PREPARED BY DERMATOLOGIST

1. DEEP FUNGAL
INFECTIONS
Dr.A.Aarti Bernett
2nd year post graduate
MODERATOR : Dr.A.N.M Maalik Babu

2. DEEP FUNGAL INFECTIONS
• SUBCUTANEOUS MYCOSIS
• Mycetoma
• Phaeohyphomycosis
• Chromoblastomycosis
• Sporotrichosis
• Lobomycosis
• Rhinosporidiosis
• Zygomycosis
• SYSTEMIC MYCOSIS
• Histoplasmosis
• Blastomycosis
• Coccidiomycosis
• Paracoccidioidomycosis
• Aspergillosis
• Systemic candidiasis
• Cryptococcosis
• Mucormycosis
• Penicillosis

3. SUBCUTENEOUS FUNGAL INFECTION
Mycoses of implantation, are sporadically
occurring infections caused by fungi present in the natural
environment that are directly inoculated into the dermis or
subcutaneous tissue through a penetrating injury

4. 1.MYCETOMA/MADURA FOOT/MADURAMYCOSIS
• Chronic , suppurative , granulomatous disease of subcutaneous tissues and bones
characterized by localized swelling with multiple sinuses discharging granules

5. AETIOPATHOGENESIS
• Eumycetoma
• Aerobic Actinomycetes
• Found in soil or on plants
• Gain access by abrasion or implantation
• Common in tropical and subtropical regions with walking on
barefoot
• Common in men , 21-40 yrs of age
• India – actinomycotic mycetoma is more common

6. CAUSATIVE ORGANISMS
EUMYCOTIC
MYCETOMA
• Madurella mycetomatis
• Madurella grisea
• Leptosphaeria senegalensis
• Pseudallescheria romeroi
• Exophiala jeanselmei
• Acremonium
ACTINOMYCOTIC
MYCETOMA
• Nocardia asteroids
• Nocardia brasiliensis
• Actinomadura madurae
• Actinomadura pelletieri
• Streptomyces somaliensis

7. CLINICAL FEATURES
• Trauma favours infection
• M/c site - foot and lower leg
• EARLY STAGE - firm painless nodules
• DEVELOPMENT STAGE – papules and pustules ,break down to form draining
sinuses over skin surface with purulent or seropurulent discharge with characteristic
granules
• LATE STAGE - Hard ,swollen , without pain.

9. COMPLICATIONS
• Periostitis , osteomyelitis , arthritis ,deformity due to destruction
• Lymph node , bone involvement
• Elephantiasis

11. DIFFERENCES
EUMYCOTIC
MYCETOMA
• Slowly invasive
• Late presentation ,relatively asymptomatic
• No pus
• Black brown granules
• Little bony changes
• Granules 4-5 µ,in clusters
• Gram negative ,GMS ,PAS positive
• Responds to itraconazole , amphotericin B
ACTINOMYCOTIC
MYCETOMA
• Rapidly invasive
• Early presentation
• Pus present
• Yellowish white granules
• More changes
• Granules <1µ ,lie singly
• Gram positive ,GMS,PAS –negative
• Responds to sulphonamides and
doxycycline

12. GRANULES
Black-Eumycotic
Red –
Actinomadura
pelletierri
White –Eumycotic/
actinomycotic

13. DIFFERENTIAL DIAGNOSIS
• EARLY STAGE
• DEVELOPMENT STAGE
• LATE STAGE
• Fibroma ,lipoma , sebaceous cyst ,
dermoid cyst ,foreign bodygranuloma
• Neoplasm ,kaposi sarcoma ,syphilis ,
yaws ,leprosy ,cutaneous leishmaniasis
• Botyomycosis ,osteomyelitis
,actinomycosis

14. INVESTIGATIONS
• KOH MOUNT
• GM STAIN - Actinomycotic granules have gm positive filamentous mycelium
without chlamydospores.
Eumycotic granules have broad septate hyphae , chlamydospores

17. INVESTIGATIONS
• AFB STAINS- Nocardia species
• BIOPSY – sulfur granules , inflammatory infiltrates, neutrophils abscess,
langhans giant cells

18. INVESTIGATIONS
• CULTURE –Sabourauds’s dextrose agar+/-antibiotics and
brain heart infusion agar, incubated at 26 °c to 37 °c
• SEROLOGICAL TESTS - ELIZA sensitive for detection of antibodies

19. TREATMENT

22. 2.CHROMOBLATOMYCOSIS
• SYNONYMS – CHROMOMYCOSIS , VERRUCOUS DERMATITIS ,
• PHAEOSPOROTRICHOSIS
• Chronic granulomatous fungal infection of skin and subcutaneous tissue caused
by pigmented fungi which produce thick walled single or multicelled clusters.

24. CHROMOBLATOMYCOSIS
AETIOLOGY
Phialophora verrucosa
Fonsecea pedrosoi
Fonsecea compacta
Cladophialophora carrionii
Wangiella dermatidis
Rhinocladiella aquaspersa
Exophiala spinifera

25. CHROMOBLASTOMYCOSIS
• EPIDEMIOLOGY
Tropics
Adult males
Agriculutral workers
Decaying vegetation and rotting wood
Trauma by splinter of wood or through abrasion ,hence the most common site
of infection is feet ,legs ,arm ,face and neck.

26. CHROMOBLASTOMYCOSIS
• CLINICAL VARIANTS AND THEIR FEATURES
Localized -common
Multiple- satellite leions
Sporotrichoid-lymphatic spread
Warty –papule to hypertrophic verrucous cauliflower like mass
Ulcerative
Psoriasiform
Flat plaques with central atrophy and scarring

29. PROGRESSION AND COMPLICATIONS
• Slowly progress over years
• Spontaneous healing rare
• Elephantiasis
• Haematogenous spread
• Secondary infection
• Ulceration
• Bone invasion
• Malignant change-squamous cell carcinoma

30. DIFFERENTIAL DIAGNOSIS
• TBVC
• Lupus vulgaris
• Sporotrichosis
• Blastomycosis
• Cutaneus leishmaniasis
• Yaws
• Tertiary syphilis
• Mycetoma
• Hanens
• Candidiasis

31. INVESTIGATIONS
• Fungal cells – muriform cells
/scelorotic bodies/medlar
bodies/copper pennies/fumagoid
bodies
• Can be seen in KOH mount and H and
E stain.
• Easily visible as golden brown/
chestnut coloured.
• These cells divide by a thick septa
into multiple planes present as ingle
or multiple clusters.

32. INVESTIGATIONS

34. TREATMENT
• Systemic antifungal therapy –combo of ITACONAZOLE 200-400mg/day and
TERBINFINE 250-500mg/day for 6-12 months or till remission
• Iodides ,fluconazole,posacoazole are also used
• Early small lesions-surgery ,cryotherapy

35. 3.SPOROTRICHOISIS
• Also known as Rose gardeners disease
• Acute or chronic fungal infection caused by dimorphic fungus –SPOROTHRIX
SCHENCKII(S.braziliensis,S.mexicana,S.globosa,S.lurei)
• Tropics and subtropics
• High humidity and temperature (16°-22°c)
• Dead and decaying vegetative matter-sphagnum mass ,timber
• Mine workers ,straw packing industry , florists , gardeners ,forestry workers
,alcoholics , AIDS pts COPD pts
• Thorn pricks ,trauma , inhalation or ingestion of conidia

37. CLASSIFICATION
• There is no age limit
• Both sexes are equally affected
• Incubation period few days to 30 days
• Classified into
Cutaneous/subcutaneous [lymphangitic ,fixed]
Extracutaneous forms [pulmonary and disseminated]

38. CLINICAL FEATURES
• Indurated nodules ,pustules ,discharging ulcers ,gummatous lesions
• Cord like lymphatics

39. COMPLICATIONS
• Pneumonitis,bronchitis ,pleural effusion , fever,cough ,cavity with caseation
• Bones and joint involvement
• Meningitis

41. CLINICAL VARIANTS
• Nodular
• Ulcerative
• Verrucous
• Acneiform
• Infiltrated erythematous plaques
• Infiltrated scaly plaques
• Mycetoma like
• Cellulitis like

42. COURSE AND PROGNOSIS
• Not life threatening
• Resolve spontaneously
• Rarely chronic persistent cases are there

43. INVESTIGATIONS
• Direct microscopy –usually negative
• Culture- SDA with antibiotics and blood agar ,incubated at 26 and 37
degrees. Conversion to yeast form is which is cigar shaped is very specific.
• Present as leathery moist ,initially white and creamy with wrinkled
surface progressively turns brown or black

45. INVESTIGATIONS -contd
Histology- 3 types of granuloma
Sporotrichotic-mass of epithelioid histiocytes with central necrosis
Tuberculoid –epithelioid cells ,fibroblasts ,lymphocytes ,langhans cells
Foreign body-no pyogenic reaction
o Asteroid body ,round to oval basophilic yeast like body ,surrounded by radiating
elongated eosinophilic material - SPLENDORE HOEPPLI PHENOMENON

47. CONDITIONS ASSOCIATED
Asteroid bodies
Sporotrichosis
Lobomycosis
Sarcoidosis
Silicosis
Actinic granuloma
Necrobiosis lipoidica
Amyloidosis
Splendid hoeppli phenomenon
Sporotrichosis
Zygomycosis
Actinomycosis
Blastomycosis
Aspergillosis
Pityrosporum folliculitis
Schistosomiasis
Cutaneous larva migrans

48. TREATMENT
• First line- itraconazole 100-200mg/day until clinical recovery upto 3 months ,terbinafine 250-
500mg/day for 3 months
• Second line- SSKI -5drops 1ml thrice a day after meals ,increased by 1 drop upto 40 drops thrice a
day upto 32 wks ,then gradual tapering by one drop /dose until 5 drops,to look for IODISM
• AmphotericinB,fluconazole,posaconzole,
voriconazole

49. 4.PHAEOHYPHOMYCOSIS
• Rare ,generally localized ,subcutaneous or intramuscular infection , usually a
cyst or abscess caused by brown pigmented dematiaceous fungi
• Exophiala jeanselmei ,Exophiala dermatidis ,Cladophialophora bantiana
Phialophora spp ,Bipolaris species ,Alternaria spp.

51. PATHOGENESIS AND VIRULENCE FACTORS
• Fungi found in moist environments
• Seen subtropical and tropical climates
• MELANIN CONTAINING FUNGUS
• They are less susceptible to phagocytosis and killing by
neutrophils and macrophages
• Thermotolerant ,maximal growth at 45°c
• Transmitted via trauma ,inhalation

52. CLINICAL MANIFESTATIONS
Superficial
Piedra ,T.nigra
Cuatneous
Dermatomycosis
onychomycosis
subcutaneous
keratitis
Invasive systemic
cerebral

53. CLINICAL FEATURES
• Present as subcutaneous cyst
• Begin as a small papule and evolve into a single large subcutaneous mycotic cyst
filled with pus
• S
• Common sites : feet ,fingers ,knee ,toes , ankles , legs and forearm
• Varied presentations : papulonodules ,pustules ,eschars ,verrucous /ulcerated
plaques ,non-healing ulcers ,sinuses and scaly hyperkeratotic lesions
• Fistulas,ulcerated ,crusted and verrucous lesions and cellulitis like lesions in I/C
individuals
• Children –dissemination

54. INVESTIGATIONS
• KOH – pigmented yeast ,hyphae , pseudohyphae
• FNAC –epithelioid cells ,giant cells , inflammatory cells
• SKIN BIOPSY – neutrophilic abscesses ,foreign body granulomma with
histiocytes, lymphocytes ,MNC giant cells
Spl stains –PAS ,Gomorri-Grocott stains,Fontanna Mason stain for
melanin is diagnostic of phaeohyphomycosis
• CULTURE – grow well on Sabouraud dextrose agar ,cornmeal agar ,malt
extract agar ,potato dextrose agar. Colonies –olivaceous to brown or black
• PCR
• SEROLOGICAL TESTS

57. TREATMENT
• TOC for localized cystic lesions –surgical excision
• Cryotherapy
• I and D
• Pre and post operative antifungal therapy 6 wks to 24 months
• Flucytosine 150 mg/kg/day ,itraconazole 200mg/day ,ketoconazole 200 mg/day ,iv
intralesional amphotericin B
• Good prognosis in subcutaneous infection

58. 5.LOBOMYCOSIS
Synonyms
• Keloidal blastomycosis
• Lobo’s disease
• Leprosy of caiabi
• Pseudo leprosy
• Amazonian blastomycosis
• Blastomycoid granuloma
• Miraip
• Piraip

59. AETIOPATHOGENESIS
• Causative agent-LACAZIA LOBOI found in soil ,water and vegetation ,gain access through trauma
• Humans had a prior h/o sting ray poisoning , snake bites ,insect bites
• Farmers ,fishermen ,gold miners ,hunters
• IP-several months to years
• After traumatic inoculation the pathogen locally spread through
autoinoculation and distant spread via lymphohaematological spread
• Chronicity is due to ‘melanin containing birefringent cell wall which resist digestion by
macrophages’

60. CLINICAL FEATURES
• Pleomorphic lesions over exposed parts like legs ,arms face
• Nodules and plaques of variable sizes , can be either hypo or hyperpigmented
• Other presentations are ulcers , scleromatoid ,keloidal verrucous , keratotic and vegetating plaques
• Generally painless ,occasionally pruritic , dysaesthetic
• Regional lymph nodes enlarged
• Systemic involvement is very rare
• c/c-SCC ,disfigurement

62. INVESTIGATIONS
• Direct microscopy with KOH –round to oval yeast like organisms 6-12 micrometers
diameter ,occur singly or in short chains connected by tubular projections
• Exfoliative cytology without special stains
• Hpe –epidermis atrophic /hyperplastic/keratotic
• Grenz zone
• Dense granulomatous infiltrates with epithelioid cells ,MNG
• Asteroid bodies are found
• Fungal forms seen at various levels of epidermis

63. TREATMENT
• Localized –surgical excision ,electrocutery cryosurgery
• Clofazimine 300mg /day initially then maintained with 100m/day upto 2
years
• Miconazole
• Itraconazole with clofazimine for 1 year
• MBMDT

64. 6.RHINOSPORIDIOSIS
• Chronic granulomatous disease of mucocutaneous tissue caused by RHINOSPORIDIUM
SEEBERI
• Pedunculated polypoid tumours and sessile polyps
• Involves mucous membranes of nose , eyes ,nasopharynx ,larynx , conjunctiva , lacrimal
sac
• Penis ,vagina ,rectum are rare
• Common in India ,Srilanka
• Adult males

66. CLINICAL FEATURES
• Vascular pedunculated polyp ,pink or red surface
• Lobulated or cauliflower like
• Close examinationmn- small white spots which are mature sporangia of the fungi
• Non contagious
• Persists for years
• Obstruction of breathing ,conjunctivitis ,photophobia

67. CLINICAL TYPES
• Mucosal – friable ,vascular , sessile/pedunculated polyps
• Cutaneous –wart like /tumourous growth with crenated surface
• Disseminated –lung ,liver ,spleen ,brain

68. INVESTIGATIONS
• Cant be cultured
• Biopsy of tissue
• Histopathology –KOH :
endospores 6-7 µm diameter
thick walled and spherical
• Mature sporangia 100-450 µ
diameter
• Hpe dd-coccidioidomycosis

70. TREATMENT
• Surgical excision
• Electrocoagulation
• Dapsone tablet

71. 7.SUBCUTANEOUS ZYGOMYCOSIS
• Localized ,subcutneous mycosis characterized by chronic woody swelling of
subcutaneous tissue
• Synonyms
Basidiobolomycosis
Conidiobolomycosis
Phycomycosis
Rhinoentomophthoromycosis

72. AETIOPATHOGENESIS
• B.ranarum ,B.haptosporus ,C.coronatus , C.incongruous
• Syncephalastrum racemosum
• Basidiobolus –common in children, male,female ratio 3 :1 ,transmitted via trauma
,insect bite
• Conidiobolomycosis 10 :1 ratio , young adults , found in feces of frogs ,lizards ,
transmitted via inhalation of spores
• Basidiobolus produce phospholipase A ,hydrolyze lecithin to lysolecithin
• Conidiobolus produces elastases ,esterases ,collagenases and lipases

74. CLINICAL FEATURES
• Slowly spreading gross ,non painful
facial swelling originating from nasal
mucosa and sinuses
• May be single or multiple
• Uniform hard consistency ,not pit
• Edges are smooth ,rounded and lobulated
• Overlying skin -tense ,oedematous ,
desquamated ,hyperpigmented or normal
• c/c disfigurement

75. INVESTIGATIONS
• KOH- sparsely septate ,branching hyphae
• BIOPSY –eosinophilic granuoma
• CULTURE –basidiobolus grows rapidly at
30° c shows waxy creamy ,yellow colonies and conidiobolus at 37° c grows white
to grey powdery and biege coloured colonies

77. TREATMENT
• First line SSKI and itraconazole
• Miconazole ,cotrimoxazole ,ketaconazole,amphotericin B , terbinafine
• Surgical debridement
• Hyperbaric oxygen therapy