8. mycosis systmk opp. & path
DESCRIPTION
mycosisTRANSCRIPT
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MYCOSIS SYSTEMIK OPPORTUNISTIK DAN MYCOSIS SYSTEMIK PATOGEN
Oleh :
Dr. dr. Hj. Efrida Warganegara, M.Kes., Sp.MK
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Oleh :
Dr.dr.Efrida Warganegara, M.Kes., Sp.MKSYSTEMIC MYCOSIS
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SYSTEMIC MYCOSIS : PathogenicDiseaseaAgent
BlastomycosisBlastomyces dermatitidis
HistoplasmosisHistoplasma capsulatum
CoccidioidomycosisCoccidioides immitis
ParacoccidioidomycosisParacoccidoides brasiliansis
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BLASTOMYCOSIS= Notrh American Blastomycosis= Gilchists diseaseEtiologic agent : Blastomyces dermatitidis, a dimorphic fungus that grows as mold at room temperature and as a yeast at 35 - 370C
Epidemiology :
B. dermatitidis is saprophytic in nature & grows in the mold form in soil
or decaying wood associated with soil, has been isolated several times, but repeated isolation from the same sites were not succesful
most of the cases have been found in Noth America, but also prevalent in Africa & has been reported in India, occurs most often in adult males
the lack of a specific skin test antigen has prevented the determination of the prevalence of asymptomatic Blastomycosis in large population
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BLASTOMYCOSISCxlinical features :
the primary site of Blastomycisis is the lung, with mild infiltrat & few clinical symptomsin severe disease, pulmonary infiltrate may be more extensive & the patients will have fever, cough & weight lose, nodular pulmonary lesion may occursome cases may progres to chronic disease with pulmonary fibrosis & the cavitationthe fungus may disseminate to any organ of the body, mostly skin & boneskin lesion are frequently a manifestationof disseminated disease, with dry & scaly, extensive granulomatous with vesicle or pustule
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BLASTOMYCOSISLaboratory diagnosis :
Direct microscopic examination :
wet mount : B. dermatitidis appear as a large, thick-walled single-budding yeast ( 8 - 18 um ), the bud has a wide base
histophatology : the yeast form is usually easily fount in infected tissue, are best detected with PAS or GMS stain
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BLASTOMYCOSISLaboratory diagnosis :Culture :is the dimorphic fungus, that grows in the mycelial form (mold) at room temperature & as a yeast at 370Cthe mold form grows slowly, became visible in 7 - 10 days, the colony is usually white & cottonythe yeast-like colony grows on blood agar at 370C after 3 - 4 days
Microscopic morpology :the mold produces small, smooth walled conidia & attached to the conidiophores that arise directly from the hyphaeyaest are large, thick-walled, single-budding & the bud has a wide base (neck) the diagnostic structure of B. dermatitidis
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BLASTOMYCOSISSerology :
ID test is the most reliable, CFT not detect antibodies in all cases, will cross-react with antibodies to H. capsulatum
Treatment : Amphoterisin B, Ketoconazole
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HISTOPLASMOSIS= reticuloendotheliosis= Darlings diseaseEtiologic agent : Histoplasma capsulatum, a dimorphic fungus, having a mold form at room temperature & yeast form at 370CEpidemiology :
H. capsulatum grows in soil, especially in soil that esriched with bat or bird manureoften be isolated from old building/caves, where birds/chickens or bats have roostedH. capsulatum grows in soil in the mycelial form & large number of conidia are producethe disease is acquired by inhaling conidia & reported from most area of the world
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HISTOPLASMOSISClinical features :
is primarily a pulmonary disease; when conidia are inhaled, infections is established in the lungs; the disease may be mild, with few or no symptom (95%)
may be severe with lung infiltrates, from mild to extensive
primary pulmonary histoplasmosis progresses to chronic pulmonary disease in about 5 % of those with disease; is characterized by fibrosis & cavitation,
symptoms includes : cough, fever, chills & weight lose (resembles to toberculosis, sarcoidosis, & other systemic fungal disease)
the most severe form of histoplasmosis is disseminated disease; the fungus invade any organs of body
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HISTOPLASMOSISLaboratory diagnosis :
Direct microskopic examination : wet mount :
H. capsulatum may be seen in sputum, bronchial washed, or in any body fluids as a small yeast, 4 - 6 um
histopathology : the yeast form can be found in tissue removed from the infected sites, ussually in the macrophage & in granulomas
GMS (gomori methenamine silver) stain should be used ( the yeat dark-brown - black )
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HISTOPLASMOSISCulture :
colony morphology : H. capsulatum grows slowly in the mold form when incubated at room temperature, appear in 7 - 10 days but conidia is not form until later; on SDA ( sabouraud dextrose agar ) the colony Is ussually white & cottony
microscopic morphology :two types of conidia are prodeced by H. capsulatum small, pyriform smoth-walled conidia (microconidia, 4 - 6 um ) and large, round, thick-waled tuberculated conidia ( macroconidia, 8 - 18 um )the diagnostic conidia
to prove the identification of H. capsulatum, convert the mold form - yeast form; be done by transferring the mold colony to blood agar & incubate at 370C in 3 - 5 days the yeast colony will be white brown
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HISTOPLASMOSISSerology :
antibodies to the fungus are produced within 10 - 21 days after a person is infected by H. capsulatum
agglutination test, measures IgM antibodies, is a quantitative test
CFT, measures both IgM & IgG, is quantitative test; ID test is a quantitative test
Treatment :
Amphotericin B, Ketoconazole
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COCCIDIOIDOMYCOSIS= valley feverEtiologic agent : Coccidioides immitis, a biphasic fungal pathogen
Epidemiology :C. immitis grows in semi-acrid, solid, is known to exist in North, Central, & South American, especially California; its inhaled into the alveoli, where it produces disease, either benign ( resembles flu ), or acute, depending on many factors ( race; inoculum )
Clinical features :most is a benign disease, prodeces only mild symptoms; among certain races ( Filipinos, Black ), immunosupressed or the used of corticosteroids, disseminated may occur
there is no site of predilection for this organism; any body tissue may become infected
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COCCIDIOIDOMYCOSISLaboratory diagnosis :
Direct microscopic examination :
wet mount : specimens in KOH mounts, C. immitis may be seen as sporangia ( spherula ) filled with endospora
histophatology : the sporangia stain well with HE & PAS stain
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COCCIDIOIDOMYCOSISCulture : Never work with culture on the laboratory bench OUTSIDE of a biohazard hood !
C. immitis is a biphasic fungal phatogen, grows at room temperature repidly producing a dirty gray-white colony; at maturity, the hyphae develops arthroconidia wich enlarged & barrel-shaped; alternate cells emptythe hyphae break easilly into separate artrhoconidia float in the air spread by the wind
Serology : used as diagnostic & prognostic tools; include CFT, latex aglutination, ID test
Treatment : Amphotericin B, Ketoconazol
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PARACOCCIDIOIDOMYCOSIS= South American blastomycosisEtiologic agent : Paracoccidioidomycosis brasiliaensis, a dimorphic fungus that grows as mold at room temperature & as a yeast at 370C / in infected tissues
Epidemiology :the saprophytic habitat of P. brasiliensis is not known; endemic mostly in South America
most cases of paracodioidomycosis are seen in adult males; is rare in children & adult women; appears to reflect a host-parasite relasionship by sex hormones
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PARACOCCIDIOIDOMYCOSISClinical features :
the primarily site of infection is the lung; disease may be benign, primary pulmonary form or may disseminate to produce acute & chronic, progresive disease, includes lymph nodes & skin
the primary benign form may ultimately results with some residual interstitial fibrosis
acute & chronic, progresive paracoccidioidomycosis, disseminated from of the disease, most prequently recognized on the basic of lesion on oropharynx & gingivae
progresive chronic pulmonary disease may involve all lobes of the lung; produce extensive fibrosis
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PARACOCCIDIOIDOMYCOSISLaboratory diagnosis :
Direct microscipic examination :wet mount : appears a large, yeast-like cells ( 30 - 360 um ), budding with one or more buds ( multiple buds ) with narrow necks
histophatology : in infected tissue appears as large cells, multiple buds, connected to the parent cell by narrow necks, it has been called a pilot wheel or mickey mouse
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PARACOCCIDIOIDOMYCOSISLaboratory diagnosis :Culture :colony morphology : P. brasiliensis is a dimorphic fungus, grows slowly in the mycelial form at room temperature; readily convert to the yeast phase when grown at 370C on enriched media
microscopic morphology : the mycelial form is thin, septate hyphae, conidia, chlamydospora & arthroconidia may be formed;yeast phase cultures will demonstrate both mycelial element & yeast; the yeast are characterized by large ( 30 um or more ); multiple-thin-walled buds, with narrow necks
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PARACOCCIDIOIDOMYCOSISLaboratory diagnosis :
Serology : CFT & ID test have been shown to be reliable; however cross reactions may occur
Tretment : Ketoconazole, Amphotericin B, Sulfadiazine
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SYSTEMIC MYCOSESSYSTEMIC MYCOSIS : Opportunistic
DiseaseAgents
Candidiasis Candida albicans; Candida sp.
Cryptococcosis Cryptococcus neoformans
Aspergillosis Aspergillus fumigatus; Aspergillus sp.
Zygomycosis Mucor, Rhizopus, Absidia
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SYSTEMIC MYCOSES PathogenicOpportunistic
Agent dimorphic fungus non-dimorphic fungus
Port dentre lung (per inhalation )lung & others
Diseaseusually chronicusually acute
Patients could be healthy patients usually ill patient
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SYSTEMIC MYCOSESCANDIDIASIS = Candidosis
acute / chronic fungal infections, involving, the mouth, vagina, skin nails, bronchi / lung, alimentary tract, urinary tract, blood steam and less commonly, the heart or meningen
are caused by Candida albicans or other species
are predisposed by : extremes of age, wasting, & nutritional disease, excessive moisture, pregnancy, diabetes, long-term antibiotics, & steroid use, indwelling catheter, immunosupressed & AIDS
are generally treated with imidazoles, polyenes or both
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CANDIDIASISCandida albicans :
is part of the normal flora of the skin, mucous membranes & GI tract along with other Candida sp.
normal colonization must be distinguised from infection
form elongated budding forms called pseudohyphae, which are often seen in clinical material along with true hyphae, blastoconidia & yaest cells
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CANDIDIASISClinical features : oral thrush
is a yeast infectoins of the oral mucocutaneus membranes
manifest as white curd-like patches in the oral cavity
occurs in premature infants; older infants being treated with antibiotics, immunosuppressed patients, long-term antibiotics & AIDS patients
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CANDIDIASISClinical features : Vulvovaginitis
is a yeast infection of the vagina; manifest with a thick yellow-white discharge, a burning sensation, curd-like patches on the vaginal mucosa & inflamation of perineum
is predisposed by diabetes, antibiotic therapy, oral contraceptive use & pregnancy
may be trasmitted to sexual partner as balanitis
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CANDIDIASISClinical features : Cutaneus candidiasis
involves the nails ( onychomycosis; paronychis ), skin folds ( intertriginosa ) or groin ( such as diaper rash )may be eczematoid or vesicular / pustular; is predisposed by moist condition
Clinical feature : alimetary tract disease :
is usually an extension of oral thrush & may include esophagitis & ultimately the entire gastrintestinal tract
is found in patients with AIDS or other immunosuppressive disorder, particularly those patients on long-term antibiotics therapy
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CANDIDIASISClinical feature : Chronic mucocutaneus candidiasis
is a chronic, often disfiguring, infections of the epithelial surfaces of the body
is diagnosed microscipically & by the lack of cell mediated immunity
Clinical feature : Bronchopulmonary infections
occurs in patient with chronic lung disease; its usually manifested by persistent cough
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CANDIDIASISClinical feature : Candidemia / blood borne infections
occurs most commonly in patients with indwelling catheter; these infections are manifested by fever, macronodular skin lesion & endopthalmitis
Clinical feature : Endocarditis
occurs in patient who have manipulated or damaged valves, or in IV drug abusers
Clinical feature : Cerebrospinal infections
may occur in compromised patients
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CANDIDIASISLaboratory diagnosis :
direct microscopic examination : wet mount of the skin / nail scraping or exudate, demonstration of the presence of pseudohyphae / hyphae, & yeast in the tissue
culture : of the specimens on to SDA at room temperature, Candida will grows as yaest-like colony
C. albicans be identified by :* germ tube test -- yeast germination in serum at 370C* culture on corn-meal-agar -- reveals chlamydospres* culture on Eosin-methylen-blue-agar : reveals spider colony* fermentation test of : glucose, lactose, maltose, sacharoseserologic : high levels of Candida precipitins or antigens
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SYSTEMIC MYCOSES : OpportunisticCRIPTOCOCCOSISinclude subacute or chronic fungal infections involving the lungs, meninges, or less commonly the skin, bones & other tissues
most commonly occur as cryptococcal meningtis; often occuring in AIDS patients
is caused by Cryptococcus neoformans; yeast that posseses an antigenic polysaccharidae capsule
is associated with pigeon feces; considered to be an opportunist in the present of underlying disease in patients with Hodgkins disease, leukomias; or leucocyte enzyme deficiency disease
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CRYPTOCOCCOSIS = Busse-Buschkes disease = European BlastomycosisClinical feature :
pulmonary infections : are ussually asymptomatic; & self resolving; most common in pigeon breeder
meningitis ( most often ) or meningoencephalitis occurs in AIDS patients most commonly with headache, ussually with fever, followed by typical sign of meningitis
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CRYPTOCOCCOSISLaboratory diagnosis :
microscopic examination : wet mount, demonstration of encapsulated yeast in CSF sediment in india-ink
detection of the capsular material in the CSF ( the cryptococcal antigen ) by latex agglutination test
culture : in SDA ( Sabouraud dextrase agar ) revealyeast colony
Treatment : Amphotericin B, 5- fluorocytosisn or fluconazol
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SYSTEMIC MYCOSES : OpportunisticASPERGILLOSIS
caaused by Aspergillus fumigatus, an opportunistic organism
is a ubiquitous filmentous fungus whose airborne spores are contantly in the air
is recognized both in tissue & in culture by its characteristic septate hyphae with dichotomous branching, produced conidial heads with numerous conidia
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ASPERGILLOSISClinical feature : Aspergilloma = fungus ball :
is a roughly spherical growth of Aspergillus in pre existing lung cavities & does not invade the lung tissue
occurs clinically as reccurent hemoptysis & diagnosed by radiologig method
Treatment : surgical ( lobectomy )
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ASPERGILLOSISClinical features : Invasive aspergillosis
occurs most commonly during severe neotropenic in leukemia & transplantm patients; most commonly occurs as fever of unknown origin in patient with neutropenia fewer than 500/mm3 & pneumonia
it may begin as sinusitis or lungs; it disseminate to any part of the body, most frequently brain
is diagnosed by microscopy & culture of lung biopsy material
is trested with amphotericin B or intraconzole & has a high fatality rate
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ASPERGILLOSISClinical features : Allergic bronchopulmonary - aspergillosis
is an allergic disease, in which the organism colonies the mucous plugs form in the lung, but does not invade lung tissue
is diagnosed by finding of high titer of IgE antibodies
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SYSTEMIC MYCOSES : OpportunisticZYGOMYCOSIS = Mucormycosis + Phycomycosis
caused by the genera Rhizopus, Mucor & Absidia; non-septate fungi; phylum Zygomycota; grow repidly & predilection for invading blood vessels & the brain
Clinical features : thoracic infectoins
occur in leukemia & lymphoma patients
abdominal-pelvic infections occurs in malnourish patients
cutaneus infections occurs in patients with leukemia30
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ZYGOMYCOSISClinical features : Rhinocerebral infections
is the common form; occurs in patients with acidotic diabetes
presents with facial swelling & blood tinged exudate in the turbinate bones & eyes; lethargy & fixated pupil
is a fatal infections & spreads rapidly
must be diagnosed rapidly; ussually by a KOH mount of necrotic tissue or exudate from the eye, nose, or ear
Treatment : control of diabetes; Surgical debridement; amnphotericin B