subcutaneous zygomycosis, 108 v Contents Lobomycosis, 112 Mycetoma, 114 Rhinosporidiosis, 118 Sporotrichosis, 120 Unusual fungal infections Hyalohyphomycosis, 124 Penicillium marneffei infection, 130 Phaeohyphomycosis, 134 Uncommon yeast infections, 140 Adiaspiromycosis, 150 Basidiomycosis, 154 Mycological aspects of the indoor environment, 158 Antifungal assays and susceptibility tests Antifungal assays, 164 Susceptibility tests, 167 Molecular methods, 170 Selected reading: recently published texts and monographs, 172 WWW sites, 174 Index, 175 vi Introduction to the second edition Introduction to the second edition The material has been revised extensively but our goal has been the same – to present, in a concise manner, the most important clinical, diagnostic and therapeutic aspects of fungal disease. In each chapter the clinical manifestations and management sections have been updated, and where appropriate, new emerging pathogens have been included. New sections include the molecular diagnosis of fungal infections and mycological aspects of the indoor environment. Medical mycology lends itself to illustration and we have included additional illustrative material in this edition. Throughout we have attempted to illustrates salient features of infection and to give an idea of the range of causative organisms including some illustrative photographs of macroscopic and microscopic morphology. Recent references have been added and the list of online resources has been updated. We have made every effort to ensure that our drug and dosage recommendations are accurate and in agreement with current guidelines. It should be noted that the formulations and usages of the different drugs described do not necessarily have the specific approval of the regulatory authorities of all countries. Because dosage regimens can be modified in the light of new clinical research findings, readers are advised to check the manufacturers’ prescribing information to see whether changes have been made in the recommended dosages, or whether additional contraindications for use have been introduced. 1 Introduction to the first edition Introduction to the first edition The main aim of this Pocket Guide is to summarize the major features of fungal infections of humans and to provide visual information for each pathogen and the infections they cause in a convenient and practical format. In this guide we have provided a succinct account of the clinical manifestations, laboratory diagnosis and management of fungal infections found in Europe, American and Australasian practice. The guide covers problems encountered both in hospitals and general practice and is designed to facilitate rapid information retrieval with representative colour illustrations. Our reading list of established literature has been carefully selected to permit efficient access to specific aspects of fungal infection. The list of World Wide Web sites allows access to an even greater wealth of information and illustrative material. 2 Acknowledgements Acknowledgements Again, we would like to thank David W. Warnock and Colin K. Campbell for kindly agreeing that the slides from the Slide Atlas of Fungal Infection could be used in this publication. Many of the illustrations were originally derived from collections of slides held at the Mycology Reference Laboratories in Bristol and Glasgow and we wish to thank friends and colleagues for their generosity in making this resource available to us. We also gratefully acknowledge additional sources of illustrations: firstly, the Medical Mycology Atlas, compiled by Stefano Andreoni, Claudio Farina and Gianlugi Lombardi, with kind permission of Gilead Sciences; secondly, Kaminski’s Digital Image Library of Medical Mycology, with kind permission of David Ellis and Rolan Hermanis, Women’s and Children’s Hospital, North Adelaide, South Australia; and last but not least, pictures made available by colleagues in Finland, the UK, and from around the world. Many thanks for these. 3 Dermatophytosis Tinea capitis Tinea capitis due to Trichophyton tonsurans. Kerion due to Trichophyton verrucosum. Definition Tinea capitis describes infection of the scalp and hair with a dermatophyte. Geographical distribution World-wide, but more common in Africa, Asia and southern and eastern Europe, occurring mainly in prepubescent children. Increasing incidence. 4 Dermatophytosis Hair infected by Microsporum gyseum showing large-spored ecothrix invasion. Macroconidia of Microsporum canis. Causal organisms and habitat • Several Trichophyton spp. and Microsporum spp. • Zoophilic M. canis (cats and dogs) is common in western Europe. • Anthropophilic T. violaceum is predominant in eastern and southern Europe and north Africa. • Anthropophilic T. tonsurans is increasing in prevalence, especially in North America. 5 Dermatophytosis Microsporum canis in culture. • Anthropophilic species can be contagious and endemic. • T. schoenleinii causes favus. Clinical manifestations • Mild scaling lesions to widespread alopecia. • Kerion: highly inflammatory, suppurating lesion caused by zoophilic dermatophytes. • Black dot appearance seen with ectothrix hair invasion. • Favus is a distinctive infection with grey, crusting lesions. • Asymptomatic carrier state recognized, may promote spread of infection. • T. tonsurans and T. violaceum – most commonly implicated in the carrier state. • Minimal inflammatory response. • Low spore numbers. • Topical treatment appears to help prevent spread of infection. • Fomites also implicated in spread. Essential investigations Microscopy Direct microscopic examination of hair roots and skin softened 6 Dermatophytosis with KOH reveals hyphae, arthrospores and distinctive patterns of hair invasion: ectothrix – large or small arthrospores form a sheath around the hair shaft; endothrix – large or small arthrospores form within the hair shaft; ectoendothrix – spores form around and within the hair shaft; and favus – hyphae and air spaces form within the hairs. Fluorescence under Wood’s light may reveal hairs infected with Microsporum spp; not effective