Superficial, Cutaneous and Subcutaneous Fungal Infections Jarrod Fortwendel,

Superficial, Cutaneous and Subcutaneous Fungal Infections Jarrod Fortwendel,

Superficial, Cutaneous and Subcutaneous Fungal Infections Jarrod Fortwendel, PhD Department of Microbiology and Immunology [email protected] MSB 2142 Nov. 18-22, 2013 Tinea Capitis in an Adult Woman 87 yo woman presents to her doctor with a 2-year history of puritic, painful, scaling scalp eruption and hair loss

Previous treatment included numerous courses of systemic antibiotics and prednisone without success Social history: recently acquired several stray cats that she kept inside her home Physical exam: numerous pustules throughout the scalp, diffuse erythema, crusting, and scale extending to neck. Extremely sparse scalp hair and prominent posterior lymphadenopathy. No nail pitting. Wood light positive Presumptive diagnosis: Tinea Capitis

Cutaneous (and Superficial) Mycoses Infections of the skin, hair, nail Invades keratinized layers Tinea latin for worm Subgroups of infections 1. Dermatophytoses classical ringworm 2. Non-dermatophytic cutaneous mycoses the other superficial group The Dermatophytes Classical ringworm - #1 mould infection

Epidemiology Anthropophilic, zoophilic, geophilic Transmissible Invade skin, hair and nails Collectively called tinea 3 major Genera: Trichophyton Epidermophyton Microsporum The Dermatophytes

Classical ringworm - #1 mould infection Epidemiology Anthropophilic, zoophilic, geophilic Transmissible Invade skin, hair and nails Collectively called tinea 3 major Genera: Trichophyton Epidermophyton Microsporum

T. rubrum T. mentagrophytes Cause 80-90% of cases worldwide The Dermatophytes: Pathogenesis Virulence factors and pathogenesis: Infectious element Arthroconidia

Keratin utilization Keratinophilic and keratinolytic Hair invasion/colonization Endothrix, Ectothrix, Favic Clinical: Classified by anatomical site affected Tinea capitis Microsporum spp. M. audouinii, gray patch ringworm M. canis, M. gypseum

Tinea corporis point lesion centrifugal spread anywhere on body from eyebrow and neck southward Trichophyton spp., Epidermophyton, (Also Candida) Tinea pedis cosmopolitan Trichophyton spp., Epidermophyton Tinea unguium Often as a secondary infected site

Almost any dermatophyte, esp Trichophyton rubrum, (Also Candida) Tinea capitis Tinea corporis Tinea imbricata Etiology: Trichophyton concentricum Tinea cruris

Tinea cruris Tinea unguium - onychomycosis Tinea barbae Tinea manum Dermatology Image Atlas: Dermatology Images - dermatlas.med.jhmi.edu Tinea pedis

The Dermatophytes - Zoophilic The Dermatophytes - Zoophilic Laboratory Diagnosis Requires demonstrating hyphae/arthroconidia from skin, hair, nails Direct preparation: Lesion scrapings/hair examined by calcofluor/KOH

Alternatively - Woods Light: UV irradiation of infected hair, false positive/negative Report: Hyphal fragments/arthrocondida seen Culture: SDA +; SDA-CC + LPCB Direct KOH prep: Hyphal fragments seen http://www.mycology.adelaide.edu.au/virtual/2009/ID2-Oct09.html The Dermatophytes:

Morphology Epidermophyton spp. - Smooth walled macroconidia borne in clusters of 2 or 3; no microconidia Trichophyton spp. - Rare, smooth, thin-walled macroconidia; numerous spherical or teardrop shaped microconidia Microsporum spp.

- Numerous, large, thick, rough-walled macroconidia; rare microconidia Treatment of the dermatophytoses Localized cutaneous - topical agents Clotrimazole (Lotrimim), Miconazole (micatin) Tolnaftate (tinactin), terbinafine (lamisil) Hair, nails oral therapy Fluconazole, itraconazole, griseofulvin

Griseofulvin Concentrates in newly keratinized layers of cells Virtually eradicated epidemic tinea capitis; used in tinea unguium and extensive infections. Recurrences are common Non-dermatophytic Onychomycosis: Candida spp. Fluconazole

Scopulariopsis spp. Scytalidium spp. partial surgical nail removal + antifungal **Possible other nail pathogens: Aspergillus spp. Fusarium spp. Acremonium spp.

**nail pathogen vs. saprobe on abnormal nail material ** Must have: > 1 KOH positive!! > culture positive isolation of same agent!! **R/O fungal contamination of the culture** Case resolution Wood Light positive Skin biopsy Enterococcus spp. and Trichophyton tonsurans Endothrix dermatophyte infection

Treated with griseofulvin and Selsun New hair growth and resolution of pustular eruption at 2 week follow-up Treatment continued for 8 weeks with complete hair re-growth and no permanent alopecia Superficial Mycoses Tinea versicolor AKA pityriasis versicolor Malessezia furfur

Tinea nigra palmaris Hortaea (Exophiala) werneckii Piedra black Piedraia hortai Piedra white Trichosporon beigelii Superficial Mycoses Tinea versicolor AKA pityriasis versicolor

Malessezia furfur Very common up to 60% infected population in certain tropical environments Most common in tropic and subtropics Person-to-person transfer Liopophilic fungus that degrades lipids to produce acids that damage melanocytes = hypopigmented patches w/ dark skin, pink or brown w/ light skin Little-to-no host immune reaction Tinea (pityriasis) versicolor

Chest Back Skin Scraping Direct Prep (KOH) Spaghetti and meatballs Diagnosis made by direct exam

Does not culture routinely - lipophilic Treatment: 2.5 % Selenium sulfide or topical cream azoles Severe cases: Oral ketoconazole collarette Superficial Mycoses Tinea versicolor AKA pityriasis versicolor Malessezia furfur

Tinea nigra Hortaea (Exophiala) werneckii Piedra black Piedraia hortai Piedra white Trichosporon beigelii Superficial Mycoses

Tinea versicolor AKA pityriasis versicolor Malessezia furfur Tinea nigra Hortaea (Exophiala) werneckii Superficial phaeohyphomycosis Solitary, irregular, pigmented macule usually on palms or soles Tropic or subtropic Traumatic inoculation Not contagious

Can resemble a malignant melanoma Tinea nigra H. werneckii 2. Culture = dematiaceous, yeast-like colony in 3 weeks 4. Treatment: Topical azoles 1. KOH prep = pigmented hyphae and yeast 3. Microscopic

= two-celled, cylindrical, yeast-like cells http://www.mycology.adelaide.edu.au/virtual/2007/ID2-Feb07.html http://www.mycology.adelaide.edu.au/virtual/2007/ID2-Feb07.html Superficial Mycoses Tinea versicolor AKA pityriasis versicolor Malessezia furfur

Tinea nigra palmaris Hortaea (Exophiala) werneckii Piedra black Piedraia hortae Piedra white Trichosporon beigelii Superficial Mycoses

Tinea versicolor AKA pityriasis versicolor Malessezia furfur Tinea nigra palmaris Hortaea (Exophiala) werneckii Piedra black Piedraia hortae Tropical, poor hygiene, uncommon Small, dark nodules surrounding hair shaft Clumped together by cement-like substance with asci and ascospores

Diagnosis = direct exam Treatment = haircut, washing Superficial Mycoses Tinea versicolor AKA pityriasis versicolor Malessezia furfur Tinea nigra palmaris Hortaea (Exophiala) werneckii Piedra black Piedraia hortai

Piedra white Trichosporon beigelii Tropical and subtropical, poor hygiene Affects hairs of groin and axillae Forms soft, white/brown swelling on hair shaft Shaving and washing Superficial Mycoses Tinea versicolor AKA pityriasis versicolor Malessezia furfur Tinea nigra palmaris

Hortaea (Exophiala) werneckii Piedra black Piedraia hortai Piedra white Trichosporon beigelii Other non-dermatophytic (several) E.g. Candida, Fusarium, and more Subcutaneous mycoses AKA: Inoculation Mycoses normal soil inhabitants

Primary infection in deep skin, muscle or connective tissue Slowly progressive and chronic, usually confined Not transmissible Subgroups of subcutaneous mycoses I. Sporotrichosis II. Chromoblastomycosis/Phaeohyphomycosis III. Mycetoma IV. Subcutaneous Zygomycosis Sporotrichosis Sporothrix schenkii Epidemiology :

Decaying vegetation, esp used for mulching Enters via splinters, thorn pricks -Occupational hazard Clinical Aspects: Primary nodular lesion necrotic ulcer, suppurative Proximal lymphatics may chronically infect (dissemination rare) Sporothrix schenckii: Direct prep: RARE blastoconidia Sporothrix is a thermal dimorph

At RT: DEMATIACEOUS colony, HYALINE septate hyphae, delicate lateral conidiophores w/ delicate rosettes of conidia At 37C in vivo & in vitro: oval, cigar-shaped blastoconidia. Treatment: Itraconazole Chromoblastomycosis Epidemiology: tropics PR, Cuba, Costa Rica and Brazil

Soil saprobes; dematiaceous fungi Trauma is required, occurs when shoes are rarely worn Clinical Manifestations:

Not contagious Incubation unknown Chronic skin and subcutaneous infections Small raised papule, ulcerates & encrusts dry, raised lesion usually on foot/leg Satellite lesions hyper-elevate - 10-15 yrs from onset Chromoblastomycosis Clinical Manifestations Chromoblastomycosis

Laboratory Diagnosis: Direct Prep: Copper-colored, multiple dividing cells Three major organisms: Cladosporium, Fonsecaea, Phialophora Culture = differ by conidial structures Can be considered dimorphs yeast-like in vivo, mould in vitro

Treatment: Specific antifungals usually ineffective Itraconazole, terbinafine, or posaconazole Combined with 5-fluorocytosine in refractory cases Phaeohyphomycosis Epidemiology: Syndrome caused by more than 20 different saprobes Fungi appear in tissue as irregular hyphae, not the sclerotic cells seen in Chromoblastomycosis Traumatic inoculation

Clinical syndromes: Solitary inflammatory cyst Slow growing (months to years) Laboratory Diagnosis: Surgical excision of cyst = inflammatory cyst with fibrous capsule, necrosis, fungal elements Treatment: Surgical excision

Itraconazole, posaconazole, voriconazole, terbinafine Mycetoma Epidemiology : tropical & subtropical Soil saprobes Trauma required for inoculation Clinical Manifestations: Not contagious Swollen deep seated lesion of hand or foot

Mycetoma Clinical Manifestation Mycetoma Laboratory diagnosis: Caused by many diverse microbes Eumycetoma (fungal mycetoma) Scedosporium (teleomorph Pseudallescheria) Resistant to Amphotericin B! Actinomycetoma (actinomycotic mycetoma)

Actinomyces, Nocardia, Actinomadura, Streptomyces Treatment: Bacterial antibiotics Fungal surgery and long-term treatment Subcutaneous Zygomycosis Epidemiology: Africa, India, Latin America Traumatic implanation Conidiobolus coronatus and Basidiobolus ranarum

Clinical Syndromes: B. ranarum large, movable mass localized to shoulder, pelvis, hip and thigh C. coronatus confined to rhinofacial area Laboratory diagnosis: Biopsy = focal clusters of inflammation, eosinophils, zygomycete hyphae Treatment: Itraconazole

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