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Opportunistic mycoses

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  • 1. OPPORTUNISTIC MYCOSES CLASSIFICATION ORGANISMS Yeast Candida Cryptococcus Torulopsis Trichosporon Rhodotorula Geotrichium Molds Aspergillus Pseudoallescheria Zygomycetes (Rhizopus, Mucor, and AbsidiaMonday, January 16, 2012
  • 2. OPPORTUNISTIC MYCOSES True Pathogenic Fungi Opportunistic Fungi Diseases Histoplasmosis Aspergillosis Blastomycosis Candidiasis Paracoccidioidomycosis Mucormycosis Coccidioidomycosis Cryptococcosis Host Normal Abrogated/ Compromised Portal of Primary infection is Various Entry pulmonaryMonday, January 16, 2012
  • 3. OPPORTUNISTIC MYCOSES True Pathogenic Fungi Opportunistic Fungi Prognosis 99% spontaneous resolution Recovery depends on the severity of impairment of host defenses Immunity Resolution results to strong No specific resistance to specific immunity infection Host Response Tuberculoid granuloma, Depends on degree of mixed pyogenic impairment necrosis to pyogenic to granulomatous Morphology in All agents showed No change in morphology Tissue dimorphism to a tissue form Distribution Geographically restricted UbiquitousMonday, January 16, 2012
  • 4. CANDIDIASIS C. albicans is the most common (4-6 um; budding) Multiplication: blastospore formation producing either pseudohyphae or septate hyphae Identification: assimilation and fermentation of CHOs; physiologic and morphologic responses they exhibit when grown under controlled nutritional conditions “germ tubes”Monday, January 16, 2012
  • 5. CANDIDIASIS “chlamydoconidia”Monday, January 16, 2012
  • 6. FACTORS THAT AFFECT CANDIDA NORMAL POPULATION poor oral hygiene use of antibiotics use of oral contraceptives diet presence of antagonistic inhibitory bacteriaMonday, January 16, 2012
  • 7. Candida albicans is a resident flora of the skin, mouth, vagina and stool! Imbalance will lead to infection....HOW? Changes in the Physiology: e.g. pregnancy, use of steroids and diabetes Prolonged administration of antibiotics Immunocompromised patientsMonday, January 16, 2012
  • 8. MUCOCUTANEOUS CANDIDIASIS (MC) a condition caused by a fungus from the candida family (lives on the surface of skin) that develops a diffuse and persistent type of infection of the mouth, nails, skin, and at times other organs affects infants (starts before age 3) and young adults, is rarely seen in adults with other diseases including chronic mucocutaneous candidaisis or CMCCMonday, January 16, 2012
  • 9. SYMPTOMS: ORAL “thrush” “glossitis” “stomatitis” “cheilitis” “perleche”Monday, January 16, 2012
  • 10. SYMPTOMS: VAGINITIS & BALANITIS “VAGINITIS = female” “BALANITIS = male”Monday, January 16, 2012
  • 11. SYMPTOMS: ALIMENTARY “Esophageal growth” OTHERS: gastritis, peritonitis, enteric and perianal diseaseMonday, January 16, 2012
  • 12. CANDIDIASIS IN NAILSMonday, January 16, 2012
  • 13. CANDIDIASIS IN DIAPER RASH “Candida may come from fecal origin”Monday, January 16, 2012
  • 14. SYSTEMIC INVOLVEMENT Urinary tract Endocarditis Meningitis Septicemia Latrogenic candidemia Dissemination to other organ systemsMonday, January 16, 2012
  • 15. DISSEMINATED CANDIDIASIS originate at a gastrointestinal site CA enters epithelial microvilli through persorption of yeast cells or by germination (a,c) In both cases, organisms enter the vasculature (b,d) for dissemination into tissues such as the kidney (e) localizes in the cortex (f) where it grows as hyphae/ pseudohyphae A vigorous host response occurs at this site consisting of both mononuclear and polymorphonuclear leukocytes Virulence factors (adhesins, morphogenesis, switch phenotypes, antioxidant proteins and invasive enzymes) promote the invasion of the organismMonday, January 16, 2012
  • 16. ALLERGIC CANDIDIASIS Eczema Asthma GastritisMonday, January 16, 2012
  • 17. LABORATORY DIAGNOSIS: CADIDIASIS Direct microscopic examination Specimen for examination can be sputum, skin scrapings, vaginal swabs, biopsy material, from any types of organs or even in blood. The specimen is treated with 1-2 drops of 10-20% KOH.Monday, January 16, 2012
  • 18. LABORATORY DIAGNOSIS: CADIDIASIS The presence of the capsule and budding yeast cells are considered as the positive results. Aside from KOH, other stains can be used such as India ink and Papanicolaou stain.Monday, January 16, 2012
  • 19. GERM TUBE TEST Most isolates of C. albicans produce a hyphal growth from blastospores when they are suspended in serum at 37°C for 2-3 hours.Monday, January 16, 2012
  • 20. IN CULTURE... SDA at either room temperature or at 37°C Colonies: usually develop in 2-3 days as white, typical yeast colonies In vitro: monomorphic, growing as non encapsulated yeast cells at any temperatureMonday, January 16, 2012
  • 21. IN CULTURE...Monday, January 16, 2012
  • 22. FROM CORN MEAL AGARMonday, January 16, 2012
  • 23. TREATMENT OF CANDIDIASIS Most localized, cutaneous, candidiasis infections may be treated with any number of topical antifungal agents (eg, clotrimazole, econazole, ciclopirox, miconazole, ketoconazole, nystatin). For Candida onychomycosis, oral itraconazole (Sporanox) For Genitourinary tract candidiasis, VVC can be managed with either topical antifungal agents orMonday, January 16, 2012
  • 24. TREATMENT OF CANDIDIASIS Caspofungin acetate (Cancidas) as a 70-mg loading dose is followed by 50 mg/d IV for a minimum of 2 weeks after improvement or after blood cultures have cleared. Chronic mucocutaneous candidiasis is treated with oral azoles, either fluconazole (Diflucan)Monday, January 16, 2012
  • 25. ASPERGILLOSIS One of the largest of the fungal genera Hundred of species have been recorded The most important species: A. fumigatus A. flavus A. nigerMonday, January 16, 2012
  • 26. ASPERGILLUS FUMIGATUS Aspergillus fumigatus identified according to the pattern of conidiophore development, morphologic features and color of the conidiaMonday, January 16, 2012
  • 27. IMPORTANT PARTSMonday, January 16, 2012
  • 28. SPECTRA OF ASPERGILLOSIS Toxicity due to ingestion of contaminated foods Allergy and sequelae to the presence of conidia or transient growth of the organism in body orifices Colonization without extension in preformed cavities and debilitated tissues Invasive, inflammatory, granulomatous, necrotizing disease of lungs and other organs Systemic and fatal disseminated diseaseMonday, January 16, 2012
  • 29. ALLERGIC ASPERILLOSIS Allergic aspergillosis maybe benign early on and severe as the patient grows older In secondary colonization, a chronic clinical situation may exist with little distress except occasional bout of hemoptysis and some pathological changes in the lungs that may lead to the formation of fungus ball.Monday, January 16, 2012
  • 30. ALLERGIC ASPERILLOSIS SKIN FUNGAL SPECIMEN IN THE TISSUEMonday, January 16, 2012
  • 31. SYSTEMIC ASPERGILLOSIS An extreme serious disorder that is usually rapidly fatal unless diagnosed early and treated aggressively The status of the host’s immune system contributes to the prognosis of the patientMonday, January 16, 2012
  • 32. SYSTEMIC ASPERGILLOSIS FUNGUS BALL/ ASPERGILLOMAMonday, January 16, 2012
  • 33. Disease Etiologic Factors Mycotoxicoses Ingestion of contaminated food products Hypersensitivity Allergic bronchopulmonary peumonitis disease Secondary Colonization of preexisting colonization cavity (pulmonary abscess) without invasion into contiguous tissue Systemic disease Invasive disease involving multiple organsMonday, January 16, 2012
  • 34. DISSEMINATED ASPERGILLOSIS Aerosols of Aspergillus fumigatus conidia are inhaled and travel to the alveoli In the healthy host, alveolar macrophages (AM) phagocytose and kill the organism after swelling of the conidium, an essential pre-germination stage The production of reactive oxygen intermediates by AM is required to eliminate the organism, but polymorphonuclear cells (PMNs) also contribute In the immunosuppressed patient, reduced numbers of PMNs and inefficient AM allow growth of the fungus Consequently, the conidia germinate and escape from the AMMonday, January 16, 2012
  • 35. LABORATORY DIAGNOSIS Aspergillosis is easy to isolate and identify....BUT! also important to distinguish a true pathogen from a contaminant If sputum sample is to be collected, it is expected to be thick and gelatinous In invasive sampling, lung aspirates or tissue biopsy is usedMonday, January 16, 2012
  • 36. LABORATORY DIAGNOSIS Direct microscopic examination will show hyaline, dichotomously branched and septate hyphae Occasionally in sputum, in cases of pulmonary aspergillosis, one may also sees very small, rough walled spores (3-4 um in diameter).Monday, January 16, 2012
  • 37. PULMONARY ASPERGILLOSISMonday, January 16, 2012
  • 38. TREATMENT Amphotericin B was used for many years BUT!!! with disappointing results In 1990 itraconazole was introduced as a new broad spectrum anti-fungal agent.Monday, January 16, 2012
  • 39. ZYGOMYCOSIS/PHYCOMYSIS Class Phycomycetes Rhizopus Absidia Mucor They formed coenocytic hyphae and reproduce asexually by producing sporangiosphores within which develops sporangiosporesMonday, January 16, 2012
  • 40. ZYGOMYCOSIS/PHYCOMYSIS Repeated isolation of the organisms from consecutive specimens provides strong evidence that the organisms may be relevant, even though coenocytic hyphal elements are not seen in histopathologic examination of tissue.Monday, January 16, 2012
  • 41. MUCORMYCOSIS (ORAL CAVITY)Monday, January 16, 2012
  • 42. CATEGORIES COMMENTS Rhinocerebral It is the most frequent presentation overall and classically affects diabetics with ketoacidosis. Usually presents with facial and/or eye pain, proptosis and progressive signs of involvement of orbital structures (muscles, nerves and vessels). Common complications include cavernous sinus and internal carotid artery thrombosis. Pulmonary It occurs most frequently among neutropenic patients. It presents with nonspecific symptoms such as fever, cough and dyspnea; hemoptysis may occur with vascular invasion. Radiological presentation includes segmental consolidation that progresses to contiguous areas of the lung, with occasional cavitation. Gastrointestinal Usually affects patients with severe malnutrition May involve the stomach, ileum, and colon Clinical picture mimics intra-abdominal abscess. The diagnosis is often made at autopsy. Cutaneous It has been reported with minor trauma, insect bites, no sterile dressing, wounds, and burns. The necrotic lesions progressively evolve from the epidermis into dermis and even muscle. Others Heart, bone, kidneys, bladder, trachea, and mediastinumMonday, January 16, 2012
  • 43. DIRECT EXAMINATION: ZYGOMYCOSIS A rapid diagnosis is critical Fungal elements are usually not numerous in discharges Scrapings from the upper turbinates, aspirated material from sinuses, sputum in pulmonary disease, and biopsy material mounted in 10% KOH typically contain thick- walled, refractile hyphae 6-15 um in diameter Swollen cells (up to 50 um) and distorted hyphae may be presentMonday, January 16, 2012
  • 44. IN CULTURE... Sabouraud dextrose agar: Incubate at 30°C DON’T: cycloheximide = sensitive Sterile bread: for recovery of Zygomycetes when other media fail WHY bread???Monday, January 16, 2012
  • 45. TREATMENT Control of the diabetes Aggressive surgical debridement of involved tissue High doses of amphotericin B are recommendedMonday, January 16, 2012

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