Superficial Fungal Infections

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Superficial Fungal Infections

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Superficial Fungal Infections

  1. 1. Superficial Fungal Infections Dr.T.V.Rao MD11/23/2012 Dr.T.V.Rao MD 1
  2. 2. SUPERFICIAL MYCOSES The superficial mycoses are usually confined to the outermost layer of skin, hair and do not invade living tissues.11/23/2012 Dr.T.V.Rao MD 2
  3. 3. SUPERFICIAL MYCOSES Pityriasis versicolor Tinea nigra Black piedra White piedra Keratomycosis11/23/2012 Dr.T.V.Rao MD 3
  4. 4. 11/23/2012 Dr.T.V.Rao MD 4
  5. 5. PITYRIASIS VERSICOLOR (Tinea versicolor)• Superficial chronic infection of Stratum corneum• Etio: Malassezia furfur (Pityrosporum orbiculare) (Lipophilic yeast)• Clinical findings: Hyperpigmented or depigmented maculae on chest, back, arms, abdomen11/23/2012 Dr.T.V.Rao MD 5
  6. 6. Superficial• Do not elicit immune response• No discomfort• Cosmetic problems• Limited to stratum conium11/23/2012 Dr.T.V.Rao MD 6
  7. 7. Pityrisis versicolor11/23/2012 Dr.T.V.Rao MD 7
  8. 8. Ring worm Infections• Infection of the Stratum corium.• Called as Dermatophytosis or Tinea.• Called as per the site of Infection.• Tinea pedis – feet are involved.• Tinea captis – Scalp.11/23/2012 Dr.T.V.Rao MD 8
  9. 9. RING WORM LESIONS11/23/2012 Dr.T.V.Rao MD 9
  10. 10. Tinea lesions on Scalp11/23/2012 Dr.T.V.Rao MD 10
  11. 11. Ring worm lesions on Face11/23/2012 Dr.T.V.Rao MD 11
  12. 12. Severe nail infection with Trichophyton rubrum in a 37-year-old male AIDS patient. Source: Intern. J. Dr.T.V.Rao MD 31(1992): 453.11/23/2012 Dermatol. 12
  13. 13. Dermatophytes,• There are 20 species of Dermatophytes infect humans.• Classed under broad category.1 Trichophyton,2 Microsporum,3 EpidermophytonInfective particles -, a fragment of keratin,11/23/2012 Dr.T.V.Rao MD 13
  14. 14. Common spp of Dermatophytes Infecting Humans• T.rubrum• T.mentagrophytes• T.tonsurans• T.verucosom• Epidermophyton floccosum• Microsporum cannis11/23/2012 Dr.T.V.Rao MD 14
  15. 15. Identification of Genus• Identified on the Basis of Macro conidia.• Identification of species depends on the disposition of Microcondia• Majority of Dermatophytes produce 1 Macro conidia and 2 Micro conidia.In Epidermophyton Micro conidia are absent11/23/2012 Dr.T.V.Rao MD 15
  16. 16. FUNGAL DISEASES. Cutaneous mycoses: Fungal infections of the skin, hair, and nails. Secrete keratinase, an enzyme that degrades keratin. Infection is transmitted by direct contact or contact with infected hair (hair salon) or cells (nail files, shower floors). Examples: – Ringworm (Tinea capitis and T. corporis) – Athlete’s foot (Tinea pedis) – Jock itch (Tinea cruris)11/23/2012 Dr.T.V.Rao MD 16
  17. 17. Cutaneous mycoses involves• Skin• Hair• Nails• Evoke cellular immune response• Dermatophytes• Clinical manifestations ringworm or tinea11/23/2012 Dr.T.V.Rao MD 17
  18. 18. Cutaneous mycoses Etiology • Microsporum Trichophyton Epidermophyton11/23/2012 Dr.T.V.Rao MD 18
  19. 19. Cutaneous mycoses• Classifications: Anatomic location Tinea pedis Tinea capitis Tinea corporis Tinea cruris Ecologic location Geophilic Zoophilic Anthrophilic 11/23/2012 Dr.T.V.Rao MD 19
  20. 20. Basic types of Dermatophytic infection: 1. The acute or inflammatory type of infection, which is associated with CMI to the fungus, generally heals spontaneously or responds nicely to treatment. 2. The chronic or non-inflammatory types of infection, which is associated with a failure to express CMI to the fungus at the site of infection, is relapsing and responds poorly to treatment.11/23/2012 Dr.T.V.Rao MD 20
  21. 21. Classification of Dermatophytes• Trichophyton• Microsporoum• EpidermophytonDifferentiated on the Basis of Macrocondia,By Microscopy11/23/2012 Dr.T.V.Rao MD 21
  22. 22. Cutaneous Mycosis11/23/2012 Dr.T.V.Rao MD 22
  23. 23. Macroconida11/23/2012 Dr.T.V.Rao MD 23
  24. 24. Macroconida11/23/2012 Dr.T.V.Rao MD 24
  25. 25. Micro conidia11/23/2012 Dr.T.V.Rao MD 25
  26. 26. Spread of Dermatophytes,• Spread of infection occurs through direct or indirect contact.• Other ways of spread, From – Floors of swimming pools. Brushes,Combs,Towels,Predisposing factorsPeeling of skin or minor traumaGenetic predisposition ?T Cell immunity is important,Phagocytes play a role.Invade Keratin ,Enzymatic, or Mechanical causes.11/23/2012 Dr.T.V.Rao MD 26
  27. 27. Trichophyton• Colonies are powdery ,velvety,• Micro conidia are abundant,• Arranged in clusters,• Hyphae are borne on conidiophores• Special hyphal structures.• Infects Skin, Hair, Nails,11/23/2012 Dr.T.V.Rao MD 27
  28. 28. Microsporum• Colonies are cotton like,• Velvety or powdery,• Macroconida are scanty,• Macrocode are large ,Multicellular spindle shaped,• Infects Hair, and Skin, Nails are not infected.11/23/2012 Dr.T.V.Rao MD 28
  29. 29. Epidermophyton• Colonies are powdery , greenish yellow,• Macroconida are multicellular, pear shaped, typically arranged in clusters.• Infects - Skin, Nails But not Hair.11/23/2012 Dr.T.V.Rao MD 29
  30. 30. General characteristics of Macroconida and Microconidia of DermatophytesGenus Macroconidia MicroconidiaMicrosporum Numerous, thick Rare walled,roughEpidermophyton Numerous, smooth Absent walledTrichophyton Rare,thin walled, Abundant smooth 11/23/2012 Dr.T.V.Rao MD 30
  31. 31. Macroconida11/23/2012 Dr.T.V.Rao MD 31
  32. 32. Pathogenesis• Depends on – site – species,• Only dry scaling• Hyperkeratosis,• Irritation, Erythema of skin,• Weeping pustules,• Ulceration,11/23/2012 Dr.T.V.Rao MD 32
  33. 33. Clinical Presentation• Can produce Lesions on Body,face,scalp• Annular lesions ,raised,inflamatory borders,• Groin lesions spread outwards from flexor areas,• Toe clefts, sole• Nails get discolored, thickening, and become friable.11/23/2012 Dr.T.V.Rao MD 33
  34. 34. On scalp• Scaling Hair loss,• Hyphal break up to chains.• Endothrix –T.tonsurans,T.violaceum• Ectothrix - Microsporum,T.verucosum.• In Endothrix breaks at the mouth of follicle, Black dot,• In Ectothrix breaks hair 2-3 mm from mouth of the follicle.• Mixed infections do occur.11/23/2012 Dr.T.V.Rao MD 34
  35. 35. The Hair may show Endothrix or Exothrix11/23/2012 Dr.T.V.Rao MD 35
  36. 36. Cutaneous mycoses • THE IDENTIFICATION REACTION(ID)• Patients infected with a dermatophytes may show a lesion, often on the hands, from which no fungi can be recovered or demonstrated.• It is believed that these lesions, which often occur on the dominant hand (i.e. right-handed or left-handed), are secondary to immunological sensitization to a primary (and often unnoticed) infection located somewhere else (e.g. feet).• These secondary lesions will not respond to topical treatment but will resolve if the primary infection is successfully treated.11/23/2012 Dr.T.V.Rao MD 36
  37. 37. Clinical Manifestations• Appear as scaly lesion• Upper trunk, neck• May be Hypo pigmented and Hyper pigmented• Spread to other sites of the body11/23/2012 Dr.T.V.Rao MD 37
  38. 38. Laboratory Diagnosis• Direct Microscopy,• Demonstration of clusters of round yeast cells• Short and stout hyphae,11/23/2012 Dr.T.V.Rao MD 38
  39. 39. Id reaction• Inflammation associated with infection with fungi• An immunological reaction to fungal infection11/23/2012 Dr.T.V.Rao MD 39
  40. 40. Laboratory Diagnosis• Collection of samples,• Specimens of skin, hair, nails• Collected in folded black paper,• Stored up to 12 months,• Nails by clippings,• Skin by scrapping with blunt scalpel,• Hair by plucking11/23/2012 Dr.T.V.Rao MD 40
  41. 41. Microscopy,• Direct Microscopy with wet mount preparation with 15-20% Potassium hydroxide (Koh) preparation• Examination under fluorescent Microscope with Calcoflour• Examination under Woods lamp11/23/2012 Dr.T.V.Rao MD 41
  42. 42. Examination under Wood’ Lamp11/23/2012 Dr.T.V.Rao MD 42
  43. 43. Culturing of Dermatophytes• Small fragments of Keratinous material used for culturing on• Sabourauds agar,• 4 % Malt extract agar,• Colony morphology and color pigmentation observed.• Microscopic observation11/23/2012 Dr.T.V.Rao MD 43
  44. 44. Treatment and Prevention,• Topical therapy• Application of Topical Azoles ,compound Terbinafin,oral Grisofulvin,11/23/2012 Dr.T.V.Rao MD 44
  45. 45. Treatment• Pityriasis responds to Topical therapy,• 1% Seliniumsulphide,• Azoles – Ketoconazole.• Oral Azoles,11/23/2012 Dr.T.V.Rao MD 45
  46. 46. Treatment• Skin – azoles,inhibits cytochrome 450 dependent enzyme systems at the demethylation step from lanosterol to ergosterol• Hair- Griseofulvin, oral , affects micro tubular system11/23/2012 Dr.T.V.Rao MD 46
  47. 47. Other Fungal Infections of Skin• Pityriasis Versicolor ,Belong to Genus Malassezia• Infection of stratum corneum• Manifest as patches of discoloration of skin,• Caused by lipophilic yeast• Depends on Host and Environments,• Tropical countries- Young adults,11/23/2012 Dr.T.V.Rao MD 47
  48. 48. Morphology• Produce round yeast cells,• Short hyphae• Appear as Gram Positive11/23/2012 Dr.T.V.Rao MD 48
  49. 49. Candidiasis can Present as Skin Lesions• Candidiasis , Monoliasis,• Can infect Skin, Mucosa, or Internal Organs,,• Called as Yeast Like fungus11/23/2012 Dr.T.V.Rao MD 49
  50. 50. Candida and other species,• Candida albicans,• Others spp C.tropicalis, C.Krusei, C.glabrata, C.parapsilosis,11/23/2012 Dr.T.V.Rao MD 50
  51. 51. Candida• Common flora Exist in Mouth, Gastrointestinal tract. Vagina, skin in 20 % of normal Individuals. Colonization increases with age, in pregnancy Hospitalization Immunity Depends on T lymphocytes, and Europhiles11/23/2012 Dr.T.V.Rao MD 51
  52. 52. Morphology and Culturing• Ovoid shape or spherical budding cells and produces pseudo mycelium• Routine cultures are done Sabroud’s Glucose agar,• Grow predominantly in yeast phase• A mixture of yeast cells and pseudo mycelium and true mycelium are seen in Vivo and Nutritionally poor media.11/23/2012 Dr.T.V.Rao MD 52
  53. 53. Pseudohypal structures in Candida11/23/2012 Dr.T.V.Rao MD 53
  54. 54. Pathogenesis and Pathology• Mucosal infection superficially –Discrete white patches on mucosal surface.• Can affect tongue• Infants and old persons are affected• Immune compromised /AIDS. Oral Candidiasis is commonly seen• Vaginal Candidiasis causes itching soreness white discharge, White colored lesions,• Pregnancy with advance,• One episode through life time11/23/2012 Dr.T.V.Rao MD 54
  55. 55. Other lesions• Esophageal infection common in HIV / AIDS• Skin – Nail infections• Axilla Groin• Toe clefts,• Napkin dermatitis,• Nails frequent immersion in water House wives, Washer man Nurses,11/23/2012 Dr.T.V.Rao MD 55
  56. 56. Predisposing factors.• Infancy, old age, Pregnancy,• Change of flora.• Moisture, occlusion Trauma• T Lymphocyte disease. Neutropenia.• Diabetes mellitus11/23/2012 Dr.T.V.Rao MD 56
  57. 57. Location of Infections• Localized and Disseminated.• Multi organ involvement.• Kidney,Liver,Splee n, Brain.GIT.Eye,• Catheter related infections,11/23/2012 Dr.T.V.Rao MD 57
  58. 58. Other lesions• Chronic muco coetaneous Candidiasis• In childhood – suspect defects of Lymphocytes and Neutrophils,11/23/2012 Dr.T.V.Rao MD 58
  59. 59. Laboratory Diagnosis• Skin scrapings,• Mucosal scrapping,• Vaginal secretion• Culturing Blood and other body fluids,• Observations Microscopic observation after Gram staining. Gram + yeast cells.11/23/2012 Dr.T.V.Rao MD 59
  60. 60. Cutaneous mycoses • Laboratory diagnosis: scrapings from clinical specimens• Hair – endothrix (spores inside the hair shaft -ectothrix -exception: T.schoenleinii Disease-favus-waxy mass of hyphal elements (scutulum) microscopic – degenerated hyphal elements11/23/2012 Dr.T.V.Rao MD 60
  61. 61. Cutaneous mycoses • Cultures • Selective media – containing Cyclohexamide and chlorampenicolincubate at 25 C. • Identification based on the conidia11/23/2012 Dr.T.V.Rao MD 61
  62. 62. Diagnosis • Diagnosis is based upon: 1. Anatomical site infected 2. Type of lesion 3. Examination with a Woods lamp (366 A°) 4. Examination of KOH-treated skin scales from the infected area 5. Culture of the organism (not too important)11/23/2012 Dr.T.V.Rao MD 62
  63. 63. Diagnosis of Deep seated infections• Difficult to culture,• Alternative methods• Antibody titers,• ELISA testing• CIE11/23/2012 Dr.T.V.Rao MD 63
  64. 64. Culturing• Sabourauds Medium or Blood agar• Yeast colonies appear within 1-2 days• Germ tube test - Incubation of colonies in serum at 37 c from 1.5 to 2 hours produce• Short hyphae known as germ tube• Candida albicans are Germ tube producers• Other tests are – Sugar assimilation and fermentation tests.11/23/2012 Dr.T.V.Rao MD 64
  65. 65. Germ Tube Test C.albicans11/23/2012 Dr.T.V.Rao MD 65
  66. 66. Germ Tube Test C.albicans11/23/2012 Dr.T.V.Rao MD 66
  67. 67. Treatment • Skin removal of the organism by: 1.Selenium sulfide 2.Thiosulfate 3.Salicylic acid 4.Hyposulfite inhibition of ergosterol by: 1.miconazole11/23/2012 Dr.T.V.Rao MD 67
  68. 68. Treatment with Modern Drugs• Nystatin,• Amphotericin B• Miconazole,• Topical Imidazole application• Systemic infection needs Intravenous – Amphotericin B Intravenous or Fluconazole.11/23/2012 Dr.T.V.Rao MD 68
  69. 69. Differential diagnosis• In a differential diagnosis you must consider: 1. Leprosy 2. Secondary syphilis 3. Pityriasis rosea 4. Psoriasis 5. Nummular eczema 6. Lichen planus 7. Alopecia areata 8. Trichotillomania 9. Dyshidrosis 10. Contact dermatitis.11/23/2012 Dr.T.V.Rao MD 69
  70. 70. Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Students in Developing World. Email doctortvrao@gmail.com11/23/2012 Dr.T.V.Rao MD 70

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