1. CUTANEOUS MYCOSES and SUPERFICIAL MYCOSES BY PROF ALPANA VERMA

2. Cutaneous Fungal Infections Dermatophytosis – "ringworm" disease of the nails, hair, and/or stratum corneum of the skin caused by fungi called dermatophytes. Dermatomycosis - General name for any skin disease caused by a fungus.

3. Cutaneous mycoses Cutaneous mycoses - infections that extend deeper into the epidermis, as well as invasive hair and nail diseases. These diseases are restricted to the keratinized layers of the skin, hair and nails. Unlike the superficial mycoses, various cellular immune responses may be evoked, causing pathologic changes in the host that may be expressed in the deeper layers of the skin. The agents causing these diseases are termed dermatophytes. The diseases are referred to as ringworm or tinea. All of the dermatophytic diseases are caused by members of three genera, Microsporum, Trichophyton and Epidermophyton, which comprise 41 species.

4. Cutaneous mycoses Disease Etiological Agent SymptomsIndentification of organism Tinea capitis Microsporum sp. Trichophyton sp. Epidermophyton sp. ringworm lesion of scalp presence/absence and shape of micro- and macroconidia in scrapings from lesion Tinea corporis Microsporum sp. Trichophyton sp. Epidermophyton sp ringworm lesion of trunk, arms, legs presence/absence and shape of micro- and macroconidia in scrapings from lesion Tinea manus Microsporum sp. Trichophyton sp. Epidermophyton sp ringworm lesion of hand presence/absence and shape of micro- and macroconidia in scrapings from lesion Tinea cruris "jock itch" Microsporum sp. Trichophyton sp. Epidermophyton sp ringworm lesion of groin presence/absence and shape of micro- and macroconidia in scrapings from lesion Tinea pedis"athlete's foot" Microsporum sp. Trichophyton sp. Epidermophyton sp ringworm lesion of foot presence/absence and shape of micro- and macroconidia in scrapings from lesion Tinea unguium Microsporum sp. Trichophyton sp. Epidermophyton sp infection of nails presence/absence and shape of micro- and macroconidia in scrapings from lesion Ectothrix Microsporum sp. Trichophyton sp. Epidermophyton sp infection of hair shaft surface mycelium and spores on hair shaft Endothrix Microsporum sp. Trichophyton sp. Epidermophyton sp infection of hair shaft interior mycelium and spores in hair shaft

5. Dermatophytosis/cutaneous and Superficial Mycoses Microsporum Trichophyton Epidermophyton Malassezia furfur P. werneckii Piedraia hortae Trichosporon beigelii 5 Cutaneous Mycoses/ Superficial Mycoses

6. Cutaneous mycoses Three important genera, (i.e., Microsporum, Trichophyton, and Epidermophyton), are involved in ringworm (Cutaneous mycoses).also called dermatophytes Dermatophytes are keratinophilic - "keratin loving". Keratin is a major protein found in horns, hooves, nails, hair, and skin. Digest keratin by their keratinase enzyme Ringworm - disease called ‘herpes' by the Greeks, and by the Romans ‘tinea' (which means small insect larvae).

7. Dermatophytes/cutaneous mycoses Severity of ringworm disease depends on (1) strains or species of fungus involved (2) sensitivity of the host to a particular pathogenic fungus. More severe reactions occur when a dermatophyte crosses non- host lines (e.g., from an animal species to man). – Geophilic species - keratin-utilizing soil saprophytes (e.g., M. gypseum, T. ajelloi). – Zoophilic species - keratin-utilizing on hosts - living animals (e.g., M. canis, T. verrucosum). – Anthropophilic species - keratin-utilizing on hosts - humans (e.g., M. audounii, T. tonsurans)

8. DERMATOPHYTOSIS Infection of the skin, hair or nails caused by a group of keratinophilic fungi, called dermatophytes ¨Microsporum --- Hair, skin ¨Epidermophyton---Skin, nail ¨Trichophyton---- Hair, skin, and nail

9. Dermatophytes Dermatophytes are keratinophilic fungi – they possess keratinase allowing them to utilize keratin as a nutrient & energy source They infect the keratinized (horny) outer layer of the scalp, glabrous skin, and nails causing tinea or ringworm Although no living tissue is invaded (keratinized stratum only colonized) the infection induces an allergic and inflammatory eczematous response in the host Lesions on skin and sometimes nails have a characteristic circular pattern that was mistaken by ancient physicians as being a worm down in the tissue These lesions are still today called ringworm infections even though the etiology is known to be a fungus rather than a worm

10. Dermatophytes Taxonomic classification – They belong to the phylum Deuteromycota (Fungi Imperfecti) – They are hyaline moulds (transparent / white) – Three genera comprise this group Microspourm Trichophyton Epidermophyton

11. DERMATOPHYTOSIS/cutaneous Myc Pathogenesis and Immunity Contact and trauma Moisture Crowded living conditions Cellular immunodeficiency  (chronic inf.)

12. Major sources of cutaneous infection Schools, military camps, prisons. Warm damp areas (e.g., tropics, moisture accumulation in clothing and shoes). Animals (e.g., dogs, cats, cattle, poultry, etc.).

13. Clinical manifestations of ringworm infections are called different names on basis of location of infection sites 1. tinea capitis - ringworm infection of the head, scalp, eyebrows, eyelashes tinea favosa - ringworm infection of the scalp (crusty hair) 2. tinea corporis - ringworm infection of the body (smooth skin) 3. tinea cruris - ringworm infection of the groin (jock itch) 4. tinea unguium - ringworm infection of the nails 5. tinea barbae - ringworm infection of the beard 6. tinea pedis - ringworm infection of the foot (athlete's foot)

14. 1. Tinea Capitis - ringworm infection of the head, scalp, eyebrows, eyelashes Gray Patch

15. 1. Tinea capitis (scalp)

16. 2. Tinea corporis – body ringworm

17. 2. Tinea corporis

18. 3.Tinea cruris (jock itch)

19. 3.Tinea Cruris – Jock Itch

20. 4.Tinea unguium (nails)

21. 4.Tinea Unguium – Nail Infection

22. 5. Tinea barbae (bearded area )

23. 6…Tinea pedis (Athlete’s foot) (feet)

24. 6.Tinea Pedis – Athlete’s Foot Infection

25. Cutaneous Mycoses Clinical manifestations Skin: Circular, dry, erythematous, scaly, itchy lesions Hair: Typical lesions,”kerion”, scarring, “alopecia” Nail: Thickened, deformed, friable, discolored nails, subungual debris accumulation

26. DERMATOPHYTOSIS Transmission Close human contact Sharing clothes, combs, brushes, towels, bedsheets... (Indirect) Animal-to-human contact (Zoophilic)

27. Diagnosis I. Clinical Appearance Wood lamp (UV, 365 nm) II. Lab A. Direct microscopic examination (10-25% KOH) Ectothrix/endothrix/favic hair

28. DERMATOPHYTOSIS Diagnosis B. Culture Mycobiotic agar Sabouraud dextrose agar

29. DERMATOPHYTES Identification A. Colony characteristics B. Microscopic morphology MacroconidiumMicroconidium Microsporum----fusiform---------------(+) Epidermophytonclavate-----------------(-) Trichophyton-- -(few)cylindrical/ --- --(+) clavate/fusiform single, in clusters

30. Microsporum No teleomorph state (sexual reproduction has yet to be observed in this species). Usually devoid of conidia (macro- or microconidia). Septate hyphae with terminal chlamydoconidia, often pointed at the end. Macroconidia are often irregular or non-uniform in shape. Colonies on culture media are flat, silky in appearance. Growth of colonies on culture media is tight. On reverse of colony - pigment is reddish-brown in color.

31. Microsporum audouinii http://www.doctorfungus.org/thefungi/microsporum_ audouinii.htm http://www.mycology.adelaide.edu.au/Fungal_Descriptions/Dermatophytes/Microsporum/Microsporum_audouinii.html

32. Microsporum canis Macroconidia are abundant, thick-walled with many septa, up to 15. Macroconidia are often hooked or curved at ends. Microconidia are small and clavate (club- shaped).

33. Microsporum canis Teleomorph: Arthroderma otae http://www.doctorfungus.org/thefungi/microsporum_canis.htm http://www.mycology.adelaide.edu.au/Fungal_Descriptions/Dermatophytes/Microsporum/Microsporum_canis.html

34. Microsporum species Thick wall, spindle shape, multicellular Macroconidium

35. Microsporum gypseum http://www.mycology.adelaide.edu.au/Fungal_Descriptions/Dermatophytes/Microsporum/Microsporum_gypseum.htm http://www.doctorfungus.org/thefungi/microsporum_gypseum.htm

36. Epidermophyton Epidermophyton floccosum Only one pathogenic species in this genus. Tinea unguium and tinea cruris are often caused by this fungus. Culture starts out white/turns sulfur color. Cultures may be wrinkled to cottony in appearance. No microconidia. Shape of macroconidia is a distinguishing characteristic - clavate macroconidia.

37. Epidermophyton floccosum Bifurcated hyphae with multiple, smooth, club shaped macroconidia (2-4 cells)(Asexual spores)

38. Trichophyton species Presence of macroconidia in cultures varies and may not help in identification of cultures. Microconidia shape and presence varies. Microconidia are globose (round-shaped), pyriforme (pear-shaped), or clavate (club-shaped). Most common species include: – Trichophyton mentagrophytes – T. rubrum – T. tonsurans – T. verrucosum – T. violaceum http://www.doctorfungus.org/thefungi/trichophyton. htm http://www.doctorfungus.org/thefungi/trichophyton. htm

39. Trichophyton mentagrophytes Most common dermatophyte on humans and animals. Highly variable in culture. Globose microconidia in grape-like clusters - en grappe. Macroconidia, when present, are cigar- shaped. Spiral hyphal cells. Cultures tend to be white and downy (some pigmentation on reverse colony) Common cause of tinea pedis.

40. Trichophyton mentagrophytes http://www.mycology.adelaide.edu.au/Fungal_Descriptions/Dermatophytes/Trichophyton/mentagrophytes.html

41. Trichophyton rubrum Infects nails and smooth skin (rarely found on hair). Most common and widely distributed dermatophyte on man and rarely isolated from animals, never from soils. Slow-growing in culture. When intensely pigmented in culture the color is reminiscent of port burgundy wine or venous blood. Production of pigment increased, if fungus grown on corn meal agar. Microconidium are clavate or "teardrop" shape with a broad attachment point of the hyphae. Microconidia may develop on sides of macroconidium.

43. Trichophyton rubrum http://www.mycology.adelaide.edu.au/Fungal_Descriptions/Dermatophytes/Trichophyton/rubrum.htm

44. Trichophyton tonsurans Anthropophilic and on hair causes endothrix. Third most common cause of tinea capitis Other leading causes of tinea capitis are M. audouinii (transmission is generally from child to child) and M. canis (transmission is from animal to human). Colonies whitish and folded. Colonies are yellowish-brown color on reverse of colony. Microconidia are longer and larger than in T. rubrum. Intercalary and terminal chlamydoconidia common in older cultures. Macroconidia not common, irregular in form.

45. Trichophyton tonsurans http://www.mycology.adelaide.edu.au/Fungal_Descriptions/Dermatophytes/Trichophyton/tonsurans.html

46. Trichophyton tonsurans

47. Direct Examination Treating skin and nail scrapings and “snippets” of hair with potassium hydroxide (KOH dissolves keratin but not chitin - hyphae) is usually very effective in detecting dermatophyte hyphae in clinical specimens. The addition of calcofluor white (1,4 polymer specific fluorochrome dye) and dimethylsulfoxide (DMSO) to the KOH and viewing with a fluorescent microscope is recommended. DMSO is a non-polar surfactant (wetting agent) which aids in clearing of the keratin by making KOH more soluble in the sample.

48. Therapy Griseofulvin Tinactin Clotrimazole Miconazole Ketoconazole Itraconazole Terbinafine

49. DERMATOPHYTOSIS Treatment Topical Miconazole, clotrimazole, econazole, terbinafine... Oral Griseofulvin Ketaconazole Itraconazole Terbinafine

50. SUPERFICIAL MYCOSES

51. Superficial mycoses Infections limited to the outermost layers of the skin and hair. DiseaseEtiological Agent Symptoms Identification of organism Pityriasis versicolor Malassezia furfur hypopigmented macules (lesions in skin rashes) "spaghetti and meatballs" appearance of organism in skin scrapings Tinea nigra Exophiala werneckii black macules black, 2-celled oval yeast in skin scrapings Black piedra Piedraia hortai black nodule on hair shaft black nodule on hair shaft composed of spore sacs and spores White piedra Trichosporum beigelii creme-coloured nodules on hair shaft white nodule on hair shaft composed of mycelia that fragment into arthrospores

52. PITYRIASIS VERSICOLOR Superficial chronic infection of Stratum corneum Etio: Malassezia furfur (Pityrosporum orbiculare) (Lipophilic yeast) Clinical findings: Hyperpigmented or depigmented maculae on chest, back, arms, abdomen

53. PITYRIASIS VERSICOLOR Short hyphae, yeast cells in skin scrappings Culture: Sabraud Agar (suppl.: olive oil) Treatm.: Topical selenium sulfide Oral ketaconazole Oral itraconazole

54. Pityriasis (Tinea)Versicolor This is a very common superficial mycoses caused by a lipophilic yeast Malassezia spp. It is seen in all countries but is particularly common in the tropics with more than 60 % of the population infected. The lesions are hypo or hyper pigmented. The etiologic agent is normal flora of man so the disease re-occurs. Recent evidence suggest that seborrheic dermatitis is also caused, or triggered by, Malassezia yeast..

55. This is pityriasis versicolor. Note the larger area of hypopigmentation in the center. In this disease there is no erythema, the infected areas are not elevated, and aside from some itching the patient feels no discomfort.

56. This is a patient with pityriasis versicolor. Again, note the blotchiness of the skin pigmentation.

57. Note the areas of hypopigmentation on the back of this Chinese patient. This again is tinea versicolor.

58. This is a high magnification of tinea versicolor. Note the round clump of yeast cells and the short strands of hyphae. This slide was made with 10% KOH and up to 10% Super Chrome ink or methylene blue stain was added.

59. TINEA NIGRA Superficial chronic infection of Stratum corneum,(Palm) Etio: Hortae werneckii (pigmented) Frequent in tropical areas Clinical findings: Brownish maculae on palms, fingers, face

60. Tinea Nigra This is a superficial infection caused by a black yeast variously known as Cladosporium or Hortaea werneckii. It is usually found in tropical areas of the world. It is seen as circumscribe areas of hyperpigmentation usually on the palms or soles. Lesions are dark brown to black with little scaling.

61. TINEA NIGRA Micr.:Septate hyphae and yeast cells (brown in color) Culture: Black colonies on SA Treatm.: Topical salicylic acid, tincture of iodine

62. This is a photograph of tissue prepared for direct examination with 10% KOH. Throughout the field one can readily observe strongly septate dematiaceous hyphae. Note: No coloring agent has been added to this slide; the dark brown color is produced in the fungus. This is how the etiologic agent of tinea nigra appears in tissue.

66. Therapy Topical antifungal agents as well as Whitefield’s ointment have been used successfully.

67. Piedras a)Black Piedra b)White Piedra

68. BLACK PIEDRA Fungal infection of the scalp hair Etio: Piedraia hortae Frequent in tropical areas Clinical findings: Discrete, hard, dark brown to black nodules on the hair

69. BLACK PIEDRA Micr. Septate pigmented hyphae, and asci; unicellular and fusiform ascospores with polar filament(s) Culture: Brown to black colonies Treatm.: Topical salicylic acid, azol cremes

70. a) Black Piedra This disease is characterized by small dark nodules seen on the hair shaft. It is found mostly in tropical areas.

71. This is a higher magnification photograph of hair with black piedra. The lesion is very discrete, surrounds the hair shaft and is dark brown. Eventually the fungus may weaken the hair shaft to the extent that the hair breaks off.

72. This is a still higher magnification of hair infected with Piedraia hortai. Close observation reveals that the nodule appears to be composed of hundreds of spherical cells. These cells are the asci, which contains ascospores. Such structures can be seen more clearly when one places infected hair in 1-2 drops of 10-20% KOH on a microscope slide, adds a coverslip, heats the preparation gently and the presses down very firmly on the coverslip. In such preparations the piedra nodules break open, and one sees many individual asci containing ascospores and, occasionally, groups of ascospores which have been squeezed out of individual asci.

73. This is a culture of the fungus Piedraia hortai. This fungus was cultured on Sabourauds medium and incubated at room temperature. It normally takes 4-6 weeks incubation weeks incubation for a colony to reach this size. The gross features of this colony are that it is slow-growing, is heaped up in the center, is a dark brown-black to metallic green and is surrounded by a clear ring where the young growing mycelium has not yet produced the dark pigment. Microscopically, there are few characteristic features. The fungus produces dermatiaceous hyphae which may contain numerous chlamydospores. No characteristic spores are produced.

74. WHITE PIEDRA Fungal infection of facial, axillary or genital hair Etio: Trichosporon (yeast) Frequent in tropical and temperate zones

75. WHITE PIEDRA Clinical findings: Soft, white to yellowish nodules loosely attached to the hair Micr.: Intertwined septate hyphae, blasto- and arthroconidia(Asexual spores) Culture: Soft, creamy colonies Treatm.: Shaving, azoles

76. b) White Piedra In this disease we also see nodules on the hair. However, differing from black piedra, the nodules are softer, pale in color and are only found on hair in the groin and axillae.

77. In this picture we see hair with white piedra (Trichosporon beigelii). Note that, when this module is compared with that seen in black piedra, it is not as discrete and lacks the dark coloration. Additionally, this fungus does not produce ascospores. When cultured on Sabouraud’s agar and incubated for 2-4 weeks at room temperature, this fungus produces a rough, membranous, white to light tan colony. Microscopically, the organism produces no characteristic spores.

78. This is a 4-5 week old culture of Trichosporon beigelii (T. cutaneum) grown on Sabourauds medium at room temperature. This is the etiologic agent of white piedra.

79. Therapy The piedras are treated by removal of the hair and application of topical antifungal agents.