UNIT VI FUNGAL AGENTS OF DISEASES

AGENTS OF CUTANEOUS MYCOSES

SUPERFICIAL MYCOSES No Ab, no immune response, no inflamm reaction, In vivo = yeast & mold
Phaeoannellomyces weneckii/ Piedraia hortae Trichosporon beigelli/ Malassezia furfur/
Cladosporium werneckii/ Exophiala werneckii T. cutaneum Pityrosporum furfur/ P. orbiculare/ P.ovale
Tinea nigra (keratomycosis nigricans palmaris/ Black piedra White piedra Tinea versicolor/ pityriasis versicolor/ liper spot/
Pityriasis nigra/ microsporosis nigra) dermatomycosis furfuracea/ chromophytosis

Brown to black nonscaly macules on the palms & soles
~melanomas
Found in soil
VIA : Trauma to superficial layer of the skin
Fungus : long strands of septae, dematiaceous hyphae
*may contain numerous chlamydospores
hard, dark brown to black gritty nodules on scalp hair, Soft, white, yellowish, beige or greenish nodules on hair patchy lesions/scaling of varying pigmentation fawn
beard, moustache, axillary/pubic hairs shafts colored liver spots on the chest, trunk, abdomen
soft mycelial mat around facial & genital hair, hair scalp
Nature, normal skin flora
infects horse
KOH MOUNTS KOH MOUNTS KOH MOUNT
nodules crushed to reveal asci (thick walled rhomboid intertwined hyaline septate hyphae Skin scraping
cells with 8 ascopores) hyphae breaking up into oval/rectangular arthroconidia yellow fluorescence on woods lamp
2-4um diameter

CULTURE CULTURE CULTURE CULTURE (not essential)

SDA : 2-3weeks (slow) SDA + antibiotics (room temp) Chloramphenicol (cycloheximide = inhibitory) olive oil + medium incubation 37C
Colonies : moist, olive to greenish black , yeast like Colonies: dark brown with dematiaceous septate hyphae Colonies: rapid growth, cream colored, soft when young, Budding yeast
Cycloheximide = inhibitory membranous and wrinkled when age
MICROSCOPIC EXAM budding blastoconidia and arthrocodnidia MICROSCOPIC EXAM
Colonies: 1 to 2 celled cylindrical to spindle shaped cells Spaghetti and meatballs
budding /annelid formation ***Conidia & ascopores = not found on routine mycological BIOCHEMICAL TEST budding yeast along with septate, sometimes branched
rounded at 1 end and tapered toward the other media Doesnt ferment CHO & KNO3 hyphae
occl mycelial Assimilates glucose, galactose, sucrose, maltose, lactose hyphae are not demonstrated on routine media
TREATMENT Urease (+)
removal of infected hair shafts TREATMENT
applicaton of topical fungicides CM 1% selenium sulfide (temporary)
Pneumonia/ non specific febrile illness
may cause fatal systemic infection Associated diseases: folliculitis, obstructive dacrocystitis,
seborrheic dermatitis in AIDS

DERMATOPHYTOSES Keratinophilic: grow on layers of hair, nails, skin (contain keratin) HOST REFERENCES:
immune response, inflammation, tissue damage, ring worms Host reaction to metabolic products of fungus 1. Zoophilic Adapted to living on animals
Genera: Microsporum, Trichophyton, Epidermophyton, 2. Anthropophilic Adapted exclusively to human hosts
3. Geophilic Inhabits the soil
Tinea Barbae Tinea Capitis Tinea Corporis Tinea Cruris Tinea Favosa Tinea Imbricata Tinea manuum Tinea Pedis Tinea Unguium
Beard/ Barbers itch Head/scalp Body glabrous skin Groin Head Body Hand feet Nails
T. mentagrophytes Gray patch T. rubrum, T. tonsurans E. floccosum T. schoenleinii, (distinctive lesion) T. mentagrophytes T. mentagrophytes
Farm workers M. auduinii/ M. canis M. canis, M. gypseum Circinate and T. violaceum T. rubrum T. rubrum
Inflammatory lesion Ectothrix infection in child Occl serpiginous lession cup shaped crusts, E. floccosum E. floccosum
Inflammatory ecothrix Anular leson on the skin inflammatory, prominent honey Athletes foot, mocassin foot Lateral/distal edges
T. mentagrophytes smooth parts of body vesicular, enlarging comb like masses itching, scaling, seeping skin of nail plate
Animal origin spreading, hemorrhagic margins lesion on the soles of the feet paroncychial
Black dot (endothrix infection) border VIA : clothing, linens, & cleft betweent the toes infection
T. tonsurans towels shared Thickened nail,
Kerions brittle with
T. tonsurans accumulation of
Fungating exophytic masses subungual keratinized
Favus (tnea favosa) debris
T. schoenleinii, T. violaceum
cup shaped crusts, prominent honey
comb like masses
 COMMONLY ENCOUNTERED DERMATOPHYTES
EPIDERMOPHYTON MICROSPORUM
E. floccosum M. audouinii M. canis M. Ferugineum M. gypseum
Anthrophophilic Antropophilic Ectothrix infection of the hair Ectothrix, Tinea capitis Ectothrix, Tinea barbae
infects skin, nail Zoophilic Anthropophilic
most common cause of ringworms in cats and dogs WOODS LAMP
Hyphae: thick septa Doesnt fluoresce
CULTURE CULTURE CULTURE : Potato dextrose agar (bamboo)
Colonies: yellow to yellow green (olive drab) and quite Isolate: Chlamydoconidium like swellings Colonies: lemon-yellow Macroconidia : fusiform, thick walled, 6 cells
wrinkled/folded terminally on hyphae Macronconidia: spindle shaped, echinulate, thick walls, Distal area : thin, filamentous tail, longer than
Microconidia : none Favic chandeliers, pectinate bodies tapered/curved ends the rest of conidium
Macroconidia: smooth, thin walled, single/cluster Macroconidia : rare, bizaar (3-15 cells) ***hair baiting
Distal end: broad, spatulate/ club shaped (beavers tail) Doesnt grow on rice Microconidia : rare
***Grows on rice!!

WOODS LAMP : Fluoresce green

TRICHOPHYTON
T. concentricum T. mentagrophytes T. rubrum T. schoenleinii T. tonsurans T. verrucosum T. violaceum
T. imbricata Athletes foot T. corporis, T. ingium, T. capitis T. favosa Tinea capitis (black dot) T. corporis, T. barbae, T. capitis T. favosa
anthropophilic Zoophilic, anthropophilic endothrix Favic chandelier and anthropophilic Found in cattle
skin Most commonly isolated anthropophilic chlamydospores VIA: fomites
dermatophyte
Infect: skin, hair, nails
CULTURE CULTURE CULTURE CULTURE CULTURE 35C CULTURE
Spiral hyphae Colonies: red, + brown mix Colonies: slow (30days) SDA Thiamine Colonies: violet/ purple and
Macroconidia: thin walled, Macroconidia: 3-8cell, Small, wrinkled, waxy Colonies: rust colored on the Macroconidia: thin walled, waxy
smooth, cigar shaped 4-5 cell cylindrical, pencil shaped reverse side string beans/ rat tails Thiamine: enhancer
Microconidia: globose to tear Microconidia: clavate, peg Thiamine microconidia: clavate, hyphae: swollen w/ granules
shaped (grape like) Macroconidia: teardrop peg teardrop
WOODS LAMP Microconidia: rare, balloon
5 DAY UREASE (+) Doesnt fluoresce WOODS LAMP
Doesnt fluoresce
HAIR PENETRATION TEST HAIR PENETRATION TEST
Perpendicular penetration peg Surface erosion

MYCOTOXINS TOXIC METABOLITES PRODUCED BY FUNGI

AFLATOXIN VOMITOXIN (Fusarium spp)
A.fla + toxin
Molds: A.flavus, A. parasiticus, Penicillium spp, Rhizopus spp PATULIN (P. expansum)
Aflatoxifcosis : human, dogs ingestion of apple juice
jaundice, ascites, portal hypertension, high mortality
massive GIT death
pulmonary interstitial fibrosis
factor of reyes syndrome
carcinogen

OCHRATOXIN (A. alutaceus, Penicillium spp)

acute toxicity (kidney), balcan (nephropathy)
carcinogen

FUMONISN (F. verticilhoides)

esophageal cancer

TICHOTHECENES (F. graminearum)

acute toxicity and immune suppression
SUBCUTANEOUS MYCOSES
CHROMOBLASTOMYCOSIS EUMYCOTIC MYCETOMA SPOROTRICHOSIS SUBCUTANEOUS PHAEOHYPHOMYCOSIS
EPIDEMIOLOGY EPIDEMIOLOGY EPIDEMIOLOGY EPIDEMIOLOGY
Fonsecaea compacta, Phialophora verrucosa, Fonsecaea pedrosoi, Pseudallescheria boydii, Acremonium falciforme, Madurella Sporothrix schenckii Exophiala jeanselmei, Wangiella
Cladophialophora carrioni ,Rhinocladiella aquaspersa mycetomatis, Madurella grisea, Exophiala jeanselmei Found in soil dermatitidis, Cladosporium trichoides,
Verrucous dermatitis and chromomycosis true fungi Asso : gardeners disease Phialophora spp, Dreschlera spicifera,
VIA: exposure to rose throns (rose handlers dse) and Hormodendrum spp
sphagnum moss Dermatiaceous fungi
CLINICAL INFECTIONS CLINICAL INFECTIONS CLINICAL INFECTIONS CLINICAL INFECTION
Chronic infection of the skin & subcutaneous tissu Lesion: granulomas, tumor like, abscesses drain to the outside 1. Extracutaneous/ Disseminated sporotrichosis 1. Deep tissue invasion
Lesion: confined to the extremities (feet, legs), verrucous nodules through sinus tract for the immunocompromised most serious
(may be ulcerated and crusted) Lesion pus: granules/grains (compact mycelial masses) 2. Fixed cutaneous deep draining systemic abscess
longstanding lesion: cauliflower like surface initially confied to subcutaneous tissue infection is confined to the site of innoculation serebral chromoblastomycosis
frequently proliferate to involve the musculature and can cause 3. Lymphocutaneous 2. Ethmoid invasion
severe bone destruction Nodular & ulcerative lesion along lymph channels massive invation
===GRANULES Drain the primary site of inoculation subsequent erosion of ethmoid bone
Fungus Color Size mm Texture 4. Mucocutaneous 3. Subcutaneous cysts
P. boydii White 0.5-1.0 Soft 5. Primary and secondary pulmonary sporotrichosis single, firm, discrete, well defined nodule
A. falciforme 0.2-0.5 Soft little pain
M. mycetomatis Black 0.5-5.0 Hard foreign body first impression
M. grisea 0.3-0.6 Soft lesions: spread, verrucous, simulate
E. jeanselmei 0.2-0.3 soft
chromomycosis
LABORATORY DIAGNOSIS LABORATORY DIAGNOSIS LABORATORY DIAGNOSIS LABORATORY DIAGNOSIS
Specimen collection Specimen collection Specimen collection Specimen collection
Punch biopsy: affected skin area Granules: color, size, texture Aspirates: cutaneous nodules, pus, exudate Biopsy : dematieous hyphae
=====Direct examination Swabs: open lesion
skin biopsy: sclerotic/ copper bodies Direct microscopic exam Curettage material Microscopic exam
Hyphal elements: seen GMA, H&E, PAS, Masson fontana stains
Microscopic examination easily distinguished from the branching filamentous rods in Direct microscopic exam detect melanin in the cell wall
Cladosporium Erect conidiophores (branched, 1 cell, brown blastoconidia) actinomycotic mycetomas small cigar shaped yeast
Conidium close to tip of conidiophore (shield cell)
carrioni
Fragile chains
Culture
Fonsecaea ~F. pedrosoi Culture Culture a) Exophiala jeanselmei
compacta More compact conidial heads P. boydii PDA 25C & 35C dimorphic 25C and 37C incubation doesnt grow at 40C
Conidia are subglobose Rapid, white to dark gray
**S.apiospermum (anamorph) = oval conidia, single, tips of
Cycloheximide nitrate (+)
Fonsecaea Primary 1 cell conidia on sympodial conidiophores
Primary conidia : conidiogenous cell secondary conidia annelids a) 25C b) Wangiella dermatitides
pedrosoi
Phialophora Condiogenous cells dematiaceous
**Teleomorphs = cleistothecia w/ ascopores initially : white, glabrous, yeast like Grow at 40C
A. falciforme Moniliaceous/light colored mold
verrucosa Flask shaped phialides w/ collarettes later: darker, mycelial Nitrate (-)
Slow, grayish brown graying violet
Conidia oval, 1 cell, in balls at tips of phialides hyphae: thin, delicate with conidia in have phialides without colarettes
Mucoid clusters of 1 or 2 cell
Rhinocladiella Conidiophores erect, dark, bearing conidia only on upper portion
near the tip
Slightly curved conidia borne from phialides rosette/flowerette pattern at the ends of
aquaspersa Conidiophores: long, unbranched, multiseptate
Conidia elliptical, 1 cell, sympodially conidiophores
M. 37C & 40C
Slow, white yellow, olivaceous/brown, diffusable brown Conidia: dark walled/dematiaceous, along the sides of
Culture mycetomatis Conidia: half of isolate from the tips of phialides hyphae, sleeve arrangements
Half of isolate : sterile b) 37C
darkly pigmented / dematiaceous molds
M. grisea 30C
slow growth Slow, olive brown to black BA tubes 37C
velvety to wooly, gray bron to olivaceous black Reddish brown pigment require several subcultures
E. Doesnt grow at 40C cigar shaped yeast cells
Olivaceous to black color, initially yeast like, mature to velvety
jeanselmei Conidia: born from annellides aggregating in masses
Nitrate (+)

EXO ANTIGEN TEST

Isolate + BHI broth
Ag are extracted from supernatant using merthiolate
detect Ag : immunodiffusion technique
ENDEMIC MYCOSES (SYSTEMIC/DEEP SEATED)
GEN CHAR: All dimorphic, VIA: inhalation of infectious conidia, all lab procedure: biologic safety cabinets
Blastomyces dermatitidis Coccidiodes immitis & Coccidiodes posadasii Histoplasma capsulatum var capsulatum Paracoccidiodes brasiliensis
/ Ajellomyces dermatitidis / Emmonsiella capsulata
EPIDEMIOLOGY EPIDEMIOLOGY EPIDEMIOLOGY EPIDEMIOLOGY
Blastomycosis disease (Gilchrist dse, NA blastomycosis, Coccidiomycosis (Posada dse, coccidiodal granuloma, Histoplasmosis (reticuloendothelial cytomycosis, cave Paracoccidioidomycosis (SA blastomycosis, Brazilian
Chicago dse) valley fever, desert rheumatism, valley bumps, California dse, spelunkers dse, darling dse) blastomycosis, lutz splendore almeida dse, paracoccidiodal
From soil, decaying wood dse, San joaquin valley fever) From soil with high nitrogen content (heavily granuloma)
Affect human, dogs, horses contaminated with bird & bat guano) sex distribution 9:1
CLINICAL INFECTION CLINICAL INFECTION CLINICAL INFECTION CLINICAL INFECTION
1. Pulmonary most virulent of all mycotic agent Inhaled microconidia phagocytosis by macro in Primary infection: asymptomatic, may disseminate
initial mild respiratory symptoms: fever, cough, primary dse: resolves w/o therapy, confers a strong pulmonary parenchyma leading to ulcerative lesion of the buccal, nasal, GI mucosa
hoarseness specific immunity (Coccidiodin skin test) 1. Primary acute Lymph node is involved
progression: few months: productive cough, fever, weight symptomatic/flu like symptoms, chest pain, shortness of Dissemination to other organs: adrenals, diminished host
loss 1. Asymptomatic pulmonary dse breath, hoarseness defenses
2. Systemic 2. Allergic manifestation diffuse/discreet lung lesion : calcify
extension -toxic erythema almost always skin test (+)
common site: liver, spleen -erythema nodosum (desert bumps) 2. Chronic cavitary
granulomatous lesions & abscess -erythema multiforme (valley fever) large pulmonary lesion after discomfort
3. Cutaneous -arthritis (desert rheumatism) ~~tuberculosis
either from direct inoculation or systemic dse 3. Symptomatic dse may progress to disseminated form
a) Primary 3. Severe disseminated
fever, respiratory distress, cough, anorexia, headache, organ involved
malaise, myalgias (6 weeks/longer) fatal in massive dissemination
b) Secondary dse
nodules, cavitary dse, progressive pulmonary dse Others: mediastinitis, pericarditis, mucocutaneous lesion
single/multisystem dissemination 1%
Filipinos, African american
9:1 female:male
LABORATORY DIAGNOSIS LABORATORY DIAGNOSIS LABORATORY DIAGNOSIS LABORATORY DIAGNOSIS
Specimen collection Specimen collection Specimen collection Specimen collection
1st morning sputum Sputum sputum Sputum
bronchial washign tracheal aspirates bronchoscopic fluid Bronchoalveolar lavage
pulmonary secretion lung biopsy tissue BM aspirates Pus from draining lymph nodes
CSF peripheral blood smear scrapings from ulcers
Direct Microscopic exam Blood exudate from mucocutaneous lesion biopsy tissue
Large, spherical, refractile yeast cell (8-15um) exudate from liver and spleen
double contoured wall Direct microscopic examination Direct microscopic exam
buds connected by a broad base Spherules w/ endospores Direct microscopic exam budding yeast (15-30 um) with multipolar
(produced by inhaled barrel shaped arthroconidia) small yeast cell budding at the periphery (mariners wheel)
Culture common within monocytes and macrophages daughter cell : connected by narrow base
Inhibitor: cycloheximide Culture non encapsulated, looks like encapsulated mickey mouse cap appearance
Heavily contaminated = plate on media with antibacterial initial: 3-4 days, white to gray, moist, glabrous
a) 25C mature: abundant aerial mycelia, enlarged colony in a Culture Culture
white, tan, brown circular bloom. Become tan to brown to lavander 2 Sets of SDA, BHI/ inhibitory mold agar a) 25C
fluffy to glabrous in concentric rings hyaline arthroconidia: separated by disjunctor cells 25C & 37C colonies: flat, glabrous to leathery, wrinkled to folded,
raised areas (spicules/prickles) in the centers of colonies Exoantigen test white to brownish mold floccose to velvety, pink to biege to brown with yellowish
anamorphic : conidia born/short lateral branches, ovoid young: round to pyriform microconidia (2-5um) brown reverse
to dumb bell shaped. Short conidiophores~ lollipops mature: large echinulate to tuberculate macroconidia small 1 cell conidia
teleomorphs (A.dermatitidis) : doesnt occur in routine confirm: BHI 37C, conversion of mold to yeast exoantigen test
---produce gymnothecia w/ ascopores Exoantigen detection: detect H & M antigen
Exoantigen technique: Kaufman, standard = b) 37C
Detects cell-free antigen in mycelial form using rapid conversion with BHI blood
Immunodiffusion test
Complement fixation , Immunodiffusion for sero
b) 37C diagnosis
broad based yeast cell

Gen char: ubiquitous agent, part of normal flora, monomorphic mostly, px: immunocompromised
Aspergillus spp
A. fumigatus, A. flavus, A. niger, A. terreus
EPIDEMIOLOGY
Aspergillosis
Found worldwide
Normal saprophyte in soil
Carcinogenic hapatoxin:
aflatoxin
abundant in environment
CLINICAL INFECTION
1. Allergic forms
a) allergic bronchopulmonary
aspergillosis
b) extrinsic allergic alveolitis
2. Aspergilloma (fungus ball)
inhaled conidia enter exisiting
cavity
rarely invasive
found in lungs
3. Extrapulmonary colonization
4. Invasive aspergillosis
5. External otomycosis, mycotic
keratis, onychomycosis
6. Eye & hair infection
LABORATORY METHODS
==Specimen Collection==
Sputum
Respiratory specimen
Blood (rarely (+))
==Direct microscopic exam==
Hyphae & hyaline = septate
==Culture==
incubation = room temp
ID: morphology of conidial
stucture
dark to brown spores
Candida albicans
C.tropicalis, C.parapsilosis, C.glabrata
EPIDEMIOLOGY
Candidiasis (moniliasis, mycotic Cryptococcosis (torulosis,
vulvovaginitis, thrush,
candidiosis, candida
endocarditis)
most frequently encountered
may be normal flora
CLINICAL INFECTION
1. Cutaneous & Mucosal
candidiasis
Risk factor: AIDS, pregnancy,
diabetes, young/old age, birth control
pills, trauma, burns, skin maceration
---oral thrush, onychomycosis,
intertrigenous infection (most/warm
parts of body), interdigital infection,
vulvovaginitis
2. Systemic Candidiasis
via indwelling catheters, surgery, IV
drug abuse, damage to skin/GIT
Asso with chronic admin of
immunosuppressive drugs
3. Chronic mucocutaneous
candidiasis
chronic superficial disfiguring
infeaction of sking & mucosa area
onset : early childhood
LABORATORY METHODS
==Specimen collection==
Swabs & scrapings: superficial lesion
blood
spinal fluid
tissue biopsy
urine
exudate
material from removed IV catheter
==Direct Microscopic exam=
gram stained smears:
Pseudohyphae, budding cells
skin/nail scrapping + 10% KOH
==Culture== 37C BHI/MH
non selective agar media
yeast colony = pseudohyphae
Germ tube test (+)
Serum + Rg (2-4hr)
Chlamydospores in cornmeal
agar (RT 3-5days =
pseudohyphae)
Urease (+)
CHROMagar: differential med.
Carbs assimilation test
API 20C AUX = Gold std.
OPPORTUNISTIC MYCOSES = Cant produce disease in immunocompetent
Cryptococcus neoformans
Teleomorph Filobasidiella neoformans
EPIDEMIOLOGY
european blastomycosis)
Found in soil (pigeon droppings) endopthalmitis, skin infection,
CLINICAL INFECTION
1. Acute/ Chronic pulmonary
-transitory/pass unrecognized
-asymptomatici infection
2. Systemic/ meningeal
most common
from meningitis
LABORATORY METHODS
==Specimen collection==
CSF = most common
serum/CSF for Ag detection
(Latex agg.test) = most sensitive
==Direct Microscopic exam=
encapsulated yeast in india ink
==Culture== 37C
Mucoid colonies
inhibitor : cycloheximide
Urease (+)
Yeast ID system
Hyaline, Septate, Monomorphic
molds
EPIDEMIOLOGY
Asso fungemia, disseminated Dimorphic fungus endemic in
infection, mycotic keratitis,
endocarditis
1. Acremonium
Septate hyphae
unbranched, tube like phialides
produce clusters of 1 cell &
2cell oblong conidia
2. Fusarium spp
1 cell microconidia
sickle /boat shaped
macroconidia + septation
3. Geotrichum
septate hyphae
barrel shaped non alternating
arthroconidia, no blastoconidia
4. Paecilomyces
long, delicate penicillus
produce numerous chains of
small, oval conidia, easily
dislodged
5. Scopulariopsis
produce penicillus with large,
flat based, rough walled conidia
Penicillium marneffei
EPIDEMIOLOGY
immunocompromised px
southeast asia
asso with bamboo rat
VIAUNKNOWN
CLINICAL INFECTION
1. Focal Cutaneous infection
2. Mucocutaneous infection
3. Disseminated infection
LABORATORY METHODS
==Specimen collection==
Infected tissue/exudate
==radiographic studies==
==Direct Microscopic exam=
Small yeast like cells with
internal crosswalls
no budding cells produced
==Culture== SDA
blue-green to yellowish
colonies
Soluble red to maroon pigment
on reverse side of colony
Mycelial to yeast conversion
(2 weeks)
mycelial produces brushlike
conidiophores (penicillus)
Pneumocystis jiroveci (P. Zygomcetes
carinii) Rhizopus, Mucos, Absidia
EPIDEMIOLOGY EPIDEMIOLOGY
Sparsely septate, hyaline
dissemination : rare monomorphic molds
only in AIDS immunocompromised px
prev : protozoan diabetes melitus px
cell membrane: cholesterol foundin decaying vege
matter and soil
VIA: inhalation of spores
common bread molds
CLINICAL INFECTION CLINICAL INFECTION
Morphologic forms: 1. GI
1. Trophozoltes 2. Perineural invasion
predominant 3. Rhinocerebral form
difficult ti ID massive necrosis with
2. Cysts vascular invasion and
pingpong ball infarction
4. Respiratory
10:1 5. Skin & subcutaneous
Troph:cysts infections
LABORATORY METHODS LABORATORY METHODS
==clinical presentation== ==Direct Microscopic exam=
branching coenoctic hyphae
==Culture==
==Direct Microscopic exam= 1. Absidia
respiratory spn pyriform sporangia + funnel
shaped apophysis
==Culture== 2. Mucor
No growth no rhizoids/stolons
3. Rhizopus
unbranched sporangiospores
with rhizoids appearing at the
point where stolon arises