HML 316: MEDICAL MYCOLOGY

Course Outline

1. Definition of medical mycology and mycoses

2. Diagnostic Mycology: Mycotic specimen types: Collection, transportation and storage of
mycological specimens and methods of diagnosis.

3. Fungi of medical importance in Tropical countries: (Mycoses)

i. Superficial mycoses

ii. Cutaneous

iii. Subcutaneous mycoses

iv. Systemic mycoses

v. Opportunistic mycoses

vi. Mycotoxicosis

4. Classification of antifungal agents

Study Objectives

1. The student should be able to identify fungal agents

2. Should identify and classify the different mycoses

3. Laboratory Diagnosis of the fungal mycoses

4. Describe the different aflatoxins that causes aflatoxicosis

5. Be able to classify and explain the modes of action antifungal agents

 Reading materials

1. Medical Mycology: A Self-Instructional Text by Blevins PhD MLS(ASCP) CLS(NCA),

Kathleen S.; Kern MD DA MLS(ASCP) CLS(NCA), Martha E.

2. Medical Mycology Case Reports by of. Dr. O. Kurzai

3. Internet etc
Definition of Medical Mycology

The branch of science that involves the study of fungi and the caused diseases in human. A fungus
or fungi are eukaryotic microorganisms such as moulds, yeasts, dimorphic fungi as well as
mushrooms that lack plastids and chlorophyll.

There are four major groups of fungi: Ascomycota (sac fungi), Basidiomycota (club fungi),
Zygomycota and Deuteromycota (fungi imperfecti) and there are over 100,000 species of
described fungi and over 200,000 undescribed. The majority of fungi obtain nutrients from dead
organic matter while other fungi survive as parasitic decomposers, absorbing their food through
their cell walls.

Mycoses

They are diseases that are caused by fungi in human. The infections are classified according to the
site of infection on the body. Fungal infections have become more common due to conditions
that compromise host immune system especially cell-mediated immunity. Such conditions are
HIV/AIDS, cancer and immunosuppressive therapy that prevent transplant rejection or control
inflammatory syndromes. Additionally, opportunistic mycoses have become more significant as
severely debilitated individuals live longer because of advances in modern medicine and
hospital-acquired fungal infections are an increasing problem.
COLLECTION, STORAGE AND TRANSPORT OF MYCOLOGICAL SPECIMENS.
Proper collection is of primary importance. Due to scarcity of viable fragments in many
specimens, it is advisable to collect as much material as possible. This is especially true in the
diagnosis of Cryptococcal meningitis, dermatophyte infection and bronchopulmonary
Aspergillosis.
General rules for good fungal specimen collection
1. Make sure that the specimen is collected from the area most likely to be affected. E.g when a
hair infection is suspected, choose hair specimen that look broken and scaly, since these are the
ones most likely to contain organisms.
2. Use sterile technique in collecting the specimen. Any fungus in the specimen may contaminate
your hands and possible cause infection. Use only flamed and cooled forceps, sterile swabs and
specimen containers.
3. The specimen must be adequate. Ask for more additional samples e.g swabs specimens if
several tests are requested.
4. The specimen must be promptly delivered to the laboratory and the lab must quickly process the
specimen. Slow growing, pathogenic fungi rapidly overgrown by bacteria and fungal opportunists.
If the specimen must delay before processing, refrigerate it.
5. The specimen must adequately be labeled including the possible disease the doctor suspects.
The specimens include:
1) Skin Scrapings.
-Clean the skin thoroughly with 70% alcohol in water. Using a scalpel blade which is curved is
used for taking samples by scraping across the inflamed margin of the lesion into the apparently
health tissue.
-The inflamed margin is evidence of a late immunology reaction i.e. Actively growing healthy
hyphae may be found some centimeters beyond this margin. If vesicles are present, the tops should
be removed with fine scissors and sent for examination.
2) Skin Strippings.
-Apply water roof transparent vinyl adhesive tape firmly to the affected area and peel it off; the
tape now bearing a thin layer of skin is then applied to a sterile glass microscope slide and
transported to the labs in a protective plastic slide mailer. This is a rapid and efficient method of
collecting samples for the isolation of dermatophytes and yeasts by culture.
3) Nails.
-Friable material should be removed from under the nail or clippings may be taken from the distal
border with a scissor or nail clippers. Scrapings can also be taken with scalpel blade by scraping
across the affected area. In case of yeast infection, exudate is probed with a flat excavator and
collecting on a swab previously maintained with sterile saline.
4) Hair.
-Infected hair should be removed by plucking with epilating forceps and never by cutting because
this fails to remove the area most likely to harbor the fungus i.e. the base of the hair shaft around
the follicle.
-The species most frequently associated with scalp ringworm cause the affected hair to fluoresce
under a woods lamp (UV light) and this is a useful means of selecting materials.
Storage and transport of skin, nail and hair.
-The specimen (nail, hair and skin) should be allowed to dry out to prevent the overgrowth of
saprophytic bacteria and fungi that occurs if moisture is retained by holding the specimen in
airtight container e.g. small bottles.
-Black paper may be folded to form a packet or envelopes especially designed for this purpose are
available commercially. In such conditions ringworm fungi remain viable for week’s even months
and also specimen may be stored and forwarded with confidence even if the lab is in remote.
-Specimen should not be refrigerated as the viability of some species of dermatophyte is affected.
-Fungi pathogenic to skin survive well as tape stripping’s stuck to a microscope slide.
-Swabs are unsuitable for diagnosis of dermatophytes as should only be sent to the labs when
yeast infection is suspected. Use transport medium suitable for yeasts.
5) Sputum.
-Total sputum collection should be obtained.
-To establish or exclude a definitive diagnosis, a 3 day collection is often required. Sputum may be
collected as 3 days 24 samples but a convenient system for wards and lab handling is for sputum
to be batched every 8 hours.
-Sputum should be refrigerated to reduce the growth of saprophytic bacteria and yeasts.
-Experience has shown that hyphae of Aspergillus produce little or no growth in sputum even after
several days at room temperatures and viability is not affected.
6) C.S.F
-Its collected through lumbar puncture and precaution should be taken to minimize contamination
by yeasts colonizing the surface skin. A large volume should be collected (enough) if this is
clinically permitted while taking account of the dangers of the patient if the CSF pressure is
increased especially where investigation for Cryptococcus in non AIDs patients are requested.
Transport the CSF to the lab without delays.
7) Swabs.
They should be heavily charged with exudate, pus or other secretions. Where plaques are present
such as in the mouth, throat or vagina, the swab should be repeatedly rubbed firmly over these
areas.
-Delays should be avoided if possible because yeasts on dry swabs are affected by the duration of
standing at strong temperatures.
-If delay is inevitable, swabs may be held at 4oc and preferably in a suitable transport medium
containing antibiotics e.g. trichomonas medium.
8) Tissues biopsies, urine, blood, and all materials not mentioned above should be collected, stored
and transported in a manner similar to that employed for bacteriological investigation.
Laboratory Methods in Medical Mycology summary
A. Collection, handling and processing of clinical mycology specimens
1. Importance
2. Collection - usually by physician or nursing staff
a. Skin - cleaned with 70% alcohol to remove dirt, oil and surface saprophytes
b. Nails - cleaned same as for skin. Usually clipped; need to be finely minced before innoculating
to media
c. Hair - obtained from edge of infected area of scalp,. Use a Wood's lamp (fluorescence) to help
locate infected hair. Hair can be obtained by plucking, brushing, or with a sticky tape.
d. Body fluids - normal sterile collection procedures
3. Preparation of specimens for immediate transport to laboratory
a. Hair & nails sent in a dry envelope, inside proper container.
b. Other specimens are usually sent frozen or on dry ice.
c. Packaging - biohazard regulations. Any growing cultures must be on tube media (not plates).
Aluminum screw-capped mailing tube with outer cardboard mailing tube.
d. Inside labeling information: patient ID, specimen source, suspected organism.
e. Outside labeling information: must state
WARNING: POTENTIAL PATHOGEN
4. Appropriate processing of specimen to recover fungus
a. Skin, nails, & hair - direct exam following KOH preparation
b. Body fluids
(1) CSF - centrifuged; examine sediment microscopically, inoculate media
(2) Pleural fluid, sputum, and bronchial aspiration - specimen must be fresh as saprophytes would
overgrow pathogens such as H. capsulatum. Specimens may be refrigerated up to 2 hours.
(3) Gastric washings - same as for pleural fluids
(4) Genito-urinary specimens - first morning specimen preferred; centrifuge
(5) Blood/bone marrow - generally inoculated directly to BHI broth and BHI slant. Extra specimen
should be inoculated to other fungal media.
(6) Wound abscess or drainage - should be cultured anaerobically, especially if actinomycosis is
suspected.
(7) Tissue specimens - examine for pus, caseous material or granules; mince aseptically , can use
small amount of sterile saline and the supernatant also inoculated.
Direct examination of specimens
1. Direct exam required on any biological material sent to lab for fungus culture. Look for spores,
hyphae, mycelial elements, budding yeast, mycotic granules.
2. Wet mount prep - good for yeast; examination is done in natural environment, so loss of fragile
structure is minimal.
3. KOH prep - Potassium hydroxide; done on skin scrapings, hail, nails, sputum, vaginal
specimens, etc. The KOH digests and clears the specimen’s tissue cells, mucous, etc., so fungal
elements can be seen.
C. Stains
1. Lactophenol Cotton Blue (LPCB) - very popular for quick evaluation of fungal structures; will
stain the chitin in cell walls of fungi.
2. Periodic Acid - Schiff Stain (PAS) - stains certain polysaccharide in the cell walls of fungi.
Fungi stain pink-red with blue nuclei.
3. Gomori Methenamine Silver Stain - silver nitrate outlines fungi in black due to the silver
precipitating on the fungi cell wall. The internal parts of hyphae are deep rose to black, and the
background is light green.
4. Gridley Stain - Hyphae and yeast stain dark blue or rose. Tissues stain deep blue and
background is yellow.
5. Mayer Mucicarmine Stain - will stain capsules of Cryptococcus neoformans deep rose.
6. Fluorescent Antibody Stain - simple, sensitive, and extremely specific method of detecting
fungi in tissues or fluids. Applications for many different fungal organisms.
7. Papanicolaou Stain - good for initial differentiation of dimorphic fungi. Works well on sputum
smears.
8. Gram Stain - generally fungi are gram positive; Actinomyces and Nocardia are gram variable.
9. Modified Acid-Fast Stain - used to differentiate the acid-fast Nocardia from other aerobic
Actinomyces.
10. Giemsa Stain - used for blood and bone marrow specimens. Histoplasma capsulatum is an
intra cellular organism, which appears as small oval to pear-shaped yeast-like cells with crescent
shaped red-stained protoplasm surrounded by clear halo in segmented neutrophils.
11. India Ink - demonstrates the capsule of Cryptococcus neoformans in CSF specimens.
D. Fungal Culturing
1. Media introduction
a. Generally tube media is used rather than plated media because:
(1) there is less chance for spore release into the environment.
(2) less chance for dehydration
(3) ease of storage.
b. The agar in a tube is inoculated in a straight line. Preliminary identification is based on
differential growth patterns on various media
2. Media (Media should be carefully selected, and more than one media should be used)
a. Sabouraud's dextrose agar (Sab-Dex) - classic medium, recommended for most studies.
b. Sabouraud's dextrose agar with chloramphenicol - chloramphenicol inhibits bacterial
growth.
c. Mycosel agar - commercially produced agar containing chloramphenicol to inhibit bacterial
growth, and cycloheximide to inhibit saprophytic fungi and some yeasts (including C.
neoformans).
Notes: (1) Aspergillus and Scopulariopsis (saprophytes) are opportunistic pathogens.
Cycloheximide will prevent their growth.
(2) Cryptococcus neoformans is also inhibited.
(3) Bacteria-like fungi (such as Actinomycetes) are inhibited by chloramphenicol.
d. Brain heart infusion slant (BHI) - more enriched than Sab-Dex. Used in recovery of H.
capsulatum.
e. Potato-dextrose agar (PDA) and Corn-meal agar - are used in slide cultures; as they induce
spore formation, which greatly aids in identification.
3. Special applications agar
Mycology.doc 12 of 25
a. Caffeic Acid Agar - Cryptococcus neoformans will produce melanin resulting in black colonies.
(protect media from light)
b. Birdseed Agar - used to isolate Cryptococcus neoformans from contaminated cultures.
c. KT Medium & Kelley Agar - used to convert dimorphic fungus Blastomycetes dermatitidis
from mycelial to yeast form.
d. Modified Converse Liquid Medium (Levine's) - used to promote spherule production by
Coccidioides immitis.
4. Fungal growth requirements
a. Temperature - Room temperature (25-30 C ) for most fungi.
Notes: (1) Nocardia sp. and some dimorphic organisms grow best at 37 degrees C.
(2) Any fungus capable of growing at 37 C, should be considered potentially pathogenic.
b. Atmosphere - True fungi are aerobic; there are a few anaerobes among the bacteria-like fungi.
c. Time - Some yeasts grow overnight. Saprophytes are fast growers (several days). Generally
cultures are held at least 4 weeks. *
Exceptions: Paracoccidioides brasiliensis may require 4-5 weeks, & 10
weeks are recommended if Histoplasma capsulatum is suspected.
V. Techniques for Identification of Fungi & Laboratory ID
A. Inoculation
1. Plates - Inoculated like a large "S", so that rapid growing fungi can removed.
2. Slants - Inoculated with a straight line.
B. Incubation
1. Aerobic (and anaerobic if Actinomycetes are suspected)
2. Room temperature & also sometimes at 37Ε if dimorphic fungus is expected.
C. General considerations
1. Type of media used. Does it contain antibiotics?
2. Growth rate & age of the culture.
Mycology.doc 13 of 25
a. Routine cultures are kept for 4 weeks & should be examined every other day.
b. Most systemic pathogens require 10 days to 2 weeks, while saprophytic fungi grow usually
grow within 1 week.
D. Colony Morphology (macroscopic features)
1. Surface topography - Some fungal colonies may be free growing, covering the entire surface of
agar in a particular manner; others grow in a restricted manner.
2. Surface texture -examples: cottony or wooly (floccose), granular, chalky, velvety, powdery,
silky, glabrous (smooth, creamy), waxy, etc.
3. Pigmentation - Fungi may be colorless or brightly colored. Color may be on fungus itself, on its
sporulating apparatus, on the agar, or on the bottom of the colony (reverse pigmentation). Pigment
color is due to the color of the sporulating apparatus. The pigment can be diffused into the agar. It
is important to note the top pigment (obverse) and the discoloration of the agar medium (reverse).
See Dematiaceous in definitions.
4. Mycelium
a. Vegetative mycelium - provides nutrition
b. Aerial mycelium - reproductive
E. Microscopic evaluation
1. Methods
a. Teased Preparation
b. Slide Culture Techniques - best as it gives undisturbed microscopic morphology.
c. Transparent Tape Preparation
2. A review of terms associated with the microscopic features is advisable.
a. Hyphae structure. Hyphae (plural); hypha (singular)
(1) Septate vs. non-septate (aseptate)
(2) Dematiaceous vs. hyaline
b. Spore bearing structures
c. Spores - Many terms addressing reproduction are provided in the terms section and in the text,
please review (perhaps categorize them).
3. Biochemical studies - generally used to ID yeast and yeast-like organisms.
a. Carbohydrate fermentation
(1) Growth and utilization of a carbohydrate under anaerobic conditions as determined by acid and
gas production.
(2) Specimen is inoculated beneath broth so that it is completely covered. Bromcresol purple is the
indicator. Acid production turns purple to yellow. Gas is detected by appearance of bubbles
trapped in the fermentation tube. Observe every 48 hours for 14 days.
b. Carbohydrate assimilation
(1) Ability to utilize a carbohydrate as sole source of carbon.
(2) Bromcresol purple indicator turns from purple to yellow.
(3) Tubes unchanged (as determined by comparing to a blank tube) by 10 days are negative.
c. Nitrogen assimilation
(1) Utilizes 3 tubes with differing sources of nitrogen. Bromthymol blue is the indicator (blue to
yellow is positive).
d. Growth on specific agars
(1) Christensen's urea agar
(a) Urea is hydrolyzed by some yeast to form ammonia (pH increases) which turns media from
yellow to dark pink.
(2) Caffeic acid medium (protect media from light)
(a) Production of melanin by Cryptococcus neoformans resulting in black colonies.
4. Other tests
a. Germ tube - Candidia albicans & Candidia stellatoidea produce germ tubes when incubated in a
protein medium.
Candida germ tube
b. Demonstration of chlamydospores - Yeast is inoculated by jabbing appropriate agar (Cornmeal
with tween 80) and observed every 24 hours for 3 days for chlamydospore production.
5. Stains (covered previously)
6. Hypersensitivity (seromycology; skin tests) and serological tests
a. Skin tests - demonstrates T-cell immunity (cellular) to a fungus
b. Serological tests - demonstrates B-cell (humoral) immunity to a fungus; sera should be drawn in
pairs (acute and convalescent).
(1) Complement fixation
(2) Agglutination tests
(3) Precipitin tests
(4) Immunofluorescence
(5) Immunodiffusion techniques
(3) Counter immunoelectrophoresis
7. Antifungal susceptibility testing - some progress has be made in the attempt to standardize
susceptibility testing as a means in evaluating unusual fungal isolates, determining the cause(s) of
patient relapse and treatment failure.
8. Determining serum concentration of antifungal agents - can be very important for patients with
renal or liver problems or in cases where poor absorption is a concern. HPLC has proven to be an
excellent method due to its accuracy and ability to analyze more than one drug in a specimen.
FUNGI OF MEDICAL IMPORTANCE IN TROPICAL COUNTRIES
Fungal infections are called mycoses. While fungal pathogens do not cause widespread or
dangerous epidemics like bacteria and viruses, they are a major cause of individual distress,
disability and disfigurement and the cause of severe life threatening conditions in those with
immosuppression caused by e.g. AIDs as treatment with immosuppresive drugs. The widest range
and most serious fungal infections and diseases caused by fungal toxins (mycotoxicoses) are found
in tropical and developing countries. Heat, humidity, inadequate water supplies, poor living
conditions, malnutrition co-infection with HIV and lack of diagnostic and care facilities for those
with mycoses, all contribute to the high prevalence and severely of fungal infection in the
countries.

Based on the sites or colonization of the fungal infection on the body the principal mycoses can be
described as categorized/classified as:-
1) Superficial mycoses (cosmetic mycoses)
They are confined to the body surfaces and do not directly involve living tissues e.g the
Mallassezia furfur infection.
2) Cutaneous mycoses
These affect mostly the nails, skin and the hairs. It affects the epidermis and though it does not
affect the living tissues, the presence of the fungi results to allergic reaction and reddening of the
skin. E.g dermatophytosis and candidiasis.
3). Subcutaneous mycosis
Which are referred to as mycoses of implantation. They are acquired when the pathogen is
inoculated through the skin by minor cuts or scratches or by thorn or splinter woods. e.g.
Mycetoma, Chromomycosis, Sporotrichosis, Rhinosporidiosis, Zygomycoses e.t.c.
4). Systemic mycoses
They are also referred as deep mycoses. They are acquired by inhalation and may spread from the
lung and involve any part of the body. Widespread infection can be fatal and skins infections are
often present e.g. Histoplasmosis, Blastomycoses, Paracoccidiodomycoses, Aspergillosis and
Coccidiodomycoses.
5) Opportunistic mycoses
Are fungal infections of the body which occur in debilitated patients whose normal immune
system is impaired. The organisms involved are cosmopolitan and normal flora in the body e.g.
Candida species most opportunistic mycoses are caused by saprophytic fungi.
The infections include:-Candida infections, Cryptococcus neoformans,
 - Aspergillus species
- Histoplasma species
- Sporotrichosis
- Histoplasmosis
- Cryptococcal meningitis
6) Mycotoxicoses
Are caused by ingesting mycotoxins in moldy foods, such as grains which has been stored under
damp humid conditions. The toxins are released by certain moulds as they grow e.g. aflatoxins are
produced by e.g Aspergillus flavus when growing on peanuts and grains. Aflatoxins poisoning can
cause hepatitis and hepatic carcinoma.

1. SUPERFICIAL MYCOSES/COSMETIC MYCOSES

Mycoses that attack the surface of the skin and hair and its usually dead. No pain and no
scratching. It can only be observed as spots and thus called cosmetic mycoses. There are of two
types:
i. For the skin mycoses infections are: a) Malassezia infection
b) Tinea nigra
ii. For the hair mycosis infections are-
a) White piedra
b) Black piedra
For The Skin Mycoses
a. Malassezia Infection
-Caused by Malassezia furfur. It’s lipophilic yeast and is part of the normal flora i.e. It requires
lipids to grow in culture.
It has four types of its clinical manifestation/ presentation
i) Pityriasis versicolor
ii) Pityriasis folliculitis
iii) Seborrhoic dermatitis and dandruff
iv) Fungemia
i. Pityriasis Versicolor
-It is characterized by well demarcated lesions on the skin which sometimes join together and
become colored and their characterized color depends on exposure to the sun and color of the skin.
The lesions will be on the shoulder, trunk, neck and face. They produce a florescence colour i.e
pale greenish colour under Woods UV light. It usually affects young adults.
ii. Pityriasis Folliculitis’
The lesions are around the follicle purpur. They are usually localized at the back, chest, upper
arms and sometimes the neck and very rare on the face. Skin scrapping’s or biopsies show
numerous yeast cell including the area around follicles of the hair.

iii. Sebarrhoic Dermatitis and Dandruff

It’s itching and when enlarged it becomes seberrhoic dermatitis. The predisposing factor is host
stress, genetic predisposition especially due to increased alkalinity in the skin. Most common with
patients with neurological disorders and those with HIVAIDs. The clinical manifestation of the
dermatitis is that it’s characterized by erythema and scaling in areas with rich supply of
sebaceous glands e.g. eyes, skin etc. In dandruff, the lesions are red and they are itching. Theses
are more common in the sculp.
iv. Fungemia (Mallasezia furfur) in Blood
Fungi find in the blood. The patient develops lesion in the lungs and other organs. It’s mostly
found in patients undergoing lipid replacement therapy and infants. Diagnosis requires culture
media and blood drawn for the catheter tip and culturing the catheter tip is recommended.
Lab Diagnosis
The clinical specimens are the skin scraping’s from patient with superficial lesions, blood, catheter
tips from patient with suspected fungemia.
After obtaining the samples, do direct microscopy through mounting with 10% KOH. 10% KOH
is used to digest the keratins and release cells with the fungi and when observed microscopically,
budding yeast like cells and short angular cells which averagely 4 micro m in diameters are
observed which is malassezia furfur species.
Culturing of the blood should be done in vitro (SDA media) for diagnosis of fungemia and the
growth be stimulated with natural oil e.g. Sabaroid olive oil. The identification is usually by the
observation of yeast budding like cells especially in culture.
No serology methods available for the infections.
Management
The patient management will depend on the clinical manifestation. In fungemia systemic
antifungal agents are used and for the superficial infections, ketoconazole and shampoo is used.
b. Tinea Nigra: Tines is Latin word meaning rings.
It’s a superficial fungal infection of the skin characterized by brown to black macules which
usually occur in the palms and occasionally in the skin of the other parts of the body. The
etiological agent is Hortea werneckii which is a common saprophytic fungus in humans. The
lesions are non inflammatory and none scaling.

Lab Diagnosis
Skin scrapping’s of the palms should be collected and do direct microscopy using 10% KOH and
parker ink. Observe for pigmented brown to dark septate hyphae elements and two joined celled
yeast cells. These cells produce annelloconodia which is a key feature of the fungi.
Also Culture the samples on SDA and observe for the growth of hyphael elements of the fungi.
Olive oil should be added in the media to facilitate the growth of the fungi. Cultured at 25- 28Oc.
iii) No Serology methods available
Management
Use a topical treatment with Benzoic acidic component and imidazole drugs.

For the hair mycosis infections

a. White Piedra
A fungal infection of the hair shaft caused by Trichosporon beigelii. The infected hair develops
white nodules along the hair shaft. Localized at the scalp and sometimes pubic and facial hairs.
Usually very common to young adults. The Presence of white irregular or brown nodules which
are 1-1.5mm in length adhering to the hair is a characteristic feature of white piedra.
Lab Diagnosis
i) Clinical material is the hair. Do direct microscopy using 10% KOH looking for the white
irregular or brown nodules which are 1-1.5mm in length adhering to the hair.
ii) Culture in SDA with sabaroids oil and observe for white or yellowish to deep cream colonies in
colour.
iii) No serological diagnosis
Management
Simply by shaving or use of imidazole compound which sometimes prevent re-infection.

b. Black Piedra
It’s caused by fungi called piedra hortae which is an Ascomycete fungus which form hard black
nodules on the hair shaft of the beard, pubic and the scalp hair. The infection is usually
localized on the scalp but can be seen in the pubic and beard hair and it affects young adults.
Sharing of combs can transfer the infection.
Lab Diagnosis
Collect the hair nodules and do direct microscopy by using 10% KOH and parker ink. Look for
hard black nodules that contain Asci.
Culture the samples on SDA added with sabaroids oils e.g olive oils and examine for black
colonies.
Management
Through shaving and use of terbinafine.
2. THE CUTANEOUS MYCOSES

These are superficial fungal infections of the skin, hair or nails. No living tissue is invaded,
however a variety of pathological changes occur in the host because of the presence of the
infectious agent and its metabolic products.

Disease Causative organisms Incidence

Dermatophytosis
Ringworm of the
Dermatophytes (Microsporum,
scalp, Common
Trichophyton, Epidermophyton)
glabrous skin and
nails.

Candidiasis of skin,
mucous membranes Candida albicans and related species.
Common
and nails.

1. Dermatophytosis - Ringworm or Tinea

Ringworm of scalp, glabrous skin, and nails caused by a closely related group of fungi known as
dermatophytes which have the ability to utilize keratin as a nutrient source, i.e. they have a unique
enzymatic capacity - keratinase. The presence of the fungi and the metabolic products causes
allergy and inflammatory eczematous response in the host. The metabolites of the fungi destroy
the living tissue.

Ringworm is a contagious infection acquired from active ringworm from active ringworm lesions
on humans, animals and sometimes from the soil. The fungus settles on the skin, germinates and
forms a mass of branching hyphae which grows out to produce circular lesions. Ringworm fungi
infect the keratinized layers of the skin, hair and nails. Some of the infections cause inflammations
and the infection caused by T. rubrum tends to be chronic and do not respond well to treatment.
Clinically, the ringworm/ dermatopytosis infection is often referred to as Tinea and the locations of
the body involved are usually the surfaces of the body, scalp, foot and nails.
1. Tinea corporis (skin)
It’s an infection of the skin and may affect the whole body. It is caused by anthrophillic, zoophillic
and geophillic dermatopytes due to following contact with either contaminated soil or an animal
host or human host eg T. rubrum, M. canis.
2. Tinea cruris
It’s an infection of the proximal medial thighs, groin and buttocks. It occurs more commonly in
males and is usually due to spread of the fungus from the feet. The usually causal agents are T.
rubrum, T. interdigitale amd E. floccosum.
3. Tinea pedis (feet)
It’s caused by anthrophillic dermatophytes. It affects the feet. It usually occurs by shedding of skin
scales which contain viable infectious hyphael elements of the fungus. It can remain viable for
months or years. Substrates like carpet and mats that hold skin scales make excellent vectors.
There causative agents are T. rubrum, T. interdigitale.
4. Tinea unguium (nails)
The same species of dermatophytes are involved i.e T. rubrum, T. interdigitale etc. This affects the
nails. The infection can be on the surface of the nail or distal or the proximal edges of the nail or
the nail beds causing hyperkeratosis. The nail plates can also be affected.
5. Tinea capitis (scalp - hair)
This is an infection of the scalp and usually the hair is involved. Three types of vivo hair invasion
are recognized. These ares-
i. Ectrothrix invasion. Where the infection occurs on the outside of the hair shaft. The
infected hair usually fluoresce a bright greenish yellow color under wood’s UV light.
It’s caused by zoophillic, anthrophillic and geophillic dermatopytes eg M. canis.
ii. Endothrix invasion. The infection occurs within the hair shaft and the infected hair
does not fluoresce under wood’s UV light.
iii. Favus invasion. The infection produces favus like crusts and causes hair loss.
Laboratory Diagnosis of dermatopytosis
The clinical materials to be collected depend on the Tinea. The materials can be skin scrapings,
nail scrapings and epilated hair. Enough specimens should be collected for direct microscopy and
culture.
i. Direct Microscopy
Fungi are usually larger than bacteria and in materials from the skin, nails and hair, they can be
seen by direct microscopy provided that the specimens are digested (softened and cleared) by 10%
KOH so that the hyphae and conidia or spores can be seen.
ii. Culture
Specimens should be inoculated onto a primary isolation media like SDA containing
antibiotics and incubated at 24-26oC for 4 weeks. The growth of any dermatopyte is
significant.
Management of dermatophytosis
i. Apply topical antifungal agent when the infection is on the body surfaces eg
fluconazole and topical nytatin.
 ii. Systemic therapy for nails, foot and scalp is required but before the treatment is started,
mycological confirmation of the clinical diagnosis should be done.

2. Candidiasis
Is a primary or secondary (opportunistic) infection caused by members of the genus candida. The
clinical manifestations can be acute, sub acute or chronic to episodic. It’s the only infection that is
able to attack every organ in the body. Candida infections are usually due to impaired epithelial
barrier function and occur in all age groups but are most common in the newborn and the elderly.
They usually remain superficial and respond easily to treatment. Systemic candidiasis is usually
seen in patient with cell mediated immune deficiency and those receiving aggressive cancer
treatment, immunosuppression or transplantation therapy.
CANDIDIASIS CLINICAL MANIFESTATIONS
1. Oropharyngeal candidiasis
These include thrush, glossitis, and stomatitis. It’s associated with newborn and severe
immunological infection e.g. HIV, diabetes, mellitus, leukemia. Acute oval candidiasis is rarely
seen in health adults but may occur in up to 5% of newborn infants and 10% of the elderly. The
use of broad-spectrum antibiotics, cytotoxic drugs, corticosteroids and radiation therapy are
among the predisposing factors.
Clinically, white plaques that resembles milk curd on the buccal mucosa and less commonly on the
tongue, gums, the palate or the pharynx. Symptoms may be absent or include burning or dryness
of the mouth, loss of taste and pain on swallowing.
2. Cutaneous candidiasis
It affects the fingertips and can be confused with Tinea. It can also affect the groin, nappy rash in
an infant which can spread to the mouth area. Moisture, heat, friction and maceration of the skin
are the principle predisposing factors in normal patients. Additional factors are obesity, diabetes
mellitus, warm water immersion and use of broad spectrum antibiotics.
3. Vulvovaginal candidiasis and balanitis
It’s common in women and it’s associated with the use of broad spectrum antibiotics, the 3rd
trimester of pregnancy, low vaginal PH and diabetes mellitus. Sexual activity and oral
contraception may also be a contributing factors, HIV infection etc. The symptoms include-Vulva
pruritus, burning, erythema with a creamy white curd like discharge.
In cases of balanitis, diabetes mellitus should be excluded and the sexual partner should be
investigated for vulvovaginitis. The symptoms include erythema vesiculopustules on the glan
penis or prepuce. Infections are seen more in uncircumcised men and poor hygiene may also be a
contributing factor.
4. Chronic mucocutaneous candidiasis
It’s caused by C. albicans. It’s a candidiasis of the skin, nails and mucous membrane that occurs in
patients with various metabolic disturbances to cell mediated immunity. E.g. defects in leukocyte
functions. The patients are usually children
5. Neonatal and congenital candidiasis
The predisposing factors are low both weight and age, prolonged IV catheterization and the use of
antibiotic drugs. These are for systematic candidiasis. Blood cultures are often positive and there is
also a high incidence of meningitis. Renal complication due to fungus ball formation in the ureters
or renal pelvis may also occur. Intrauterine candidiasis may also occur of which can lead to
abortion.
6. Oesophogeal candidiasis
Frequently associated with leukemia and HIV/ AIDs. Concomitant oral candidiasis is often
present. Oesophagus candidiasis may also lead to septicemia and disseminated candidiasis.
Symptoms include burning pain, nausea and vomiting. The clinical diagnosis relies on radiological
and endoscopic findings, which usually shows white mucosal plaques with erythema resembling
those seen in oral candidiasis. The clinical diagnosis may need to be confirmed by histopathology
and culture.
7. Gastrointestinal candidiasis
This is ulceration of the stomach and less common with the intestine. This is associated with
patients with acute leukemia or other hematological malignancies. Perforation can occur which
can lead to peritonitis and hematogenic spread to the liver, spleen and other organs. Colonization
and invasion of the stomach or intestinal mucosa is often accompanied by the excretion of large
number of yeasts which may be detected in stools.
8. Pulmonary candidiasis
This may be hematogenous dissemination causing diffuse pneumonia or bronchial extension with
oropharyngeal candidiasis due to infection of the lungs. Aspiration of yeasts from the oral cavity
has also been reported in infants. This type of candidiasis is difficult to diagnose because of non
specific radiological and culture findings. Only histopathology can prude a definitive diagnosis
and this is not always possible in patients with coagulation problems.
9. Others candidiasis include Peritonitis, Urinary tract candidiasis, Meningitis (brain candidiasis),
hepatic and hepatosphleen candidiasis, Candidemia, Ocular candidiasis and Osteoarticular
candidiasis.

LAB DIAGNOSIS OF CANDIDIASIS

Clinical maternal depend on the infected organ. It can be skin and nail scrapings, urine, sputum
and bronchial washings, CSF, pleural fluid and tissue biopsies of various visceral organs and
indwelling catheter tips etc.
1. Direct microscopy
Skin and nail scrapings should be examined using 10% KOH and parker ink. Exudates and body
fluids should centrifuged and the sediment examined using either 10% KOH or parker ink or gram
stain smears. Tissue sections should be stained using PHs digest or gram stain.
NB: Examine specimen for the presence of small, round to oral thin walled, clusters of budding
yeasts cells as branching pseudohyphae.
Interpretation
Positive direct microcopy from a sterile site should be considered significant. The demonstration
of pseudohyphae in scraping smears for cutaneous, oral, esophageal and vaginal lesions should be
considered significant provided clinical manifestation support the diagnosis. However the finding
of just budding yeast cells in such material is of little diagnostic importance. Direct microscopy
body fluid e.g. CSF, joint fluid will require positive culture to make a diagnosis because it
relatively insensitive.
2. Culture
Colonies are typically white to cream colored with a smooth, glabrous to waxy surface. A positive
culture from blood, sterile body fluid, should be considered significant. Lysis centrifuges currently
the most sensitive method of isolation of candida from blood. However positive culture from non
sterile specimens e.g. sputum, bronchial lavage, urine, stool and surgical drains are of little
diagnostic value. Candida species are commonly isolated from the mouth, vagina, anus and less
often most skin surface individuals who do not have candidiasis.
3. Serology
This detects the presence of candida antibodies ranging immunodiffusion to more sensitive tests
e.g. counter immune electrophoresis, ELISA, RIA. However these are often negative in the
immune compromised patients especially at the beginning of an infection.
Testing for circulating antigen by immunological or non immunological techniques e.g. use of gas
liquid chromatography to detect mannose derivations of the cell wall D-arabinitol have proved the
most useful. But small cats uses latex agglutation test and have proved to be useful.
Identification
The genus candida is characterized by elongated yeast cells that replicate by multilateral budding.
Also characterized by the presence of well developed pseudohyphae. Causative agents-candida
albicans, candida famata, Candida krusei, candida norvegensis, candida tropicalis etc
MANAGEMENT
Candidiasis in immunocompetent patients.
Restore the normal epithelial barrier function. For cutaneous candidiasis, treat with imidazole
compound. Sometimes it is combined with tropical steroid to control excessive motion, heat and
friction. Nystatin suspension dropped into the mouth 4-6 hours intervals or after each feed is
usually used. Azole suppositories and cream are often used with good results e.g with vaginal
candidiasis.
Candidiasis in immunosuppressed patients
Give oral fluconazole-This is currently a drug of choice for controlling oropharangeal candidiasis
in AIDs patient and maintenance treatment fluconazole is required. Neutropenia Patients require
high doze of Amphotericin B given in combination with 5-flucytosine.
Candiduria
Drug of choice is oral fluconazole for 2-4 weeks. Amphotericin B is used in patients with
indwelling urethral catheters. For renal candidiasis, systemic antifungal therapy with either
Amphotericin B or fluconazole has been used.
Prophylactic treatment in AIDs patients or patients undergoing immunosuppressive
therapies.
Give Fluconazole prophylaxis. Fluconazole (400mg/1 day) is effective in prevailing candidiasis
and is recommended for primary prophylaxis against candida. Itraconazole-Is an alternative
antifungal which appear to suppress bronchopulmonary colonization, however its absorption is
often erratic and requires monitoring.

3. SUBCUTANEOUS MYCOSES
Are chronic, localized infection of the skin and subcutaneous tissue following the traumatic
implantation of the etiologic agent e.g. implantation on wound, bite or sting. The causative fungi
are all soil saprophytes and have the ability to adapt to the tissue environment and elicit
disease is extremely viable. The infections include:-
a) Sporotrichosis caused by sporothrix schenkii
b) Chromoblastomycosis caused by fonsecaea, phialophora e.t.c
c) Phaeohyphomycosis which is caused by cladosparium, Exophiala
d) Mycotic mycetoma caused by madurella, pseudallescheria
e) Subcutaneous zygomycosis caused by Basidiobolus , Rhizopus, mucor
f) Lobomycosis caused by loboa loboi
1. Sporotrichosis
It’s a chronic infection of the cutaneous or subcutaneous and the adjacent lymphatic’s
characterized by nodular lesions which may suppurate and ulcerate. The infection is caused by
implantation of the fungus into the skin. The infection may also occasionally involve the CNS,
lungs or GIT but secondary spread to articular surfaces, bone and muscle is not frequent.
Clinical Manifestations
i. Fixed cutaneous sporotrichosis
Primary lesions develop at the site of implantation of the fungus usually at more exposed sites
mainly the limbs, hands and fingers. Lesions start as a painless nodule which soon become
palpable and ulcerate often discharging a purulent fluid. The lesions remain localized around
the initial site of implantation and do not spread to the lymphatic channels.
ii. Lymphocutaneous sporotrichosis
Primary lesions develop at the site of implantation of the fungus but secondary lesions also appear
along the lymphatic channels which start from painless nodule to palpable and ulcerated.
Lab Diagnosis
Clinical materials are tissue biopsy, serosanguinous fluid containing the granules which differ in
size, color and degree of hardness depend on the causative species.

Direct Microscopy
Serosauguinous fluid contain granules should be examined using 10% KOH and parks ink and
tissue section should be stained using H and E and Grocotts methanamine silver(GMS).
Examine for the presence of white to black granules and in tissues, tissue invasion is of
particular importance.
Culture
Clinical specimen should be inoculated into primary isolation media like SDA and examine for
buddy yeasts like colonies.
Serology: No commercial available serology procedures. The causative agents are:-Madurella
mycetomatis, Madurella grisea
iii. Pulmonary sporotrichosis
It’s rare but usually is caused by inhalation of conidia but cased of haematogenous dissemination
have been reported. Symptoms include cough, sputum production, fever and weight loss.
iv. Osteoarticular sporotrichosis
Characterized by stiffness and pain in large joints usually the knee, elbow, ankle or wrist. Lesions
occur on the long bones near affected joints.
Management
Give saturated potassium iodide, Triconazole, Terbinafine or combination of antifugal treatment
with Amphotericin B.
2. Chromoblastomycosis
An infection characterized by the development in tissue of dematiaceos (brown pigment), planate
dividing and rounded sclerotic bodies. Infection are caused by the traumatic implantation of fungal
elements into the skin and are chronic slowly progressive and localized. Tissue proliferation
usually occurs around the area of implantation. The infection is more common in bare footed
population living in tropical regions.
Clinical manifestations
Lesions are often found on exposed parts of the body and it starts as a painless nodule but itchy.
But as the disease develops, rash like areas enlarge and become raised irregular plaques. In long
standing infection, lesions may become tumorous and even cauliflower like in appearance. Other
prominent feature includes epithelial hyperplasia, fibrosis and micro abscess formation. It’s caused
by cladophialophora carrionii.
Lab Diagnosis
Clinical materials are skin scrapping’s and biopsy.

Direct Microscopy
Skin scrapping’s should be examined using 10% KOH and parker inks. Tissue section should be H
and E. Direct microscopy of tissue is necessary to differentiate between chromoblastomycosis and
phaeohyphomycosis where tissue morphology of the causative organ is mycelial.
Interpretation
The pressure in tissue of brown pigmented, planate dividing, rounded sclerotic bodies from a
patient with supporting clinical symptom should be considered significantly.
Culture
Clinical specimens should be inoculated into primary isolation media like SDA and examine for
typically olivaceous-black with suede like surface colonies. N/B Culture should be supported with
microscopy and by clinical history when positive results are obtained from a non sterile specimen
become dematiceous hyphomycetes are recognized as environmental fungi.
Management
Removal of the margin of the infected tissue to prevent local dissemination of the infection. This
is through surgical evasion. Also administer Flucytosine, Itraconazole and Terbinafine.
3. Phaeohyphomycosis
An infection of human and lower animals caused by many fungi agents that are dematiceous and
mycelial in morphology. The etiological agents include various dematiaceous hyphomycetes
especially species of: Exophiala, Phialophora, Wangiella and Cladosporium.
Clinical Manifestations
i) Subcutaneous phaeohyphomycosis
It occurs following the traumatic implantation of fungal elements from contaminated soil, thorns
or wood splinters. Exophiala jeanselmei and Wangiella dermatitidis are the most common agents
and cystic lesions occur most often in adults. However overlying verrucous lesions are formed
especially in the immune suppressed patient. This is caused by Wangiella dermatitidis.
ii) Paranasal sinus phaeohyphomycosis
Sinusitis caused by dematiaceous fungi is reported especially in patients with a history of allergic
rhinitis or immunosuppression.
iii) Cerebral phaeohyphomycosis
Occur mostly in immunosuppressed patients following the inhalation of conidia. This is caused by
cladophialophora bantiana. This fungus in neurotropic and dissemination to sites than the CNS is
rare.
Lab Diagnosis
Clinical materials are skin scrapings or biopsy, sputum and bronchial washings, CSF, pleural fluid
and blood tissue biopsies from various visceral organs and in dividing catheter tips.
Direct Microscopy
Skin scrapings, sputum, bronchial washing and aspirate should be examined using 10% KOH and
parker ink. Exudates and body fluids should be centrifuges and the sediment examined using 10%
KOH and parker ink. Tissue section should be stained using H&E.
NB//-The pressure of brown pigmented, branding septate hyphae in any specimen from patient
with supporting clinical symptom should be considered significant. In Biopsy, tissue invasion
evidence is also of clinical importance.
Direct microscopy is essential for the differentiation between chromoblastomycoses which is
characterized by brown pigmented, rounded sclerotic bodies and phaeohyphomycosis where the
tissue morphology of the causative organism is mycelial.
Culture
Clinical specimen should be inoculated SDA and examine for the growth of mycelial fungal
elements. Interpretation
Culture results should be supported by direct microscopic findings because the causative agents
are found on the environment and thus the positive results from no sterile areas/specimen should
be confirmed with microscopy to be significance.
4. Mycotia mycetoma.
In infection of human or animal caused by a number of different fungi and actinomycetes
characteristics by draining sinuses granules and tumefaction. The disease results from the
traumatic implantation of the etiologic agent or usually involves the subcutaneous and cutaneous
tissue, fascia and bone of the foot or hand. Sinuses discharge fluid containing granules are the
hallmark of mycetoma. The causative agents are madurella, exophiala fusarium and aspergillus.
Clinical manifestation.
-Its clinic supportive infection of the subcutaneous tissue and contiguous bone. The feet are the
most common site for the infection and account for at least 2/3 of cases. Other sites include the
lower legs, hands, head, neck, chest, shoulder and arms. In most case it starts as a small hard
painless nodule which over time begins to soften in the surface or ulcerate to discharge a viscous,
purulent fluid containing grains. The infection spread to adjacent tissue including bone, often
causing considerable deformity. The infection (sinuses) continues to discharge fluid containing the
granules which vary in colour or degree of hardness, depending on the etiologic species. These
granules are the hallmark of mycetoma.
Laboratory diagnosis.
Tissue biopsy or excised sinus, serosanguinous fluid containing the granules.
Direct microscopy.
Tissue biopsy should be stained using H and E. The fluid containing the granules should be
examined using either 10% KOH or parker ink. Its caused by madurella mycetomatis.
Interpretation: The presence of white yellow or black pigmented grains from a patient with
supporting clinical symptoms should be considered significant. For tissue biopsy evidence or
tissue invasion should be of clinical importance.
Culture. Examine for yellow to black colonies.
5. Zygomycosis.
An infection due to number of zygomycetes. These are primitive, fast growing largely saprophytic
fungi with a cosmopolitan distribution. Medically important orders or generic include; Mucorales
e.g rhizomucor, rhizopus and Entomophthorales e.g conidiobolus and basidiobolus.

Clinical Presentations
i. Rhinocerebral zygomycosis
Predisposing facts include uncontrolled diabetes mellitus acidosis, steroid induced hypeghycemia
especially in patient with leukemia and lymphoma. The infection occur following the inhalation of
sporangiospores and may involve the orbit, palate, face, nose or brain.
ii. Pulmonary Zygomycosis
Predisposing factors include Hematological malignancies, lymphoma and leukemia, severe
neutropenia, organ transplantation and diabetes. Infection result by inhalation of sporangiospores
into the bronchioles and alveoli leading to pulmonary infection and necrosis with cavitation.
iii. GIT zygomycosis
It’s associated with severe malnutrition, particularly in children and GIT diseases which disrupt
the integrity of the mucosa. Primary infection results following the ingestion of fungal elements
and usually present as necrotic ulcers.
iv. Cutaneous Zygomycosis
Local traumatic implantation of fungal elements through its skin especially in patients with
extensive burns, diabetes asteroid induced hyperglycema and trauma. lesions vary considerably in
morphology but include plaques, pustules, ulceration e.t.c.
v. Disseminated Zygomycosis
May originate from any of the above especially to severe debilitated patients with hematological
malignancies, burns, diabetes or uraemia.
vi. CNS alone. Caused by traumatic implantation leading to brain abscess.
Lab Diagnosis
Clinical materials include skin scrapping’s for lesions, sputum and needle biopsies from
pulmonary lesions, discharge, biopsies tissue from patient with disseminated.
Direct Microscopy
Examine for broad, infrequently septate, thin walled hyphae which shown irregular branching.
These belong to the mucorales.
Culture: Look far fast growing, white to grey or brownish downy colonies.
Interpretation: In patients which any of the predisposing conditions with supporting clinical
symptoms should be considered portably significant.
Serology
In some labs, ELISA tests are used for detection of zygomycetes.
6. Lobomycosis
This is a chronic, localized infection characterized by the presence of keloidal, nodular lesions or
sometimes by vegetating crusty plaques. The lesions contain masses of spheroidal, yeast like
organisms referred to as Loboa Loboi.
Clinical Manifestation
Caused by traumatic implantation such as arthropod sting, snake bite or wound acquired while
cutting vegetation. The lesions begin as small, hard nodules resembling keloids and many spread
slowly in the dermis. Older lesions become verrucoid and may ulcerate. The disease may be
transferred to other area of the skin by further trauma or autoinoculation. Lesions are usually
found on the arms, legs, face or ears. 90% of cases are men, mostly in farmers and other high risk
groups exposed to various harsh condition as well as aquatic habitats.
Lab Diagnosis
Clinical materials are tissue sample obtained by curettage or surgical biopsy.
Direct Microscopy
The presence of chains of darkly pigmented, spheroidal yeast like organism referred to as Loboa
loboi is typical for lobomycosis.
Management: Wide surgical excision of the affected area and administration of Clofazimine.
4. SYSTEMIC MYCOSES
These are infections of the body that are caused by fungal pathogens which overcome the
physiological and cellular defenses of the body by changing their morphological to yeast form.
The pathogens enter through inhalation of conidia and the primary site of infection is usually the
lungs before dissemination to other body sites mostly through the blood.
The diseases that are systemic mycoses are:
1. Histoplasmosis
This is an infection of reticuloendothelial system caused by the inhalation of conidia of
Histoplasma capsulatum from the environment especially in soil enriched with excreta from
chicken, starlings and bats. Most cases (95%) of Histoplasmosis infection are in apparent,
subclinical or benign and 5% of the cases have chronic progressive lung disease, chronic
cutaneous, systemic disease or an acute fulminating fatal systemic disease. All stages of
histoplasmosis infection mimic TB.
Laboratory Diagnosis
The clinical materials that are collected for diagnosis of histoplasmosis depend on the part of the
body infected and they include: skin scrapings, sputum, bronchial washings, CSF, blood, bone
marrow, urine, pleural fluids and tissue biopsies from various visceral organs. The techniques that
are used for diagnosis are direct microscopy and culture.
i. Direct Microscopy
Skin scrapings/stripping’s should be examined using 10% KOH and Parker ink. Exudates and
body fluids should be centrifuged and the sediment examined using either 10% KOH or parker ink
or white mounts. Tissue sections should be stained using PAS digest or Gram stained. Yeasts or
budding yeasts are observed in diagnosis and when they observed, the results are significant
(positive).
Interpretation of the results: As a rule, positive direct microscopy demonstrating yeast like cells
from any specimen should be considered positive or significant.
ii. Culture
The clinical specimens should be inoculated onto primary isolation media i.e Sabouraud Dextrose
agar and brain Infusion agar supplemented with 5% sheep blood and incubated at 25oC and
examine for growth of yeast colonies. A positive culture from any specimen should be considered
significant. The point to note is that cultures of H. capsulatum present a severe biohazard to lab
personnel and must be handled with extreme caution in an appropriate pathogen handling cabinet.
Traditionally, positive identification requires conversion of the mould form of the fungi to the
yeast phase by growth at 25% on enriched media. However, culture identification of the fungi by
the exoantigen test is now the method of choice.
2. Blastomycosis
This is a clinic granulomatous and suppurative disease having a primary pulmonary stage that is
frequently followed by dissemination to other body sites chiefly the skin and bone. All available
clinical and epidemiological evidence indicates that human and lower animals contract
blastomycosis from some source in nature. However the natural habitat of Blastomycetes
dermatitidis has since of its isolation from the soil.
Clinical manifestation
Blastomycosis is usually manifested as:-
i. Pulmonary blastomycosis
Pulmonary lesions are asymptomatic until infection has spread to other organs.Sometimes the
pulmonary blastomycosis develops symptoms after an incubation period of 3-15 weeks.The
common symptoms are cough, fever, malaise, weight loss and when the lesion becomes more
extreme, necrosis results.Occasionally patients develop high fever, chills, productive coughs,
myalgia, and pleuristic chest pains.Some patients appear to recover after 2-12 weeks of
symptomatic but in some patients; the infection will return months later with lesions appearing in
other body sites but in patients with acute onset of the infection, the patients will fail to recover
and will develop a chronic chest infection.
ii. Cutaneous blastomycosis
Haemotogenous spread of the infection results to cutaneous lesion and these tend to be painless
and present as ulcers. The face, upper limbs, neck and scalp are the most frequent sites involved.
iii. Osteoarticular blastomycosis
Occur in 30 % of patients with the spine, pelvic, cranial bones, ribs and long bones mostly
commonly involved. Patients often remain a symptomatic until the infection spread into joints or
into adjacent soft tissue causing subcutaneous abscesses. Arthritis occurs in up to 10% of patients.
Others forms of blastomycosis include genitourinary blastomycosis which involves the prostate,
epididymis or testis and haematogenous spread to the brain results to meningitis and spinal or
brain abscess.
Laboratory diagnosis
The clinical materials include skin scrapings, sputum and bronchial washings, CSF, pleural fluid
and blood, bone marrow, urine and tissue biopsies from various visceral organs. The techniques
used are:-
i. Direct microscopy
Skin scrapings should be examined using 10% KOH and parker ink.Exudates and body fluids
should be centrifuged and the sediment examined using 10% KOH and parker ink or caliofluor
white mounts. Tissue sections should be stained using PAS digest or Gram stain. Tissue sections
showing large, broad base, unipolar budding yeast like cells should be examined. Tissue
sections needs to be stained by Grocotts methylamine silver method to clearly see the yeast like
cells which are often difficult to observe in H&E preparation.
Interpretation – As arule, a positive direct microscopy demonstrating characteristic yeast like
cells from any specimen should be considered significant.
ii. Culture
Clinical specimen should be in inoculated into a primary isolation media like Sabourands dextrose
agar and brain heart infusion agar supplemented with 5 % sheep blood, incubated at 25oC and
examine for yeast like colonies. A positive culture from any of the above specimen should be
considered significant. All specimens should be handled in an appropriate pathogen handling
cabinet because B. dermatitispresents a severe bio-hazard laboratory personnel.
iii. Serology
Serological tests are of limited value in the diagnosis of Blastomycosis.
3: Coccidiodomycosis
It’s a respiratory infection resulting from the inhalation of conidia that typically resolves rapidly
leaving the patient much a strong specific immunity to infection. However, it may progress to a
chronic pulmonary condition or to a systemic disease involving the brain, bones, subcutaneous
tissues, joints. Coccidiodoycosis is caused by coccidioides immitis which is a soil inhabiting
fungus.
Clinical manifestations
The infection manifests itself like acute febrile ` flu-like’’ illness. The common symptoms include
fever, pleuristic chest pains, coughs, headaches, night sweats and loss of appetite. Lesions usually
appear on the face, neck and chin.
Laboratory diagnosis
Clinical materials are skin scrapings, sputum, bronchial washings, CSF, pleural fluid and blood,
bone marrow, urine and tissue biopsies from various visceral organs.
i. Direct Microscopy
Skin scrapings should be examined using 10% KOH and parker ink.Exudates and body fluids
should be centrifuged and the sediment examined using either 10% KOH or parker ink. Tissue
sections should be stained using PAS digest or Gram stain. For skin scraping, examine for
sporangia with endospores of coccidiodes immitis. Tissue sections showing typical
endosporulating spherules should be observed. As a rule, a positive direct microscopy
demonstrating spherules with endospores from any specimen should be considered significant.
ii. Culture
Clinical specimen should be inoculated into primary isolation media like Sabourauds dextrose
agar and brain heart infusion agar supplemented with 5% sheep blood and incubated at 25oC.
Cultures of Coccidiodes immitis showing suede like to downy greyish white colonies with tan to
brown color should be examined.A positive culture should be considered significant and the fungi
should be handledin appropriate pathogen for handling cabinet.
iii. Serology
Immunodiffusion and complaint fixation tests for the detection of antibody are useful especially in
immune competent patients.However, 20-50% of patients test negative. Currently, exoantigen test
are now the method of choice for identifying isolates of Coccidioidesimmitis.
4: Paracoccidiodomycosis
It is a disease that produces a primary pulmonary infection often in apparent and then disseminates
form ulcerative granuloma of the buccal, nasal and occasionally GIT mucosa. The infection is
caused by P. brasiliensis.
Clinical manifestation
Paracoccidiomycosis infection is manifested as:-
i. Pulmonary paracoccidiodomycosis
It has an indolent onset and patients present with chronic symptoms such as cough, fever, night
sweats and weight loss.
ii. Mucocutaneous paracoccidioidomycosis
The mouth and nose is the most usual mucosal site of infection. Painful ulcer lesions develop on
gums, tongue and lips. In some cases, perforation of septum may occur. Cutaneous lesions often
appear on the face around the mouth and nose although patients with severe infection can have
wide spread lesions. The infections can results to extensive destruction of facial features and
ulcerated lesions also develop in the pharyngeal mucosa.
iii) Lymphonodular paracoccidioidomycosis
Lymphadenitis is common in younger patients. Cervical and submandibular chains are the most
obvious and lymph nodes may progress to form abscess with draining sinuses.
Laboratory Diagnosis
Skin scrapings, exudates and body fluids, sputum, bronchial washing, CSF, pleural fluid and
blood, tissue biopsies from various visceral organs.

I. Direct Microscopy
Skin scrapings should be examined using 10% KOH and parker ink. Exudates and body fluids
should be centrifuged and sediment examined using either 10% KOH or parker ink. Tissue
sections should be stained using PAS digest or Gram stain. Multiple, narrow base budding yeast
cells ‘steering wheels’ of P. brasiliensis should be observed. A positive direct microscopy
demonstrating the presence of large, round, narrow base budding yeast cells with multiple
budding `` steering wheels’’ from any specimen should be considered significant.
ii. Culture
Clinical specimen should be inoculated into primary isolation media like Sabourauds dextrose
agar and brain heart infusion agar supplemented with 5% sheep blood and incubated at 37oC.
Examine for large, round, narrow base budding yeastcolonies.
5. CRYPTOCOCCOSIS
Is a chronic, sub acute to acute pulmonary, systemic or meningitis disease initiated by the
inhalation of basidiospores or desiccated yeast cells of Cryptococcus neoformans. Primary
pulmonary infection has no diagnostic symptoms and is usually subclinical. On dissemination, the
fungus usually shows a predication for the Central Nervous System. However, skin, bones and
other visceral organs may also be involved. Although C. neoformans is regarded as the principle
pathogenic species; Candida albicans and C. laurentii have on occasion also been implicated in
human infection.
Clinical Manifestations
Cryptococcus is encapsulated basidiomycete yeast like fungus. Two species Cryptococcus
neoformans and C. gatii are distinguishable biochemical and by molecular technique. In human
Cryptococcus neoformans affects immunocompromised host predominantly and is the commonest
cause of fungal meningitis worldwide and 7-10% of patients with AIDS are affected. AIDS
associated Cryptococcosis accounts for 50% of all Cryptptococcal infection and usually occurs in
HIV patients when their CD4 lymphocyte count is below 200/mm3. Meningitis is the predominant
clinical presentation with fever and headache as the most common symptoms. Cryptococcus due
to C. gatii is geographically restricted and non immune compromised hosts are usually affected.
Large mass lesion in lungs and brain are characteristic and morbidity from neurological disease is
high.

i. Pulmonary Cryptococcosis
It affects the respiratory tract and skin in healthy people as a result of normal environmental
exposure. Patients with chronic lung disease such as bronchitis may also have a symptomatic
colonization with Cryptococcus being isolated from their sputum. Invasive pulmonary
Cryptococcosis may occur and patients may become pyremix and have an accompanying cough.
However, many pulmonary lesions are often a symptomatic especially when chronic granulomas
are formed. Chronic pulmonary Cryptococcosis also increases the risk of dissemination to the
Central Nervous System.
ii. Central Nervous System Cryptococcosis
Dissemination to the brain and meningitis is the most common clinical manifestation of
Cryptococcosis and include meningitis, meningoencephalitis or expanding Cryptococcoma. The
symptoms of meningitis include, Drowsiness, dizziness, irritability, confusion, nausea, vomiting,
neck stiffness and patients deteriorate rapidly and die in a matter of weeks. Menengoencephalitis
and cryptococcoma are rare.
iii.Cutaneous Cryptococcosis
Ulcerated lesions usually occur especially in immunosppressed patients. However, all patients
with skin lesion should be monitored carefully for possible dissemination to the Central Nervous
System. Lesions usually begin as small papules that subsequently ulcerate but may also present as
abscesses, erythymatous or nodules. In patients with AIDS, skin manifestation represent the
second most common site of disseminated Cryptococcosis and lesions often present as papules,
nodules, plague, ulcers, abscesses etc.
iv. Cryptococcosis of bones
It may involve many bone prominescence, cranial bones and vertebrae bones. The lesions are lytic
without periosteal reaction and symptoms of pains on movements are reported. Occasional cases
of arthritis have also been reported most involving the knee joint.
Other forms of lesions are adrenal cortical lesion, endocarditic, hepatitis lesion, and sinusitis and
localized esophageal lesion.
Laboratory diagnosis
Clinical materials are CSF, biopsy tissue, sputum, bronchial washings, pus, blood and urine
i. Direct microscopy
For exudates and body fluids, make a thin wet film under a cover slip using Indian ink to
demonstrate encapsulated yeast cells. Sputum and pus may need to be digested with 10% KOH
prior to Indian inkstaining.For tissue sections use PAS digest and Grain stain and H& E Stain are
also useful to demonstrate polysaccharide capsule. Also examine for globose to ovoid budding
yeast cells surrounded by wide gelatinous capsule. Non encapsulated yeast cells may also occur in
tissue sections.
Interpretation: The demonstration of encapsulated yeastcells in CSF, biopsytissue, blood orurine
should be considered.Positive sputum specimen should be considered potentiallysignificant (due
to respiratory Cryptococcosis). Basically all patients with a positive microscopy Cryptococci from
any site should be investigated for disseminateddiseaseespecially by culture and Ag detection.
ii. Culture
Clinical specimens should be inoculated into primary isolation media like Sabarouds dextrose agar
observe fortranslucent, smooth gelatinous color, later becoming mucoid and cream in color.
Interpretation: The isolation of C. neoformans or C. gattii from any specimen should be
considered significant and patients withoutclinical symptoms should be thoroughly investigated
for disseminated disease.Positive culture of CSF is definitive significant.
iii. Serology
Detection of Cryptococcal capsular polysaccharide Ag in CSF is now the method of choice for
diagnosis patients with Cryptococcal meningitis. In AIDS patients’, Cryptococcal antigen can be
detected in the serum in nearly 100% of cases. However, in non AIDS patients, antigen detection
in serum is less sensitive with only about 60% of patients with Cryptococcosis reported as being
positive. Serum specimen should be pretreated with pronase to enhance detection of antigen and
avoid false results.
Identification: The causal agent is characterized by globose to elongate yeast like cells or
blastoconidia that reproduce by multilateral budding. With Cryptococcus, fermentation of sugar is
negative; assimilation of nitrate is variable and assimilation of insotol positive. The causative
agents’ are Cryptococcus neoformans, C. albidus, C. gattii and C. lauentii.

MYCOTOXICOSES
These are infections which are caused by ingesting mycotoxins in moldy foods such as grains
which have been stored under humid conditions.

The mycotoxins are secondary metabolites produced by food-borne filamentous fungi which
majorly belong to toxigenic species ,i.e aspergillus, fusarium and penicilium.
These toxins may be produced before harvests,or they may also be released by certain molds as
they grow, and may be passed through the food chain and thus contaminating food conditions that
are not molded e.g aflatoxin M1,in milk and dairy products.

The mycotoxins vary in their severity, i.e carcinogenic or allergenic, are non-volatile and of low
molecular weight with some being lethal.
Production of the myotoxins depends on factors such as;
a) Temperature (4-32°C),
b) Moisture (22-23% in grain),
c) Aeration (1-2% of O₂),
d) Relative humidity (>70%)
e) Substance on which the fungus is growing ,i.e substrate.

The toxicity exhibited by mycotoxins is of four types , i.e;

I. Acute ; rapid onset from single exposure,
 II. Chronic ; delayed onset from multiple long term exposure,
III. Mutagenic ; causing damage to DNA,
IV. Teratogenic ; causing birth defects.

The medically important mycotoxins

are;Aflatoxins,Fumonisins,Tricothecenes,Ochratoxins,Cyclopiazonic acid,Zearalenone and
Patulin.

These mycotoxins may lead to development of either acute or chronic diseases, in which acute
effects present as rapid, fatal illnesses accompanied with signs such as coughing ,wheezing and
shortness of breath, dizziness ,eye irritation ,head ache ,heightened sensitivity to chemicals and
foods ,irregular heart beat ,skin rashes , fatigue and joint/muscle pain.

The chronic effects of mycotoxins on the other hand include weight loss , vision changes , slow
reaction time , reduced color distinction ,loss of balance , sleep problems ,depression and or
anxiety ,immunosuppression , cancer , nervous system disorders ,reproductive irregularities and
kidney failure
These are infections which are caused by ingesting mycotoxins in moldy food such as grains
which have been stored under humid conditions. The toxins are released by certain molds as they
grow. They may also be produced before harvests. Mycotoxins may be passed through the food
chain thereby contaminating food commodities that are not molded example aflatoxina M1 in milk
and dairy products.
Acute effects include rapid, often fatal diseases while the chronic effects include weight loss,
immunosuppression, cancer, nervous system disorders, reproductive irregularities and kidney
failure. The main example of mycotoxins of highly medical importance is aflatoxins whereby it’s
poisoning results to hepatitis and hepatic carcinoma.

AFLATOXINS
Aflatoxins are the main type of mycotoxins that are highly medically significant , whose poisoning
may result to hepatitis and hepatic carcinoma.

Aflatoxicosis is poisoning that results from ingesting aflatoxins and may present as acute severe
intoxication . It results in severe liver damage and subsequent illness or death . Chronic
sub-symptomatic aflatoxicosis presents with lethargy , anorexia and muscle weakness followed
by spasm.
Reyes syndrome is an acute aflatoxicosis which presents with encephalopathy and fatty
degeneration of viscera.
Chronic rhinusitis syndrome(CRS) is a chronic aflatoxicosis syndrome that involves the
paranasal sinuses.

These are naturally occurring mycotoxins that are produced by many species of Aspergillus
fungus, most notably A. flavus and A. parasiticus. Aflatoxins are toxic and are among the most
carcinogenic substances known. The expression of aflatoxins related diseases is influenced by
factors such as age, nutrition, sex, species and concurrent exposure to other toxins. The main
target organ in mammals is the liver so aflatoxicosis is primarily a hepatic disease. Conditions
increasing the likelihood of aflatoxicosis in humans include limited availability of food, an
environmental condition that favors mould growth on food stuffs and lack of regulatory systems
for aflatoxins monitoring and control.
A. flavus and A. parasiticus are weedy moulds that grow on a large number of substrates
particularly under high moisture conditions. Aflatoxins have been isolated from all major cereals
crops and from sources as diverse as peanut butter and marijuana. The staple foods regularly
contaminated with aflatoxins include cassava, cooton seeds, sorghum, tree nuts, millet, peanuts,
rice and a variety of spices intended for human or animal food use. When processed aflatoxins get
into the general food supply where they have been found in both pet and human foods as well as in
feed stocks for agricultural animals. Aflatoxins transformation products are sometimes found in
eggs, milk products and meat when animals are fed contaminated grains.

MAJOR TYPES OF AFLATOXINS AND THEIR METABOLITES

At least 14 different types of aflatoxins are produced in nature. Aflatoxin B1 is considered the
most toxic and is produced by both Aspergillus flavus and A. parasiticus. Aflatoxins G1 and G2
are produced exclusively by A. parasiticus. While the presence of Aspergillus in foods products
does not always indicate harmful levels of aflatoxins are also present, it does imply a significant
risk in consumption. Aflatoxin M1 and M2 were originally discovered in the milk of cows which
feed on moldy grain. These compounds are products of a conversion process in the animal’s liver.
However, aflatoxin M1 is present in the fermentation broth of A. parasiticus.
Aflatoxin M1 is a metabolite of Aflatoxin B1 in humans and animals (exposure of aflatoxins
levels from milk i.e mother’s milk. Aflatoxin M2 kis a metabolite of aflatoxins B2 in milk of cattle
fed on contaminated foods.
Aflatoxin B – B1 and B2 resulted from exhibition of blue fluorescence under UV light.
Aflatoxin G1- G1 and G2 exhibits of yellow green fluorescence under UV light.
PATHOGENICITY OF AFLATOXINS (AFLATOXICOSIS)
Aflatoxins cause aflatoxicosis which is primarily a hepatic disease. High level of aflatoxins
exposure produces an acute hepatic necrosis resulting later in cirrhosis and carcinoma of the liver.
Acute hepatic failure is made manifest by hemorrhage, edema,, alteration in digestion and
absorption and metabolism of nutrients and mental changes or coma.
Chronic, subclinical exposure does not lead to symptoms as dramatic as acute aflatoxicosis.
Children however, are particularly affected by aflatoxins which lead to stunted growth and delayed
development. It also leads to a high risk of developing liver cancer, as Aflatoxin metabolite can
intercalate into DNA and alkalyte the bases through epoxide moiety. Medicla researches indicate
that a regular diet including vegetables such as carrots reduces the carcinogenic effects of
aflatoxins.
Methods of analysis of aflatoxins in foods
Before analysis, its important that the entire primary sample must be grounded and mixed so that
the analytical test portion has the same concentration as the original sample.
The methods include: Thin Layer chromatography, Liquid chromatography, Mass spectrometry
and Immunochemical methods. The immunochemical methods are highly specific and are based
on the affinities of monoclonal or polyclonal antibodies for aflatoxins. These are RIA, ELISA etc.
These immunochemical methods are commonly used in monitoring aflatoxins exposure in humans
which targets the Aflatoxin B1 adduct in urine or AFB1 albumin in blood serum.

ANTIFUNGAL AGENTS

An antifungal agent is a drug that selectively eliminates fungal pathogens from a host with
minimal toxicity to the host.

The development of antifungal agents has lagged behind that of antibacterial agents. This is a
predictable consequence of the cellular structure of the organisms involved. Bacteria are
prokaryotic and hence offer numerous structural and metabolic targets that differ from those of the
human host. Fungi, in contrast, are eukaryotes, and consequently most agents toxic to fungi are
also toxic to the host. Furthermore, because fungi generally grow slowly and often in multicellular
forms, they are more difficult to quantify than bacteria. This difficulty complicates experiments
designed to evaluate the in vitro or in vivo properties of a potential antifungal agent. Despite these
limitations, numerous advances have been made in developing new antifungal agents and in
understanding the existing ones. Three groups of drugs are emphasized: the polyenes, the azoles,
and one antimetabolite.
Classification of antifungal drugs with their mode of actions

1. Polyene Antifungal Drugs

The polyene compounds are so named because of the alternating conjugated double bonds that
constitute a part of their macrolide ring structure. The polyene antibiotics are all products of
Streptomyces species. These drugs interact with sterols in cell membranes (ergosterol in fungal
cells; cholesterol in human cells) to form channels through the membrane, causing the cells to
become leaky. The polyene antifungal agents include nystatin, amphotericin B, and pimaricin.
Amphotericin B is the mainstay antifungal agent for treatment of life-threatening mycoses and for
most other mycoses, with the possible exception of the dermatophytoses. Its broad spectrum of
activity includes most of the medically important moulds and yeasts, including dimorphic
pathogens such as Coccidioides immitis, Histoplasma capsulatum, Blastomyces dermatitidis, and
Paracoccidioides brasiliensis. It is the drug of choice in treating most opportunistic mycoses
caused by fungi such as Candida species, Cryptococcus neoformans, Aspergillus species, and the
Zygomycetes. Resistance to this agent is rare, but is noteworthy for Pseudallescheria boydii,
Fusarium spp., Trichosporon spp., certain isolates of Candida lusitaniae and Candida
guilliermondii.

The drug must be administered intravenously and is associated with numerous side effects,
ranging from phlebitis at the infusion site and chills to renal toxicity, which may be severe. A
major advance in the use of this agent has resulted from an understanding of the mechanism of its
renal toxicity, which is presumed to involve tubule glomerular feedback. The suppression of
glomerular filtration can be reduced by administering sodium chloride.

Nystatin was the first successful antifungal antibiotic to be developed, and it is still in general use.
It is representative of the polyene antifungal agents developed later. The promise of its
broad-spectrum antifungal activity is offset by host toxicity. Therefore, it is limited to topical use,
where it has activity against yeasts such as the Candida species.

Pimaricin (natamycin), another polyene, is used topically to treat superficial mycotic infections of
the eye. It is active against both yeasts and moulds.

2. Azole Antifungal Drugs

The azole antifungal agents have five-membered organic rings that contain either two or three
nitrogen molecules (the imidazoles and the triazoles respectively). The clinically useful imidazoles
are clotrimazole, miconazole, and ketoconazole. Two important triazoles are itraconazole and
fluconazole. In general, the azole antifungal agents are thought to inhibit cytochrome
P450-dependent enzymes involved in the biosynthesis of cell membrane sterols leading to inhibition
of fungal growth.

Ketoconazole set the stage for the orally administered antifungal azoles. It can be administered
both orally and topically and has a range of activity including infections due to H. capsulatum and
B. dermatitidis, for which it is often used in non-immunocompromised patients. It is also active
against mucosal candidiasis and a variety of cutaneous mycoses, including dermatophyte
infections, pityriasis versicolor, and cutaneous candidiasis. It is not indicated for treatment of
aspergillosis or of systemic infections caused by yeasts.

The triazoles (fluconazole, itraconazole) have become the standard for the azoles, and have
replaced amphotericin B for managing certain forms of the systemic mycoses. Fluconazole is now
routinely used to treat candidemia in non-neutropenic hosts, and is gaining acceptance for use in
cryptococcosis and selected forms of coccidioidomycosis. Itraconazole has proven to be effective
for histoplasmosis, blastomycosis, sporotrichosis, coccidioidomycosis, consolidation treatment for
cryptococcosis, and certain forms of aspergillosis. Fluconazole can be administered either orally,
or intravenously. The licensed formulation for itraconazole is oral, but an intravenous formulation
is under study, and could be a significant addition directed at bioavailability problems relating to
absorption of the oral formulation.

Side effects are not as common with the azoles as with amphotericin B, but life-threatening liver
toxicity can arise with long-term use. Liver toxicity noted with ketoconazole has been less
problematic with the triazoles. Other side effects include nausea and vomiting. Drug interactions
are a potential problem between azoles and other drug classes and include cyclosporin, certain
antihistamines, anticoagulants, and antiseizure, oral hypoglycemic and other medications that are
metabolized via similar pathways in the liver.

3. Antimetabolite Antifungal Drugs

In contrast to the situation with antibacterial agents, few antimetabolites are available for use
against fungi. The best example is 5-fluorocytosine, a fluorinated analog of cytosine. It inhibits
both DNA and RNA synthesis via intracytoplasmic conversion to 5-fluorouracil. The latter is
converted to two active nucleotides: 5-fluorouridine triphosphate, which inhibits RNA processing,
and 5-fluorodeoxyuridine monophosphate, which inhibits thymidylate synthetase and hence the
formation of the deoxythymidine triphosphate needed for DNA synthesis. As with other
antimetabolites, the emergence of drug resistance is a problem. Therefore, 5-fluorocytosine is
seldom used alone. In combination with amphotericin B it remains the treatment of choice for
cryptococcal meningitis and is effective against a number of other mycoses, including some
caused by the dematiaceous fungi and perhaps even by C albicans.

4. Allylamines Antifungal Drugs

These include Amorolfin, Butenafine, Naftifine and Terbinafine. Allylamines inhibit squalene
epoxidase , another enzyme required for ergosterol synthesis. The two allylamines (naftifine and
terbinafine) inhibit ergosterol synthesis at the level of squalene epoxidase; one morpholene
derivative (amorolfine) inhibits at a subsequent step in the ergosterol pathway.

5. Echinocandins Antifungal Drugs

These are Anidulafungin, Caspofungin and Micafungin. These may be used for systemic fungal
infections in immunocompromised patients, they inhibit the synthesis of glucan in the cell wall via
the enzyme 1,3-β glucan synthase. Echinocandins are poorly absorbed when administered orally.
When administered by injection they will reach most tissues and organs with concentrations
sufficient to treat localized and systemic fungal infections.

6. Other Antifungal Agents

Griseofulvin is an antifungal antibiotic produced by Penicillium griseofulvum. It is active in vitro

against most dermatophytes and has been the drug of choice for chronic infections caused by these
fungi (e.g., nail infections with Trichophyton rubrum) since it is orally administered and
presumably incorporated into actively growing tissue. It is still used in such instances but is being
challenged by some of the newer azole antifungal agents. The drug inhibits mitosis in fungi.

Potassium iodide given orally as a saturated suspension is uniquely used to treat cutaneous and
lymphocutaneous sporotrichosis. This compound, interestingly, is not active against Sporothrix
schenckii in vitro. It appears to act by enhancing the transepidermal elimination process in the
infected host.

Benzoic acid – has antifugal properties, but must be combined with a keratolytic agent such as in
Whitfield's ointment.

Crystal violet – a triarylmethane dye, it has antibacterial, antifungal, and anthelmintic properties
and was formerly important as a topical antiseptic.
Ciclopirox – (ciclopirox olamine) – is a hydroxypyridone antifungal that interferes with active
membrane transport, cell membrane integrity, and fungal respiratory processes. It is most useful
against tinea versicolour.

end