MYCOSIS SYSTEMIK OPPORTUNISTIK DAN MYCOSIS SYSTEMIK PATOGEN

Oleh :

Dr. dr. Hj. Efrida Warganegara, M.Kes., Sp.MK

Oleh :

Dr.dr.Efrida Warganegara, M.Kes., Sp.MKSYSTEMIC MYCOSIS

SYSTEMIC MYCOSIS : PathogenicDiseaseaAgent

BlastomycosisBlastomyces dermatitidis

HistoplasmosisHistoplasma capsulatum

CoccidioidomycosisCoccidioides immitis

ParacoccidioidomycosisParacoccidoides brasiliansis

BLASTOMYCOSIS= Notrh American Blastomycosis= Gilchists diseaseEtiologic agent : Blastomyces dermatitidis, a dimorphic fungus that grows as mold at room temperature and as a yeast at 35 - 370C

Epidemiology :

B. dermatitidis is saprophytic in nature & grows in the mold form in soil

or decaying wood associated with soil, has been isolated several times, but repeated isolation from the same sites were not succesful

most of the cases have been found in Noth America, but also prevalent in Africa & has been reported in India, occurs most often in adult males

the lack of a specific skin test antigen has prevented the determination of the prevalence of asymptomatic Blastomycosis in large population

BLASTOMYCOSISCxlinical features :

the primary site of Blastomycisis is the lung, with mild infiltrat & few clinical symptomsin severe disease, pulmonary infiltrate may be more extensive & the patients will have fever, cough & weight lose, nodular pulmonary lesion may occursome cases may progres to chronic disease with pulmonary fibrosis & the cavitationthe fungus may disseminate to any organ of the body, mostly skin & boneskin lesion are frequently a manifestationof disseminated disease, with dry & scaly, extensive granulomatous with vesicle or pustule

BLASTOMYCOSISLaboratory diagnosis :

Direct microscopic examination :

wet mount : B. dermatitidis appear as a large, thick-walled single-budding yeast ( 8 - 18 um ), the bud has a wide base

histophatology : the yeast form is usually easily fount in infected tissue, are best detected with PAS or GMS stain

BLASTOMYCOSISLaboratory diagnosis :Culture :is the dimorphic fungus, that grows in the mycelial form (mold) at room temperature & as a yeast at 370Cthe mold form grows slowly, became visible in 7 - 10 days, the colony is usually white & cottonythe yeast-like colony grows on blood agar at 370C after 3 - 4 days

Microscopic morpology :the mold produces small, smooth walled conidia & attached to the conidiophores that arise directly from the hyphaeyaest are large, thick-walled, single-budding & the bud has a wide base (neck) the diagnostic structure of B. dermatitidis

BLASTOMYCOSISSerology :

ID test is the most reliable, CFT not detect antibodies in all cases, will cross-react with antibodies to H. capsulatum

Treatment : Amphoterisin B, Ketoconazole

HISTOPLASMOSIS= reticuloendotheliosis= Darlings diseaseEtiologic agent : Histoplasma capsulatum, a dimorphic fungus, having a mold form at room temperature & yeast form at 370CEpidemiology :

H. capsulatum grows in soil, especially in soil that esriched with bat or bird manureoften be isolated from old building/caves, where birds/chickens or bats have roostedH. capsulatum grows in soil in the mycelial form & large number of conidia are producethe disease is acquired by inhaling conidia & reported from most area of the world

HISTOPLASMOSISClinical features :

is primarily a pulmonary disease; when conidia are inhaled, infections is established in the lungs; the disease may be mild, with few or no symptom (95%)

may be severe with lung infiltrates, from mild to extensive

primary pulmonary histoplasmosis progresses to chronic pulmonary disease in about 5 % of those with disease; is characterized by fibrosis & cavitation,

symptoms includes : cough, fever, chills & weight lose (resembles to toberculosis, sarcoidosis, & other systemic fungal disease)

the most severe form of histoplasmosis is disseminated disease; the fungus invade any organs of body

HISTOPLASMOSISLaboratory diagnosis :

Direct microskopic examination : wet mount :

H. capsulatum may be seen in sputum, bronchial washed, or in any body fluids as a small yeast, 4 - 6 um

histopathology : the yeast form can be found in tissue removed from the infected sites, ussually in the macrophage & in granulomas

GMS (gomori methenamine silver) stain should be used ( the yeat dark-brown - black )

HISTOPLASMOSISCulture :

colony morphology : H. capsulatum grows slowly in the mold form when incubated at room temperature, appear in 7 - 10 days but conidia is not form until later; on SDA ( sabouraud dextrose agar ) the colony Is ussually white & cottony

microscopic morphology :two types of conidia are prodeced by H. capsulatum small, pyriform smoth-walled conidia (microconidia, 4 - 6 um ) and large, round, thick-waled tuberculated conidia ( macroconidia, 8 - 18 um )the diagnostic conidia

to prove the identification of H. capsulatum, convert the mold form - yeast form; be done by transferring the mold colony to blood agar & incubate at 370C in 3 - 5 days the yeast colony will be white brown

HISTOPLASMOSISSerology :

antibodies to the fungus are produced within 10 - 21 days after a person is infected by H. capsulatum

agglutination test, measures IgM antibodies, is a quantitative test

CFT, measures both IgM & IgG, is quantitative test; ID test is a quantitative test

Treatment :

Amphotericin B, Ketoconazole

COCCIDIOIDOMYCOSIS= valley feverEtiologic agent : Coccidioides immitis, a biphasic fungal pathogen

Epidemiology :C. immitis grows in semi-acrid, solid, is known to exist in North, Central, & South American, especially California; its inhaled into the alveoli, where it produces disease, either benign ( resembles flu ), or acute, depending on many factors ( race; inoculum )

Clinical features :most is a benign disease, prodeces only mild symptoms; among certain races ( Filipinos, Black ), immunosupressed or the used of corticosteroids, disseminated may occur

there is no site of predilection for this organism; any body tissue may become infected

COCCIDIOIDOMYCOSISLaboratory diagnosis :

Direct microscopic examination :

wet mount : specimens in KOH mounts, C. immitis may be seen as sporangia ( spherula ) filled with endospora

histophatology : the sporangia stain well with HE & PAS stain

COCCIDIOIDOMYCOSISCulture : Never work with culture on the laboratory bench OUTSIDE of a biohazard hood !

C. immitis is a biphasic fungal phatogen, grows at room temperature repidly producing a dirty gray-white colony; at maturity, the hyphae develops arthroconidia wich enlarged & barrel-shaped; alternate cells emptythe hyphae break easilly into separate artrhoconidia float in the air spread by the wind

Serology : used as diagnostic & prognostic tools; include CFT, latex aglutination, ID test

Treatment : Amphotericin B, Ketoconazol

PARACOCCIDIOIDOMYCOSIS= South American blastomycosisEtiologic agent : Paracoccidioidomycosis brasiliaensis, a dimorphic fungus that grows as mold at room temperature & as a yeast at 370C / in infected tissues

Epidemiology :the saprophytic habitat of P. brasiliensis is not known; endemic mostly in South America

most cases of paracodioidomycosis are seen in adult males; is rare in children & adult women; appears to reflect a host-parasite relasionship by sex hormones

PARACOCCIDIOIDOMYCOSISClinical features :

the primarily site of infection is the lung; disease may be benign, primary pulmonary form or may disseminate to produce acute & chronic, progresive disease, includes lymph nodes & skin

the primary benign form may ultimately results with some residual interstitial fibrosis

acute & chronic, progresive paracoccidioidomycosis, disseminated from of the disease, most prequently recognized on the basic of lesion on oropharynx & gingivae

progresive chronic pulmonary disease may involve all lobes of the lung; produce extensive fibrosis

PARACOCCIDIOIDOMYCOSISLaboratory diagnosis :

Direct microscipic examination :wet mount : appears a large, yeast-like cells ( 30 - 360 um ), budding with one or more buds ( multiple buds ) with narrow necks

histophatology : in infected tissue appears as large cells, multiple buds, connected to the parent cell by narrow necks, it has been called a pilot wheel or mickey mouse

PARACOCCIDIOIDOMYCOSISLaboratory diagnosis :Culture :colony morphology : P. brasiliensis is a dimorphic fungus, grows slowly in the mycelial form at room temperature; readily convert to the yeast phase when grown at 370C on enriched media

microscopic morphology : the mycelial form is thin, septate hyphae, conidia, chlamydospora & arthroconidia may be formed;yeast phase cultures will demonstrate both mycelial element & yeast; the yeast are characterized by large ( 30 um or more ); multiple-thin-walled buds, with narrow necks

PARACOCCIDIOIDOMYCOSISLaboratory diagnosis :

Serology : CFT & ID test have been shown to be reliable; however cross reactions may occur

Tretment : Ketoconazole, Amphotericin B, Sulfadiazine

SYSTEMIC MYCOSESSYSTEMIC MYCOSIS : Opportunistic

DiseaseAgents

Candidiasis Candida albicans; Candida sp.

Cryptococcosis Cryptococcus neoformans

Aspergillosis Aspergillus fumigatus; Aspergillus sp.

Zygomycosis Mucor, Rhizopus, Absidia

SYSTEMIC MYCOSES PathogenicOpportunistic

Agent dimorphic fungus non-dimorphic fungus

Port dentre lung (per inhalation )lung & others

Diseaseusually chronicusually acute

Patients could be healthy patients usually ill patient

SYSTEMIC MYCOSESCANDIDIASIS = Candidosis

acute / chronic fungal infections, involving, the mouth, vagina, skin nails, bronchi / lung, alimentary tract, urinary tract, blood steam and less commonly, the heart or meningen

are caused by Candida albicans or other species

are predisposed by : extremes of age, wasting, & nutritional disease, excessive moisture, pregnancy, diabetes, long-term antibiotics, & steroid use, indwelling catheter, immunosupressed & AIDS

are generally treated with imidazoles, polyenes or both

CANDIDIASISCandida albicans :

is part of the normal flora of the skin, mucous membranes & GI tract along with other Candida sp.

normal colonization must be distinguised from infection

form elongated budding forms called pseudohyphae, which are often seen in clinical material along with true hyphae, blastoconidia & yaest cells

CANDIDIASISClinical features : oral thrush

is a yeast infectoins of the oral mucocutaneus membranes

manifest as white curd-like patches in the oral cavity

occurs in premature infants; older infants being treated with antibiotics, immunosuppressed patients, long-term antibiotics & AIDS patients

CANDIDIASISClinical features : Vulvovaginitis

is a yeast infection of the vagina; manifest with a thick yellow-white discharge, a burning sensation, curd-like patches on the vaginal mucosa & inflamation of perineum

is predisposed by diabetes, antibiotic therapy, oral contraceptive use & pregnancy

may be trasmitted to sexual partner as balanitis

CANDIDIASISClinical features : Cutaneus candidiasis

involves the nails ( onychomycosis; paronychis ), skin folds ( intertriginosa ) or groin ( such as diaper rash )may be eczematoid or vesicular / pustular; is predisposed by moist condition

Clinical feature : alimetary tract disease :

is usually an extension of oral thrush & may include esophagitis & ultimately the entire gastrintestinal tract

is found in patients with AIDS or other immunosuppressive disorder, particularly those patients on long-term antibiotics therapy

CANDIDIASISClinical feature : Chronic mucocutaneus candidiasis

is a chronic, often disfiguring, infections of the epithelial surfaces of the body

is diagnosed microscipically & by the lack of cell mediated immunity

Clinical feature : Bronchopulmonary infections

occurs in patient with chronic lung disease; its usually manifested by persistent cough

CANDIDIASISClinical feature : Candidemia / blood borne infections

occurs most commonly in patients with indwelling catheter; these infections are manifested by fever, macronodular skin lesion & endopthalmitis

Clinical feature : Endocarditis

occurs in patient who have manipulated or damaged valves, or in IV drug abusers

Clinical feature : Cerebrospinal infections

may occur in compromised patients

CANDIDIASISLaboratory diagnosis :

direct microscopic examination : wet mount of the skin / nail scraping or exudate, demonstration of the presence of pseudohyphae / hyphae, & yeast in the tissue

culture : of the specimens on to SDA at room temperature, Candida will grows as yaest-like colony

C. albicans be identified by :* germ tube test -- yeast germination in serum at 370C* culture on corn-meal-agar -- reveals chlamydospres* culture on Eosin-methylen-blue-agar : reveals spider colony* fermentation test of : glucose, lactose, maltose, sacharoseserologic : high levels of Candida precipitins or antigens

SYSTEMIC MYCOSES : OpportunisticCRIPTOCOCCOSISinclude subacute or chronic fungal infections involving the lungs, meninges, or less commonly the skin, bones & other tissues

most commonly occur as cryptococcal meningtis; often occuring in AIDS patients

is caused by Cryptococcus neoformans; yeast that posseses an antigenic polysaccharidae capsule

is associated with pigeon feces; considered to be an opportunist in the present of underlying disease in patients with Hodgkins disease, leukomias; or leucocyte enzyme deficiency disease

CRYPTOCOCCOSIS = Busse-Buschkes disease = European BlastomycosisClinical feature :

pulmonary infections : are ussually asymptomatic; & self resolving; most common in pigeon breeder

meningitis ( most often ) or meningoencephalitis occurs in AIDS patients most commonly with headache, ussually with fever, followed by typical sign of meningitis

CRYPTOCOCCOSISLaboratory diagnosis :

microscopic examination : wet mount, demonstration of encapsulated yeast in CSF sediment in india-ink

detection of the capsular material in the CSF ( the cryptococcal antigen ) by latex agglutination test

culture : in SDA ( Sabouraud dextrase agar ) revealyeast colony

Treatment : Amphotericin B, 5- fluorocytosisn or fluconazol

SYSTEMIC MYCOSES : OpportunisticASPERGILLOSIS

caaused by Aspergillus fumigatus, an opportunistic organism

is a ubiquitous filmentous fungus whose airborne spores are contantly in the air

is recognized both in tissue & in culture by its characteristic septate hyphae with dichotomous branching, produced conidial heads with numerous conidia

ASPERGILLOSISClinical feature : Aspergilloma = fungus ball :

is a roughly spherical growth of Aspergillus in pre existing lung cavities & does not invade the lung tissue

occurs clinically as reccurent hemoptysis & diagnosed by radiologig method

Treatment : surgical ( lobectomy )

ASPERGILLOSISClinical features : Invasive aspergillosis

occurs most commonly during severe neotropenic in leukemia & transplantm patients; most commonly occurs as fever of unknown origin in patient with neutropenia fewer than 500/mm3 & pneumonia

it may begin as sinusitis or lungs; it disseminate to any part of the body, most frequently brain

is diagnosed by microscopy & culture of lung biopsy material

is trested with amphotericin B or intraconzole & has a high fatality rate

ASPERGILLOSISClinical features : Allergic bronchopulmonary - aspergillosis

is an allergic disease, in which the organism colonies the mucous plugs form in the lung, but does not invade lung tissue

is diagnosed by finding of high titer of IgE antibodies

SYSTEMIC MYCOSES : OpportunisticZYGOMYCOSIS = Mucormycosis + Phycomycosis

caused by the genera Rhizopus, Mucor & Absidia; non-septate fungi; phylum Zygomycota; grow repidly & predilection for invading blood vessels & the brain

Clinical features : thoracic infectoins

occur in leukemia & lymphoma patients

abdominal-pelvic infections occurs in malnourish patients

cutaneus infections occurs in patients with leukemia30

ZYGOMYCOSISClinical features : Rhinocerebral infections

is the common form; occurs in patients with acidotic diabetes

presents with facial swelling & blood tinged exudate in the turbinate bones & eyes; lethargy & fixated pupil

is a fatal infections & spreads rapidly

must be diagnosed rapidly; ussually by a KOH mount of necrotic tissue or exudate from the eye, nose, or ear

Treatment : control of diabetes; Surgical debridement; amnphotericin B