Fungi and Yeasts, Fungi and Yeasts, Part IIPart II

KCOM/Texas Dermatology KCOM/Texas Dermatology ConsortiumConsortium

Dan Ladd, DO Dan Ladd, DO November 2003November 2003

GEOTRICHOSISGEOTRICHOSIS• Oral erythema, pseudomembranes, Oral erythema, pseudomembranes,

mucopurulent sputum mucopurulent sputum • Intestinal, bronchial and pulmonary Intestinal, bronchial and pulmonary

forms are similar to forms are similar to CandidaCandida• Geotrichum candidumGeotrichum candidum is pathogenic is pathogenic

only when repeatedly cultured, usually only when repeatedly cultured, usually just a contaminant saprophyte.just a contaminant saprophyte.

• Tx: Oral Nystatin, Amphotericin B, Tx: Oral Nystatin, Amphotericin B, ItraconazoleItraconazole

Geotrichum candidumGeotrichum candidumChains of rectangular cells, Chains of rectangular cells, and branching septate and branching septate myceliummycelium

Tinea NigraTinea Nigra

Black to brown spots on palms.Black to brown spots on palms.

Not elevated or scalyNot elevated or scaly

Young colonies are glossy, black Young colonies are glossy, black whereas older colonies are whereas older colonies are filamentous and gray.filamentous and gray.

Exophiala phaeoannellomyces Exophiala phaeoannellomyces (werneckii) (werneckii) saprophyte produces saprophyte produces melanin-like pigmentmelanin-like pigment

Tx: Topical econazole, ketoconazoleTx: Topical econazole, ketoconazole

Tinea Nigra–AOCD Grand Tinea Nigra–AOCD Grand RoundsRoundsExophiala phaeoannellomycesExophiala phaeoannellomyces

Piedra (Trichosporosis)Piedra (Trichosporosis)• Dark, pinhead-sized gritty formations Dark, pinhead-sized gritty formations

on the hairs of the scalp, brows, lashes on the hairs of the scalp, brows, lashes or beard. Minute round or ovoid, hard or beard. Minute round or ovoid, hard nodules distributed irregularly on the nodules distributed irregularly on the shaft of the hairs, not on the root.shaft of the hairs, not on the root.

• White: White: Trichosporon beigelii Trichosporon beigelii

• Black: Black: Piedraia hortaiPiedraia hortai

• Tx: Cutting hair, LamisilTx: Cutting hair, Lamisil

blacblackk

Piedraia Piedraia hortaihortai

whitewhite

•Trichosporon Trichosporon beigelii beigelii

Tinea VersicolorTinea Versicolor

• Upper trunk and armsUpper trunk and arms

• Young adults who perspire freelyYoung adults who perspire freely

• Hypopigmented: fungus causes Hypopigmented: fungus causes production of abnormally small production of abnormally small melanosomes that do not transfer to melanosomes that do not transfer to keratinocytes properly keratinocytes properly

• Hyperpigmented: Increase in size and Hyperpigmented: Increase in size and distribution of melanosomes. distribution of melanosomes.

Malassezia furfur….Malassezia furfur….

Tinea Versicolor TreatmentsTinea Versicolor Treatments

• Imidazoles, selenium sulfide, ciclopirox, Imidazoles, selenium sulfide, ciclopirox, olamine, zinc pyrithione, sulfur, olamine, zinc pyrithione, sulfur, salicyclic acid, propylene glycol, BPO. salicyclic acid, propylene glycol, BPO.

• Ketoconazole to damp skin 5 min x 3d.Ketoconazole to damp skin 5 min x 3d.• Ketoconazole, Fluconazole, Itraconazole.Ketoconazole, Fluconazole, Itraconazole.• Warn patients pigment slow to resolve.Warn patients pigment slow to resolve.• Relapse likely in 2 to 12 months if no Relapse likely in 2 to 12 months if no

monthly prophylaxis is given.monthly prophylaxis is given.

Pityrosporum FolliculitisPityrosporum Folliculitis

• Chronic, mildly pruritic dome shaped Chronic, mildly pruritic dome shaped papules and tiny pustules on upper papules and tiny pustules on upper back and adjacent areas, seborrheic back and adjacent areas, seborrheic distributiondistribution

• Sometimes associated with TV or SD.Sometimes associated with TV or SD.

• Often associated with Often associated with immunocompromise.immunocompromise.

• Due to Due to Malassezia furfur….Malassezia furfur….

Pityrosporum Pityrosporum folliculitisfolliculitis

Confluent and Reticulated Confluent and Reticulated Papillomatosis of Gougerot Papillomatosis of Gougerot & Carteaud& Carteaud

• Greatest intensity between breasts Greatest intensity between breasts and periumbilical, may spread to trunk.and periumbilical, may spread to trunk.

• May be initially mistaken for TV.May be initially mistaken for TV.

• Minocycline 100mg BID for 6 weeks.Minocycline 100mg BID for 6 weeks.

• Etretinate 50mg daily x 4 weeks.Etretinate 50mg daily x 4 weeks.

DEEP MYCOSESDEEP MYCOSES

• Inhalation of contaminated dustInhalation of contaminated dust

• Animal droppingsAnimal droppings

• Puncture wounds, abrasions, traumasPuncture wounds, abrasions, traumas

• Chancriform nodules with ulceration Chancriform nodules with ulceration and secondary lymphagitisand secondary lymphagitis

• CXR to rule out internal focus with CXR to rule out internal focus with dissemination dissemination

Coccidiomycosis – CA and SW Coccidiomycosis – CA and SW USAUSA

• Coccidiodes immitis, Coccidiodes immitis, San Joaquin Valley San Joaquin Valley FeverFever

• 1) Pulmonary: maculopapular or EN like rash 1) Pulmonary: maculopapular or EN like rash – EN is favorable prognostic sign– EN is favorable prognostic sign

• 2) Disseminated: (rare) Subcutaneous 2) Disseminated: (rare) Subcutaneous abcesses, may suppurate with sinuses – abcesses, may suppurate with sinuses – esp. face, scalp and nasolabial fold (HIV?)esp. face, scalp and nasolabial fold (HIV?)

• 3) Primary cutaneous (rare) = indurated 3) Primary cutaneous (rare) = indurated nodule with sporotricoid spreadnodule with sporotricoid spread

• Most forms (1 and 3) resolve spontaneouslyMost forms (1 and 3) resolve spontaneously

Coccidioides immitisCoccidioides immitis

ArthrosporesArthrospores

EndosporEndosporeses

Coccidio “endospores” PAS Coccidio “endospores” PAS ++

Surrounded by Surrounded by infectious infectious granulomatous pattern, granulomatous pattern, ie neuts, plasma cells, ie neuts, plasma cells, epithelioid and giant epithelioid and giant cellscells

Coccidioides immitisCoccidioides immitis

• Diagnosis by DNA probe, positive Diagnosis by DNA probe, positive intradermal coccidioidin test, KOH, intradermal coccidioidin test, KOH, precipitin and latex agglutination testsprecipitin and latex agglutination tests

• Skin biopsy with Skin biopsy with Gridley or Gomori Gridley or Gomori methenamine silver stain.methenamine silver stain.

• TOC: Fluconazole 400 to 800mg/day.TOC: Fluconazole 400 to 800mg/day.• If meningeal, need itraconazole or If meningeal, need itraconazole or

amphotericin intrathecally.amphotericin intrathecally.

Histoplasmosis -> Ohio & Histoplasmosis -> Ohio & Mississippi River Valleys Mississippi River Valleys

• 1) Pulmonary: acute pneumonitis, usually 1) Pulmonary: acute pneumonitis, usually resolves quickly, 10% may have EN, but EM resolves quickly, 10% may have EN, but EM and panniculitis have also been described.and panniculitis have also been described.

• 2) Disseminated: (rare) skin lesions in 6% 2) Disseminated: (rare) skin lesions in 6% nodules (granulomas) with “punched out” nodules (granulomas) with “punched out” ulcerations, MC nasopharyngeal (HIV, etc)ulcerations, MC nasopharyngeal (HIV, etc)

• 3) Primary cutaneous (rare) = cancre type 3) Primary cutaneous (rare) = cancre type lesion, usually on the penis, adenopathylesion, usually on the penis, adenopathy

• Most forms (1 and 3) resolve spontaneouslyMost forms (1 and 3) resolve spontaneously• African variant “cold abcesses” African variant “cold abcesses” H. duboisiiH. duboisii

H&E stain (left) shows macs filled with H&E stain (left) shows macs filled with organisms giving the cytoplasm a slightly organisms giving the cytoplasm a slightly vacuolated appearance. A GMS (Gomori vacuolated appearance. A GMS (Gomori methenamine stain) (right) shows clustered methenamine stain) (right) shows clustered organisms in cytoplasm.organisms in cytoplasm.

Geimsa stain: intracellular oval bodies Geimsa stain: intracellular oval bodies surrounded by an artefactual surrounded by an artefactual “capsule”“capsule”

Histoplasma capsulatumHistoplasma capsulatum

• Transmission: soil, spore inhalation, Transmission: soil, spore inhalation, bat or bird fecesbat or bird feces

• DX: urinary ELISA test avaliableDX: urinary ELISA test avaliable• Skin biopsy with Wright’s, Geimsa, PAS Skin biopsy with Wright’s, Geimsa, PAS

or or Gomori methenamine silver stain.Gomori methenamine silver stain.• TX: Disseminated disease requires TX: Disseminated disease requires

Amphotericin B or ItraconazoleAmphotericin B or Itraconazole• Minimal disease heals spontaneouslyMinimal disease heals spontaneously

CryptococcosisCryptococcosis• MC pulmonary, with MC spread to CNS.MC pulmonary, with MC spread to CNS.• MC cause mycotic meningitisMC cause mycotic meningitis• Disseminated, immunosupp., Disseminated, immunosupp., • 50% of HIV pts have MCV like lesions50% of HIV pts have MCV like lesions• 10-15% of cases have secondary skin 10-15% of cases have secondary skin

infection MC head and neck, may be infection MC head and neck, may be abcesses, tumors, draining sinuses etc. abcesses, tumors, draining sinuses etc.

• Primary skin infection rare, so discovery Primary skin infection rare, so discovery of crypto in the skin should prompt work of crypto in the skin should prompt work up to rule out other sites of infectionup to rule out other sites of infection

Cutaneous Crypto….Cutaneous Crypto….

Teardrop shaped, “Crying Teardrop shaped, “Crying Crypto”Crypto”

Oval thick walled Oval thick walled spherule that spherule that stains with stains with Methylene Blue, Methylene Blue, Alcian Blue (left) Alcian Blue (left) or Mucicarmine or Mucicarmine (right)(right)

Mycology of Crypto, KOH…Mycology of Crypto, KOH…

Without…Without… & with India & with India InkInk

Cryptococcus neoformansCryptococcus neoformans

• Transmission from inhalation of soil, Transmission from inhalation of soil, dust, pigeon droppingsdust, pigeon droppings

• Latex agglutination test, complement Latex agglutination test, complement fixation and EIA (enzyme immunoassay)fixation and EIA (enzyme immunoassay)

• Tx for disseminated is Amphotericin B Tx for disseminated is Amphotericin B followed by Fluconazole orally. followed by Fluconazole orally. Meningeal disease gets Ampho B plus Meningeal disease gets Ampho B plus Flucytosine, then Fluconazole orally.Flucytosine, then Fluconazole orally.

North American North American BlastomycosisBlastomycosis• Aka Aka Gilchrist’s diseaseGilchrist’s disease• Cutaneous form exhibits Cutaneous form exhibits

sporotricoid sporotricoid spread and if spread and if chronic almost always originates in chronic almost always originates in the lungs.the lungs.

• Most common site of dissemination Most common site of dissemination from lung is the skin. (80% of cases)from lung is the skin. (80% of cases)

• MC hands and feet, nodular, draining MC hands and feet, nodular, draining sinuses or papillomatous and crusted.sinuses or papillomatous and crusted.

• LESIONS ARE USUALLY MULTIPLELESIONS ARE USUALLY MULTIPLE

North American BlastomycosisNorth American BlastomycosisBlastomyces dermatitidesBlastomyces dermatitides

• Southeastern US, Ohio Southeastern US, Ohio & Mississipi river & Mississipi river basins, Kentucky.basins, Kentucky.

• Transmission: soil in a Transmission: soil in a beaver dam, dog bite beaver dam, dog bite (dog had pulmonary (dog had pulmonary blasto), men (with blasto), men (with prostatic blasto) to prostatic blasto) to their sexual partnerstheir sexual partners

Broad Based Broad Based Budding yeast Budding yeast

BlastomycBlastomyces es dermatitiddermatitideses

KOH will show single KOH will show single or singly budding or singly budding spherical cells with spherical cells with refractile wallsrefractile walls

Blasto culture is Blasto culture is difficult, requires difficult, requires Sabouraud’s Sabouraud’s dextrose agar, dextrose agar, Mycosel and a brain-Mycosel and a brain-heart infusion agar to heart infusion agar to which blood has been which blood has been added.added.

DNA probe assay is DNA probe assay is commercially commercially avaliableavaliable

North American North American Blastomyces BLASTO = Blastomyces BLASTO = BROAD BASED BUDSBROAD BASED BUDS

•TX: Itraconazole, Amphotericin B, TX: Itraconazole, Amphotericin B, FluconazoleFluconazole

South American South American BlastomycosisBlastomycosis• Aka Aka ParacoccidiomycosisParacoccidiomycosis• Lungs MC, but mucocutaneous type Lungs MC, but mucocutaneous type

begins in the mouth -> nose, lips, facebegins in the mouth -> nose, lips, face• Lymphangitic type spread w/ regional Lymphangitic type spread w/ regional

lymphadenopathy mimics Hodgkins.lymphadenopathy mimics Hodgkins.• Visceral and mixed types exist.Visceral and mixed types exist.

• Brazil, Argentina, Venezuela, Brazil, Argentina, Venezuela, US, US, Mexico and Central AmericaMexico and Central America

• Dx: Complement fixation test avaliableDx: Complement fixation test avaliable• Tx: Itraconazole, Ketoconazole, Ampho B, Tx: Itraconazole, Ketoconazole, Ampho B,

Bactrim can be suppressive in HIV patientsBactrim can be suppressive in HIV patients

Paracoccidioides Paracoccidioides brasilensisbrasilensis

““MARINER’S MARINER’S WHEEL”WHEEL”

• SPOROTRICHOSIS, Sporothrix schenckiiSPOROTRICHOSIS, Sporothrix schenckii

• Localized skin wound -> regional lymphangitic Localized skin wound -> regional lymphangitic spread spread “Sporotrichoid”“Sporotrichoid”

• Most common and least serious of the deep mycoses.Most common and least serious of the deep mycoses.

• Disseminated disease is rare.Disseminated disease is rare.

Sporothrix schenckiiSporothrix schenckii

““Asteroid Asteroid body”body”

Cigar BodiesCigar Bodies

Conidia in Conidia in sleeve like sleeve like arrangement arrangement =>=>

Conidia Conidia in in <=cluste<=clustersrs

Sporothrix schenckiiSporothrix schenckii• Pathogen lives as a saprophyte on Pathogen lives as a saprophyte on

grasses, shrubs, carnations, rose grasses, shrubs, carnations, rose bushes, barberry, sphagnum moss.bushes, barberry, sphagnum moss.

• Has been found in horses, mules, Has been found in horses, mules, dogs, dogs, catscats, mice and rats., mice and rats.

• Dx: Sporotrichins skin test is like TB Dx: Sporotrichins skin test is like TB test, only shows previous or current test, only shows previous or current exposureexposure

• Agglutination test is best 1:80Agglutination test is best 1:80

Sporothrix schenckii Tx:Sporothrix schenckii Tx:

• Treatment Itraconazole 200mg/day x 6 Treatment Itraconazole 200mg/day x 6 months months

• Potassium Iodide, begin with 5 drops Potassium Iodide, begin with 5 drops TID with grapefruit juice or milk after TID with grapefruit juice or milk after meals, then gradually increase to 50 meals, then gradually increase to 50 drops TID for a total of 12 weeks. drops TID for a total of 12 weeks. Should check TSH as hypothyroidism Should check TSH as hypothyroidism may occur. Multiple side effects for this may occur. Multiple side effects for this medication.medication.

ChromoblastomycosisChromoblastomycosis

• Usually affects on leg or foot, slowly Usually affects on leg or foot, slowly spreads with satellite lesions, may be spreads with satellite lesions, may be nodular or verrucous “cauliflower-nodular or verrucous “cauliflower-like”like”

• Small lesions may mimic common Small lesions may mimic common warts. Also plaque-like, keloidal or warts. Also plaque-like, keloidal or cicatricial.cicatricial.

Chromoblastomycosis – 5 Chromoblastomycosis – 5 fungifungi• Cladosporium Cladosporium carrioniicarrionii

• Phialophorra Phialophorra verrucosaverrucosa

• Fonsecaea Fonsecaea pedrosoipedrosoi

• Fonsecaea Fonsecaea compactacompacta

• Rhinocladiella Rhinocladiella aquaspersaaquaspersa

MC barefooted farm MC barefooted farm laborers in Brazil, Cuba, laborers in Brazil, Cuba, West Indies, US, Russia, West Indies, US, Russia,

Madagascar.Madagascar.

Copper pennies, Medlar bodies, Sclerotic Copper pennies, Medlar bodies, Sclerotic bodiesbodies

Chromoblastomycosis TXChromoblastomycosis TX

• Best treated by surgical excision and Best treated by surgical excision and grafting of the affected areagrafting of the affected area

• If lesions are chronic or burrowing If lesions are chronic or burrowing Itraconazole 100mg/day for 18 monthsItraconazole 100mg/day for 18 months

• Lamisil 500mg/day has been Lamisil 500mg/day has been remarkably effectiveremarkably effective

• Application of heat is effective!Application of heat is effective!

• Amputation may be unavoidableAmputation may be unavoidable

PhaeohyphomycosisPhaeohyphomycosis• 30 causative fungi30 causative fungi

• Exophiala jeanselmeiExophiala jeanselmei is the MC in temperate is the MC in temperate climatesclimates

• BipolarisBipolaris and and ExserohilumExserohilum genera are being genera are being MC recovered as causes of both MC recovered as causes of both subcutaneous lesions and systemic infections.subcutaneous lesions and systemic infections.

• Black & White piedra are superficial examplesBlack & White piedra are superficial examples

• Has yeast-like cells, hyphae, pseudohypha-Has yeast-like cells, hyphae, pseudohypha-like elements, unlike Chromo, which has like elements, unlike Chromo, which has spherical cellsspherical cells

• Exophiala jeanselmeiExophiala jeanselmei

• Dactylaria gallopavaDactylaria gallopava

• Phialophora parasiticaPhialophora parasitica

• Phaeoannellomyces werneckiiPhaeoannellomyces werneckii

• Hendersonula toruloideaHendersonula toruloidea

• Wangiella dermatitidisWangiella dermatitidis

• Exserohilum rostratumExserohilum rostratum

• Bipolaris spiciferaBipolaris spicifera

• Cladophialophora bantianaCladophialophora bantiana

• Xylohypha bantianaXylohypha bantiana

Multi-tasking fungi….Multi-tasking fungi….

• Exophiala jeanselmeiExophiala jeanselmei may cause may cause mycetoma in some patients, and mycetoma in some patients, and phaeohyphomycosis in some patients, phaeohyphomycosis in some patients, and chromoblastomycosis in others.and chromoblastomycosis in others.

• Phialophora verrucosaPhialophora verrucosa can cause can cause both phaeohyphomycosis and both phaeohyphomycosis and chromoblastomycosischromoblastomycosis

Phaeohyphomycosis TXPhaeohyphomycosis TX

• May respond to topical antifungalsMay respond to topical antifungals

• Surgical excision along with Surgical excision along with Itraconazole 400mg per day for 6 Itraconazole 400mg per day for 6 months needed for deeper lesions.months needed for deeper lesions.

MycetomaMycetoma• Clinical entity, not a etiologic one.Clinical entity, not a etiologic one.

• Actinomycetomas, Eumycetomas Actinomycetomas, Eumycetomas (true fungi), Staph and Strep can (true fungi), Staph and Strep can cause mycetomascause mycetomas

• Subcutaneous swelling of instep or Subcutaneous swelling of instep or toe web, painless, firm, rubbery with toe web, painless, firm, rubbery with draining sinuses that secrete grains draining sinuses that secrete grains of the causative organism. of the causative organism. Underlying bone may be involved.Underlying bone may be involved.

MycetomaMycetoma

Eumycetomas (true fungi)…Eumycetomas (true fungi)…

• Pseudallesceria boydiiPseudallesceria boydii

• Acremonium falciforme & recifeiAcremonium falciforme & recifei

• Leptosphalaeria senegalensis & Leptosphalaeria senegalensis & tompkinsiitompkinsii

• Madurella grisea & mycetomatisMadurella grisea & mycetomatis

• Exophiala jeanselmeiExophiala jeanselmei

• Pyrenochaeta romeriPyrenochaeta romeri

• Phialophora verrucosaPhialophora verrucosa

• Black grain mycetoma: subcutaneous Black grain mycetoma: subcutaneous nodule due to nodule due to Madurella mycetomatisMadurella mycetomatis

• mycetoma caused by mycetoma caused by Madurella griseaMadurella grisea

Actinomycetomas…Actinomycetomas…• Nocardia asteroidesNocardia asteroides

• Nocardia brasilensisNocardia brasilensis

• Nocardia caviaeNocardia caviae

• Actinomadura maduraeActinomadura madurae

• Actinomadura pelletierActinomadura pelletier

• Actinomyces israeliiActinomyces israelii

Grains = White/Cream/Sulfur Grains = White/Cream/Sulfur Yellow Yellow

• Actinomyces israeli Actinomyces israeli • Actinomadura maduraeActinomadura madurae• Nocardia sp.Nocardia sp.• Streptomyces somalensisStreptomyces somalensis• Pesudallescheria boydiiPesudallescheria boydii• Acremonium sp.Acremonium sp.• Aspergillus nidulansAspergillus nidulans• Fusarium sp.Fusarium sp.• Neotestudinea rosatiNeotestudinea rosati

Grains = redGrains = red

• Actinomadura pelletieriActinomadura pelletieri

Black GrainsBlack Grains• Curvularia geniculataCurvularia geniculata• Helminthosporium spiciferumHelminthosporium spiciferum• Leptosphaeria senegalensisLeptosphaeria senegalensis• Madurella griseaMadurella grisea• M. mycetomatisM. mycetomatis• Exophiala jeanselmeiExophiala jeanselmei• Phialophora verrucosaPhialophora verrucosa• Pyrenochaeta romeriPyrenochaeta romeri

Epidemiology DX & TXEpidemiology DX & TX

• Mycetoma occurs everywhereMycetoma occurs everywhere

• Mexico, Venezuela, Argentina, Senegal, Mexico, Venezuela, Argentina, Senegal, Sudan SomaliaSudan Somalia

• Probably acquired from soil -> barefootProbably acquired from soil -> barefoot

• Dx Triad: Tumefaction, Sinuse, GranulesDx Triad: Tumefaction, Sinuse, Granules

• TX: Antibiotics or Antifungals if organism TX: Antibiotics or Antifungals if organism dictates, then surgical excisiondictates, then surgical excision

LobomycosisLobomycosis

• Aka Keloidal BlastomycosisAka Keloidal Blastomycosis

• Central and South AmericaCentral and South America

• Keloidal plaques +/- sinusesKeloidal plaques +/- sinuses

• MC ear, may resemble cauliflower earMC ear, may resemble cauliflower ear

• Dolphins may harbor this infectionDolphins may harbor this infection

• TX: Excision, Amphotericin B usually TX: Excision, Amphotericin B usually unsuccessful.unsuccessful.

Lobomycois (Keloidal Lobomycois (Keloidal Blasto)Blasto)

• Thick walled Thick walled refractile refractile spherules spherules larger than larger than those of those of ParacoccidiodeParacoccidiodess

RhinosporidiosisRhinosporidiosis

• Polypoid, nasal mucosa MCPolypoid, nasal mucosa MC• Begin as small papilloma, become Begin as small papilloma, become

pedunculated tumors, friable, may pedunculated tumors, friable, may resemble cauliflowerresemble cauliflower

• Rhinosporidium seeberiRhinosporidium seeberi• Characteristic large sporangiaCharacteristic large sporangia• Endemic in Ceylon and India, but Endemic in Ceylon and India, but

seen in Argentina and Brazil.seen in Argentina and Brazil.

ActinomycosisActinomycosis• Anaerobic Gram + bacteriaAnaerobic Gram + bacteria

• MC cervicofacial areasMC cervicofacial areas

• Middle aged men MCMiddle aged men MC

• Lesions are characteristic local dusky Lesions are characteristic local dusky red swellings; firm fluctuating nodules; red swellings; firm fluctuating nodules; and sinuses exuding purulent and sinuses exuding purulent discharge including yellow sulfur discharge including yellow sulfur granules.granules.

• TX: PCN G in large doses 10-20 million TX: PCN G in large doses 10-20 million units daily for 1 monthunits daily for 1 month

ActinomycosisActinomycosis – sulfur – sulfur granulesgranules

NocardiosisNocardiosis

• Usually pulmonary, but 1/3 CNSUsually pulmonary, but 1/3 CNS

• May resemble TB clinicallyMay resemble TB clinically

• Nocardia asteroides MC disseminatedNocardia asteroides MC disseminated

• N. brasilensas MC sporotrichoid patternN. brasilensas MC sporotrichoid pattern

• Traumatic implantation or dust Traumatic implantation or dust inhalationinhalation

• Bactrim DS drug of choice, may use Bactrim DS drug of choice, may use Minocycline or AugmentinMinocycline or Augmentin

Zygomycosis Zygomycosis (Phycomycosis)(Phycomycosis)• EntomophthoromycosisEntomophthoromycosis - 2 sites - 2 sites• Face – Face – Conidiobolus coronatusConidiobolus coronatus• Trunk – Trunk – Basidiobolus ranarumBasidiobolus ranarum• MC Indonesia, Africa, Asia & AmericasMC Indonesia, Africa, Asia & Americas• MucormycosisMucormycosis - characteristic skin lesions - characteristic skin lesions

as it has a propensity for invasion of blood as it has a propensity for invasion of blood vessels and therefore leads to infarction, vessels and therefore leads to infarction, gangrene and black necrotic lesions.gangrene and black necrotic lesions.

• Ubiquitous molds.Ubiquitous molds.

MucormycosisMucormycosis

HyalohyphomycosisHyalohyphomycosis

• Non dematiaceus moldsNon dematiaceus molds

• Fusarium, Penicillium, PaecilomycesFusarium, Penicillium, Paecilomyces

• UbiquitousUbiquitous

• Fusarium oxysporumFusarium oxysporum superficial superficial white onychomycosis in HIV.white onychomycosis in HIV.

• Excision and Amphotericin B have a Excision and Amphotericin B have a low success rate.low success rate.

AspergillosisAspergillosis

• Second only to Candida as fungal Second only to Candida as fungal opportunistic in HIV, transplant pts.opportunistic in HIV, transplant pts.

• Blood cultures and serologic tests usually Blood cultures and serologic tests usually negativenegative

• Usually pulmonary involvementUsually pulmonary involvement• Aspergillus fumigatus MC disseminated.Aspergillus fumigatus MC disseminated.• Aspergillus flavus MC primary cutaneous, Aspergillus flavus MC primary cutaneous,

may look like hemorrhagic bullae or may look like hemorrhagic bullae or molluscum lesionsmolluscum lesions

AspergillosAspergillosisseptate isseptate hyphae, hyphae, 45 degree 45 degree angles.angles.

AlternariosisAlternariosis

• Genus of molds that are common Genus of molds that are common plant pathogens, but rarely infect plant pathogens, but rarely infect humans.humans.

• Usually immunocompromised Usually immunocompromised patients.patients.

• Standard antifungal therapy.Standard antifungal therapy.

Protothecosis (Algae Protothecosis (Algae etiology)etiology)

• Prototheca wickerhamii and zopfiPrototheca wickerhamii and zopfi

• Stagnant water and soilStagnant water and soil

• Olecranon bursa if healthy, or any Olecranon bursa if healthy, or any type of immunocompromised.type of immunocompromised.

• PAS stains positivePAS stains positive

• Amphotericin B and TCN synergisticAmphotericin B and TCN synergistic

• DiflucanDiflucan