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Subcutaneous

Mycoses
Dr. R. Tan
Subcutaneous Mycoses
these are chronic, localized infections of the skin and
subcutaneous tissue following the traumatic
implantation of the etiologic agent
The causative fungi are all soil saprophytes (grow in
soil or in decaying vegetation) of regional
epidemiology whose ability to adapt to the tissue
environment and elicit disease is variable
Should be introduced into subcutaneous tissue in
order to produce disease
Lesions spread slowly from the implantation area
Pathology is frequently the result of the interaction
between host and pathogen, with contributions both
from fungal invasiveness and from host
responses
the pathogens of subcutaneous mycoses have only a
few common characteristics and belong to very
different taxonomic groups
Mode of Transmission :

Direct subcutaneous inoculation via:
Traumatic implantation
 rose thorn

 stepping on a stick

Exposure of subcutaneous tissue to air


 Burn

 motor vehicle accident

 Inhalation of airborne fungal cells, followed by

implantation in paranasal sinuses or lungs


 Iatrogenic

intravenous catheter
contaminated dressings
Disease Causative Incidenc
Organism e
Sporothricosis Sporothrix schenckii  Rare

Chromoblastomyco Fonsecaea, Phialophora, Rare


sis Cladosporium

Mycotic mycetoma Pseudallescheria, Rare


Madurella, 
Acremonium, Exophiala
Rhinosporidiosis Rhinosporidium
etc. seeberi Very rare

Lobomycosis Loboa loboi Very rare


SPOROTRICHOSIS

Common name: “Rose Gardener’s Disease”

etiologic agent: Sporothrix schenckii


is primarily a chronic mycotic granulomatous infection
of the cutaneous or subcutaneous tissues and
adjacent lymphatics characterized by nodular lesions
which may suppurate and ulcerate
infections are caused by the traumatic implantation
of the fungus into the skin (usually due to
puncture by contaminated plant material e.g.
wood splinters,thorns, sphagnum moss)
very rarely, dessimination to the bones, muscles,
central nervous system, lungs or genitourinary tract
porothrix schenckii
rarely seen in pus and tissues from human
infections
yeastlike cells are of various sizes and shapes:
appear as small, round to cigar shaped, and
often have elongated gram (+) “pipe-stem”
budding cells
budding is on a narrow base
rate of growth: rapid (mature within 5 days)
thermally dimorphic
Sabouraud’s Agar
 Filamentous (mold) when cultured at 25-
30°C

Yeast when cultured at 35-37°C
Filamentous appearance

olony morphology:
Cream-colored to black, moist,
wrinkled, leathery or velvety
colonies with narrow white
border develop within 3 – 5 days

icroscopic morphology:

yphae are narrow, branching,


and septate, with slender ,
tapering conidiophores rising at
right angles
Yeast-like appearance
incubated at 35-37°C
Macroscopic: colonies are
cream or tan, smooth
and yeastlike

Microscopic: budding yeast


cells appearing as short,
round, oval or cigar-
shaped
Pathogens & Clinical Finding:

Fungus Trauma skin of extremities

pustule, abscess or ulcer

lymphatics become
thickened, cordlike

multiple subcutaneous nodules


and abscess along the lymphatics

usually has little systemic illness


but dissemination of the
infection sometimes occur
in debilitated patient
Clinical manifestations:
Fixed cutaneous sporotrichosis:
 Presence of only 1 lesion

 Primary lesions develop at the site of

implantation of the fungus


 usually at more exposed sites mainly

the limbs, hands and fingers


 Lesions often start out as a painless

nodule which soon become palpable


and ulcerate often discharging a
serous or purulent fluid
 Importantly, lesions remain localized

around the initial site of implantation


and do not spread along the
lymphatic channels
Lymphocutaneous
sporotrichosis
 75% of cases of Sporotrichosis

 Primary lesions develop at the

site of implantation of the


fungus
 secondary lesions also appear

along the lymphatic channels


which follow the same indolent
course as the primary lesion
 Initially, a small, movable, non-

tender, subcutaneous nodule


develop which becomes
discolored; the overlying skin
darkens to a reddish color and
eventually blackens and
ulcerates
 No systemic symptoms are
Pulmonary sporotrichosis
 This is a rare entity usually caused by the

inhalation of conidia but cases of hematogenous


dissemination have been reported

Symptoms are nonspecific and include cough,
sputum production, fever, weight loss and upper-
lobe lesion
 Hemoptysis may occur and it can be massive and

fatal
 The natural course of the lung lesion is gradual

progression to death

Osteoarticular sporotrichosis
 Most patients also have cutaneous lesions and

present with stiffness and pain in a large joint,


usually the knee, elbow, ankle or wrist
 Osteomyelitis seldom occurs without arthritis


Treatment:
In most Cases: self – limited infection
Potassium Iodide
 4-6 ml three time a day for 2-4 months
orally
 has therapeutic benefits in the cutaneous
manifestations
Extracutaneous forms of sporotrichosis may need a
combination of antifungal treatment with
Amphotericin B or itraconazole together with surgical
debridement

Control:
Prevention of trauma in the following occupations:
- gardeners
- miners
-
Chromoblastomycosis
Chromomycosis/Chromoblastomycosis is caused by
traumatic implantation of any of the several
dematiaceous fungus specie into the subcutaneous
tissue
dematiaceous fungus
 fungi that produce varying degree of melanin-like

pigments
 These pigments are found in the conidia and/or

hyphae and give the organism a green, brown or


black color
Specie causing chromoblastomycoses
1) Fonsecaea pedrosoi - most common
2) Phialophora verrucosa - second most common
3) Cladosporium carrionii
Natural reservoir of these fungi
 Soil

 plant debris

World-wide distribution but more common in bare footed


populations living in tropical regions
A slowly progressive granulomatous mycotic infection of
the cutaneous and subcutaneous tissues caused by
the traumatic implantation of fungal elements into the
skin characterized by the development of tissue
proliferation usually occurs around the area of
inoculation producing crusted, verrucose, wart-like
lesions
Morphology & Identification:
In exudates and tissues appear as “scleotic
bodies”
 round, dark brown, thick walled, septate cell
5 – 15µm in diameter usually with a single
septum or 2 intersecting septa

colonies vary in pigmentation form olive gray to
brown
to black (dematiacious fungi) so name because
they produce melanin-like pigments
Fonsecaea pedrosoi
colony morphology: surface is dark green,
gray, brown to black covered with fuzzy or
velvety surface

Usually undistinguishable with other
dematiaceous fungi
Microscopic morphology: hyphae are
septate, branched, and brown; conidia are dark
4 types of conidial forms:

Fonsecaea type Rhinocladiella Cladosporium type Phialophora


Conidiophores type Conidiophores are type
are Conidiophores are erect and give rise to Phialides are vase
septate and erect, septate, erect and large 1° conidia that shaped w/ terminal
distal end of swollen, denticle in turn produce short, cuplike collaretes,
conidiophore bears 1°conidia at branching oval 2° conidia
develop the tip & side conidia accumulate
swollen dentricles
Phialophora verrucosa
colony morphology: surface is dark gray,
greenish brown to black with a close mat-
like olive to gray velvety to wooly
mycelium
 some strains are heaped and granular

 others are flat

Microscopic morphology: hyphae are


brown, branched and
septate
 phialides - vase-shaped with round

to oval conidia at the


apex giving a vase of
flower appearance
Cladosporium carrionii
colony morphology: surface is dark , flat
with slightly raised center, covered with
velvety dull gray short-napped
mycelium

Microscopic morphology: septate hyphae,


dark colored with lateral and terminal
conidiophores
Conidiophores produce long branching
chains of brown, smooth-walled, oval
somewhat pointed conidia
Pathogenesis & Clinical Findings:
fungi introduced by trauma into the skin
Lesions of chromoblastomycosis are most often found on
exposed parts of the body and usually start a small
scaly papules or nodules which are painless but
may be itchy
most common site:
 legs

 Feet

dissemination to other parts of the body is rare


Other prominent features include epithelial
hyperplasia, fibrosis and microabscess formation in
the epidermis
Satellite lesions may gradually arise and as the
disease develops rash-like areas, enlarge and
become raised irregular plaques that are often scaly
or verrucose (wartlike) growth that extend along
the lymphatics of the affected area with crusting
abscesses
In long standing infections, lesions may become
tumorous and even cauliflower-like in appearance
Diagnostic Laboratory Tests:
Specimen: Scraping or biopsy from lesions
Microscopic Examination
(a) Skin scrapings should be examined using 10%
KOH
= presence of dark brown, round fungus
cells
(sclerotic bodies) inside leukocytes or
giant cell

(b) Tissue sections should be stained using H&E, PAS


digest and Grocott's methenamine silver
= showing characteristic dark sclerotic
bodies
Treatment:
- Flucytosine = 150ml/k/ day P.O
- has achieved the most success
- Itraconazole 400 mg/day
for 6 to 12 months
terbinafine 500 mg/ day
- Successful surgical excision requires the removal
of a margin of uninfected tissue to prevent local
dissemination
- skin grafting may be required
Mycetoma
A mycotic infection of humans and animals induced
by inoculation by a number of different actinomycetes
and fungi
Fungal mycetoma Aka: Madura foot, Maduromycosis
Mycetoma characteristics:

Suppuration and abscess formation
 Tumefaction and deformation of the tissue

 draining sinus tracts containing granules

 cardinal sign of mycetoma is the so-called

“granule” (sometimes called “sulfa granule”) or


“sclerotia”
• Are microcolonies of the fungi packed with tissue debris
• Appear as variety of colors (white, brown, yellow, black)
• like a grain of sand and gritty to the touch
the disease results from the traumatic implantation of
• world-wide distribution but most common in bare-footed
populations living in tropical or subtropical regions
Etiologic agents of Mycetoma:
Actinomycotic Mycetoma

caused by actinomycetes (filamentous bacteria)
 differentiated by biochemical test and

chromatographic analysis of cell wall component


n Nocardia spp.
n Actinomadura spp.
n Streptomyces spp.
Mycotic Mycetoma (caused by the TRUE fungi)
a) Madurella mycetomatis - most cases worldwide
b) Exophiala jeanselmei
c) Pseudallescheria boydii (sexual state) most common
Scedosporium apiospermum (asexual state) etio. agent in
US
d) Madurella grisea - common etiologic agent in South
America
e) Acremonium sp.
Morphology & Identification
Actinomycotic mycetoma
 granules (white, yellow, red) are composed of narrow

intertwined filaments that are radially oriented and


most numerous at the edge of the granule

Mycotic Mycetoma
 Granules ( white, yellow, red or black) are extruded in

pus
 the granules contain septate, variously shaped hyphae

and depending on the species, may have longer, thick-


walled cells at the periphery; and are often
accompanied by numerous chlamydoconidia and
swollen cells

Black grains are generally fungal


small white grains bacterial (nocardial)
large white grains either fungal or bacterial
Madurella mycetomatis
colony morphology: Colonies are slow
growing, flat and leathery at first, white to
yellow to yellowish-brown, becoming
brownish, folded and heaped with age
and the formation of aerial mycelia
A brown diffusable pigment is
characteristically produced in primary
cultures
Microscopic morphology:
 two types of conidiation have been

observed:
1) flask-shaped phialides that bear
rounded conidia
2) simple or branched conidiophores
bearing pyriform conidia (3-5 um) with
truncated bases
Exophiala jeanselmei
colony morphology: surface is brownish
black, or greenish black and skin-like; it
then becomes covered with short velvety,
grayish hyphae

Microscopic morphology:
 young culture consist of many yeast-like
budding cells
 septate hyphae form with numerous
conidiogenous cells (annellides) that
are slender, tubular, sometimes
branched, and characteristically tapered
to a narrow, elongated tip

 Conidia are hyaline, smooth, thin-walled,


broadly ellipsoidal held in slimy gel at
Pseudallescheria boydii (Sexual state)

colony morphology: : surface has a


spreading, white, cottony aerial
mycelium w/c later turns gray or brown

Microscopic morphology:

large brown to black, spherical
cleistothecia are formed
 mostly submerged in the agar and

consist of irregularly interwoven


brown hyphae
 When crushed, cleistothecia release

faintly brown, ellipsoidal ascospores


Scedosporium apiospermum (Asexual
state)
Microscopic morphology:
 numerous, single-celled, pale-brown

broadly clavate to ovoid conidia,


borne singly or in small groups on
elongate, simple or branched
conidiophores laterally on hyphae

Graphium eumorphum
 the Graphium type of asexual

conidiation is seen occasionally


characterized by long, erect,
narrow conidiophores that are
cemented together, diverge at the
apex, and bear clusters of oval,
Pathogenic & Clinical Findings:
Causative agent introduced into subcutaneous tissue
by trauma (usually foot, hand, back , head, neck,
chest, shoulder and arms)

start out as a small hard painless nodule which over
time begins to soften on the surface and ulcerate to
discharge a viscous, purulent fluid containing granules
abscess may extend to muscle and bones
within the abscess, the granule is often surrounded by
eosinophilic matrix representing host materials and
antigen antibody complexes

untreated lesions persist for years and extend deeper


and peripherally causing deformity and loss of
function

Histologically - lesions resemble actinomycosis with


prominent abscess formation,
granulation tissue, necrotic foci and
fibrosis
Diagnostic Laboratory Test:
Clinical specimens for diagnosis:
 pus -  with granules


tissue -  for histological examination
Direct Microscopy:
 Serosanguinous fluid containing the granules should be

examined using 10% KOH


 tissue sections should be stained using H&E, PAS digest,

and Grocott's methenamine silver (GMS)


Culture: Sabouraud’s agar
 With the exception of Pseudoallescheria boydii, most

agents of eumycotic mycetoma grow well on media


containing cyclohexamide
 Pseudoallescheria boydii is inhibited by cyclohexamide

but grows well on Emmons' modification of Sabouraud’s


medium
Treatment:
Surgical draining assist in healing
No established therapy for fungal mycetoma since
drugs frequently do not penetrate the infected
tissue well enough to reach the fungal
pathogens
Until recently, only surgical removal of the whole
affected area was successful
recent study:
 Itraconazole yields the best results for the

treatment of fungal mycetomas


 Ketoconazole is an alternative

 Amphotericin B – for Madurella infections

 Nystatin and Potassium iodide – for P. boydii

infections

Control:
RHINOSPORIDIOSIS
A chronic infection characterized by the development
of polypoid masses of the nasal mucosa
Etiologic agent: Rhinosporidium seeberi
 Produce large spherules in lesions and in epithelial

cell tissue cultures


 Has not grown in vitro in culture media

 Habitat: water, fish, aquatic insects

90% of cases are found in India and Sri Lanka


More common in children and young adults
 Many patients are divers
Lesions:
 Found on the mucosa of the nose, nasopharynx, or

soft palate as well as other mucocutaneous sites


(conjunctiva, larynx, skin, genitalia and
rectum)
 initially flat, but develop into discolored,
cauliflower-like polypoid masses varying in size
Laboratory Diagnosis:
 Histologic exam of infected tissue reveals epithelial
hyperplasia, and a cellular infiltrate of neutrophils,
lymphocytes, plasma cells, and giant cells
Treatment:
 Surgical removal
 Topically or local injection of ethylstilbamidine
LOBOMYCOSIS
A chronic subcutaneous infection of humans and
dolphins
Etiologic agent: Loboa loboi
Patients have been men, mostly adults
Natural infection has been discovered in Atlantic
bottle-nose dolphins off the coast of Florida and South
America
Initial lesions are small, hard, painless subcutaneous
nodules, usually appearing on the extremities, face or
ear presumably as a result of traumatic inoculation of
the etiologic agent

Lesions become verrucose or ulcerative and
resemble chromomycosis, mycetoma or carcinoma
Lymph nodes are not involved
Laboratory Diagnosis:
Direct microscopic examination of skin scrappings,
biopsies, or wet preparation of exudative lesions
 Appears as large, spherical, or oval yeasts (10µm in

dm) that exhibit multiple budding and


characteristically form short chains of 3-6 or
more yeast cells
 are multinucleated and thick-walled

 Tissue sections reveal granulomatous nodules and

occasional asteroid bodies


Treatment:
 Surgical excision

 Sulfa drugs
The
End

Thank You!

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