Mycotic Diseases Microbiology Powerpoint

Fungal diseases in humans

1. Mycotic Disease Alfon, Humadas, Villaruel

2. Mycotic disease Disease or infections caused by fungus that are either molds or yeasts. These colonies consist of branching cylindrical tubules called hyphae , varying in diameter from 2 to 10 μm. The mass of intertwined hyphae is a mycelium . Some hyphae are divided into cells by cross-walls or septa . Mycotic diseases are also called mycoses Most pathogenic fungi are exogenous. Different classification of mycoses: superficial, cutaneous, subcutaneous, or systemic (endemic or opportunistic pathogens)

3. SUPERFICIAL MYCOSES

4. Superficial Mycoses Are fungal infections of the skin and hair shaft that invade only the stratum corneum and the superficial layers of the skin. No living tissue is invaded and there is no cellular response from the host. These infections are often so innocuous that patients are often unaware of their condition. Examples of Superficial Mycoses are: Pityriasis versicolor, Tinea nigra, White piedra, Black piedra .

5. Pityriasis versicolor Also called Tinea versicolor is a chronic mild superficial infection of the stratum corneum caused by Malassezia globosa, Malassezia restricta, and other members of the Malassezia furfur complex. Malassezia is a lipid-dependent, dimorphic fungus that is a component of normal skin flora. The lesions are chronic and occur as macular patches of discolored skin that may enlarge and coalesce, but scaling, inflammation, and irritation are minimal that can occur on the chest, upper back, arms, or abdomen.

6. Pityriasis versicolor has been reported worldwide, but it is more common in warm and humid conditions. It occurs more frequently in adolescents and young adults probably due to the increase of sebum production by the sebaceous glands which allow for a more lipid-rich environment in which Malassezia can grow. If tinea versicolor is severe or doesn't respond to over-the-counter antifungal medicine, you may need a prescription-strength medication. Some of these medications are topical preparations that you rub on your skin. Others are drugs that you swallow. Examples include: Ketoconazole (Ketoconazole, Nizoral, others) cream, gel or shampoo Ciclopirox (Loprox, Penlac) cream, gel or shampoo Fluconazole (Diflucan) tablets or oral solution Itraconazole (Onmel, Sporanox) tablets, capsules or oral solution Selenium sulfide (Selsun) 2.5 percent lotion or shampoo

7. Tinea nigra Tinea nigra (or tinea nigra palmaris) is a superficial chronic and asymptomatic infection of the stratum corneum caused by the dematiaceous fungus Hortaea (Exophiala) werneckii. The lesions appear as a dark (brown to black) discoloration, often on the palm and soles. Microscopic examination of skin scrapings from the periphery of the lesion will reveal branched, septate hyphae and budding yeast cells with melanized cell walls.

8. This condition is more prevalent in warm coastal regions and among young women. Tinea nigra develops following direct contact with the fungus in the environment. Minor skin trauma can contribute to infection, which contributes to the palm as a common location. Plantar infections tend to occur in individuals who have walked barefoot in wet or sandy areas Tinea nigra will respond to treatment with keratolytic solutions, salicylic acid, or azole antifungal drugs.

9. White piedra White piedra, due to infection with Trichosporon sp. (Trichosporum beigelii), presents as larger, softer, yellowish nodules on the hairs. Axillary, pubic, beard, and scalp hair may be infected. The spread of white piedra directly from person to person is uncommon. However, it is possible to transmit the infection in the genital region through sexual activity. After a person is exposed, the fungus needs the right conditions to survive and colonize human hair.

10. White piedra is an uncommon fungal infection that most frequently occurs in humid, tropical climates but also occurs worldwide.. The infection has a predilection for children and young adults, particularly females. Predisposing factors to infection may include persistent, warm, moist conditions; long hair, especially when tied up or occluded with hair coverings or oil; and poor hygiene. Treatment for white piedra consists of removal of the infected hair and application of a topical antifungal agent.

11. Black piedra Black piedra is a nodular infection of the hair shaft caused by Piedraia hortae , is characterized by black-colored nodules. Axillary, pubic, beard, and scalp hair may be infected. The soil appears to be the primary source of infection in black piedra, although P. hortae, has also been traced in stagnant water and crops. Factors such as poor hygiene, long hair, excessive use of hair oil may contribute to the infection. Most infections occur in young men, young women, and children in moist, tropical regions of South America and Asia. Treatment consists of removal of the infected hair and application of a topical antifungal agent.

12. CUTANEOUS MYCOSES

13. Cutaneous Mycoses Cutaneous mycoses are caused by fungi that infect only the keratinized tissue (skin, hair, and nails), and its appendages. The most important of these are the dermatophytes, a group of about 40 related fungi that belong to three genera: Microsporum, Trichophyton , and Epidermophyton. Dermatomycoses are cutaneous infections due to other fungi, the most common of which are Candida spp. Dermatophytosis constitutes a group of superficial fungal infections of the keratinized tissues like the epidermis, hair and nail. The word dermatophyte literally means “skin plant”, while dermatomycosis includes any fungal infection of the skin such as secondary spread from systemic mycosis,

14. Dermatophytosis Dermatophytosis is a ringworm disease of hair, nails, and skin caused by fungi called dermatophytes. The most prevalent infections in the world. Although they can be persistent and troublesome, they are not debilitating or life threatening. Dermatophytosis=Ringworm=Tinea Dermatophytes have keratinases that digest keratin and they are resistant to cycloheximide. Dermatophytes are classified as geophilic, zoophilic, or anthropophilic depending on whether their usual habitat is soil, animals, or humans.

15. Tinea corporis Tinea corporis is a superficial fungal infection of the skin that can affect any part of the body, excluding the hands and feet, scalp, face and beard, groin, and nails. It is commonly called ‘ringworm’ as it presents with characteristic ring-shaped lesions. Causative agents: Trichophyton rubrum, and Microsporum audouinii A person infected with Tinea corporis can have a scaly ring-shaped area, typically on the buttocks, trunk, arms and legs, itchiness, a clear or scaly area inside the ring, perhaps with a scattering of bumps whose color ranges from red on white skin to reddish, purplish, brown or gray on black and brown skin, slightly raised, expanding rings, a round, flat patch of itchy skin, and overlapping rings.

16. Tinea corporis is exceedingly common worldwide. Excessive heat, high relative humidity, and fitted clothing have correlations to more severe and frequent disease. Infection typically occurs with direct contact with the skin from the soil, animals, or the skin of other humans. Specific populations can also be more predisposed to tinea corporis; for example, children. Tinea capitis and tinea corporis are the most common dermatophytic infections in prepubertal children. The most effective drugs are itraconazole and terbinafine. However, a number of topical preparations may be used, such as miconazole nitrate, tolnaftate, and clotrimazole. If applied for at least 2–4 weeks, the cure rates are usually 70–100%. Treatment should be continued for 1–2 weeks after clearing of the lesions. For troublesome cases, a short course of oral griseofulvin can be administered.

17. Tinea pedis Tinea pedis or foot ringworm is an infection of the feet affecting soles, interdigital clefts of toes, and nails with a dermatophyte fungus. It is also called athlete’s foot. The infection is caused by the dermatophyte, Trichophyton rubrum and Trichophyton mentagrophytes. It commonly occurs in people whose feet have become very sweaty while confined within tight-fitting shoes. Signs and symptoms of athlete's foot include an itchy, scaly rash. Sharing washing facilities is likely to increase the chances of infection. The condition is more common in adult males than in females.

18. The most effective drugs are itraconazole and terbinafine. However, a number of topical preparations may be used, such as miconazole nitrate, tolnaftate, and clotrimazole. If applied for at least 2–4 weeks, the cure rates are usually 70–100%. Treatment should be continued for 1–2 weeks after clearing of the lesions. For troublesome cases, a short course of oral griseofulvin can be administered.

19. Tinea cruris Tinea cruris, also known as jock itch, is an infection involving the genital, pubic, perineal, and perianal skin caused by pathogenic fungi known as dermatophytes. These dermatophytes affect keratinized structures such as hair and the epidermis' stratum corneum resulting in a characteristic rash. T. rubrum, T. mentagrophytes, and Epidermophyton floccosum are the most common causative agents of this disease. Tinea cruris is a contagious infection transmitted by fomites, such as contaminated towels or hotel bedroom sheets, or by autoinoculation from a reservoir on the hands or feet

20. Cutaneous mycoses, including tinea cruris, affect 20 to 25 percent of the world's population. Developing and tropical countries have an increased prevalence of dermatophyte infections secondary to high temperatures and increased humidity. Adolescent and adult males comprise the majority of patients seen for tinea cruris and are affected by the disorder with increased frequency. Over-the-counter (OTC) and prescription antifungal creams, ointments, gels, sprays or powders effectively treat jock itch. These products contain clotrimazole , miconazole , tolnaftate or terbinafine . Some prescription antifungal medications are pills. These pills contain fluconazole , itraconazole or terbinafine. It’s important to finish your full course of medicine. If you stop too soon, your jock itch may come back and be harder to treat.

21. Tinea capitis Tinea capitis is a fungal infection of the scalp hairs. It is also known as ringworm and herpes tonsurans infection. It is caused primarily by the dermatophyte species Microsporum and Trichophyton. The fungi can penetrate the hair follicle outer root sheath and ultimately may invade the hair shaft. Common agents include Microsporum canis, Microsporum gypseum, Trichophyton equinum, and Trichophyton verrucosum. The most common symptom of ringworm is itchy patches on the scalp . Sections of hair may break off near the scalp, leaving scaly, red areas or bald spots. You may see black dots where the hair has broken off. Left untreated, these areas can gradually grow and spread.

22. Cutaneous mycoses, including tinea cruris, affect 20 to 25 percent of the world's population. Developing and tropical countries have an increased prevalence of dermatophyte infections secondary to high temperatures and increased humidity. Adolescent and adult males comprise the majority of patients seen for tinea cruris and are affected by the disorder with increased frequency. Scalp infections are treated for several weeks with oral administration of griseofulvin or terbinafine. Frequent shampoos and miconazole cream or other topical antifungal agents may be effective if used for weeks. Alternatively, ketoconazole and itraconazole are quite effective

23. Tinea barbae Tinea barbae is a rare dermatophyte infection affecting the skin, hair, and hair follicles of the beard and mustache. Hence, it was commonly referred to as barber's itch and beard ringworm. Tinea barbae is also known as tinea sycosis, as one of the clinical manifestations is inflammation of the hair follicles. The most common causes are Trichophyton mentagrophytes and T. verrucosum. Main symptoms that occur when affected with tinea barbae is pimple or blister amongst affected area, swelling and redness around infected area, red and lumpy skin on infected area. Also, crusting around hairs in infected area will occur.

24. It’s rare for this fungal infection to spread from person to person or from contact with a contaminated object like a towel. Most people pick up this fungal infection through direct contact with an infected animal. Livestock animals, especially dairy cattle, are most likely to have this fungus. But sheep, pigs, dogs and cats can have it, too. Due to the rarity of the disease, predicting a true incidence or lifetime risk is difficult. The distribution of dermatophytes is worldwide, and so are the cases of tinea barbae that were reported in the literature. Since tinea barbae is an infection of hair and hair follicles of the beard and mustache area, it is exclusively seen in adolescent boys and men. Treatment of tinea barbae is with an antifungal drug, such as griseofulvin, terbinafine, or itraconazole, taken by mouth. If the area is severely inflamed, doctors may add a corticosteroid such as prednisone taken by mouth to lessen symptoms and perhaps reduce the chance of scarring.

25. Tinea unguium Onychomycosis is fungal infection of the nail plate, nail bed, or both. The nails typically are deformed and discolored white or yellow. Infection may be distal subungual, with nail thickening and yellowing and accumulation of keratin and debris underneath the nail or white superficial, with spreading of chalky white scale beneath the nail surface. The most frequent etiologic agents are Trichophyton rubrum, Epidermophyton floccosum, and Trichophyton mentagrophytes https://www.aafp.org/pubs/afp/issues/2014/1115/p702.html#afp20141115p702-f5

26. Nail fungi like warm, moist, dark places. You can get toenail fungus by: Walking around the perimeters of swimming pools. Using a public locker room or shower. Walking barefoot in a public area. You can spread the fungus to someone else through direct contact. You can also get toenail fungus by touching an infected surface. Prevalence estimates range from 1% to 8%, and the incidence is increasing. It has been reported that patients are genetically susceptible to dermatophyte infections in an autosomal dominant pattern. Risk factors include aging, diabetes, tinea pedis, psoriasis, immunodeficiency, and living with family members who have onychomycosis. Nail infections are the most difficult to treat, often requiring months of oral itraconazole or terbinafine as well as surgical removal of the nail. Relapses are common.

27. Dermatophytosis

28. SUBCUTANEOUS MYCOSES The fungi that cause subcutaneous mycoses normally reside in soil or on vegetation. They enter the skin or subcutaneous tissue by traumatic inoculation with contaminated material. In general, lesions become granulomatous and expand slowly from the area of implantation. Extensions via the lymphatics draining the lesion is slow except in sporotrichosis. These mycoses are usually confined to the subcutaneous tissues, but in rare cases they become systemic and produce life-threatening disease.

29. Sporotrichosis S. schenckii is a thermally dimorphic fungus that lives on vegetation. It is associated with variety of plants, grasses, trees, sphagnum moss, rose bushes, and other horticultural plants. At ambient temperatures, it grows as mold, producing branching, septate hyphae and conidia, and in tissue or in vitro at 35-37 degrees Celsius as a small budding yeast. Following traumatic introduction into the skin, S. schenkii causes sporotrichosis, a chronic granulomatous infection. The initial episode is typically followed by secondary spread with involvement of the draining lymphatics and lymph nodes. The conidia or hyphal fragments of S. schenkii are introduced into the skin by trauma . Patients frequently recall a history of trauma associated with outdoor activities and plants. Fixed sporotrichosis is a single nonlymphangitic nodule that is limited and less progressive. Immunity limits the local spread of infection

30. Sporotrichosis In some cases, the infection is limited. Although the oral administration of saturated solution of potassium iodide in milk is quite effective, it is difficult for many patients to tolerate. The treatment of choice is oral itraconazole or another azole. For systemic disease, amphotecirin B is given. Prevention includes measures to minimize accidental inoculation and the use of fungicides, where appropriate, to treat wood. Animals are also susceptible to sporotrichosis.

31. Chromoblastomycosis (chromomycosis) is a subcutaneous mycotic infection that is usually caused by traumatic inoculation of any of the recognized fungal agents, which reside in soil and vegetation. All are dematiaceous fungi, having melanized cell walls: P. verrucosa, F. pedrosoi, Fonsecaea compacta, Rhinocladiella aquaspersa, and Cladophialophora carrionii. The infection is chronic and characterized by the slow development of progressive granulomatous lesions that in time induce hyperplasia of the epidermal tissue. The fungi are introduced into the skin by trauma, often of the exposed legs or feet. Over months to years, the primary lesion becomes verrucous and wart-like with extension along the draining lymphatics.

32. Chromoblastomycosis Cauliflower-like nodules with crusting abscesses eventually cover the area. Small ulcerations or “black dots” of hemopurulent material is present on the warty surface. Surgical excision with wide margins is the therapy of choice for small lesions. Chemotherapy with flucytosine or itraconazole may be efficacious for larger lesions. The application of local heat is also beneficial. The disease occurs chiefly on the legs of barefoot agrarian workers following traumatic introduction of the fungus. Chromoblastomycosis is not communicable. Wearing shoes and protecting the legs probably would prevent infection.

33. Phaeohyphomycosis

34. Phaeohyphomycosis Term applied to infcetions chracterized by the presence of darkly pigmented septate hyphae in tissue. Both cutaneous and systemic infections have been described. They are all exogenous molds that normally exist in nature. Some of the more common causes of subcutaneous phaeohyphomycosis are Exophiala jeanselmei, Phialophora richardsiae, Bipolaris spicifera, and Wangiella dermatitidis. In general, itraconazole or flucytosine is the drug of choice for subcutaneous phaeohyphomycosis.

35. Mycetoma Chronic subcutaneous infection induced by traumatic inoculation with any of several saprophytic species of fungi or actinomycetous bacteria that are normally found in soil. Actinomycetoma is a mycetoma caused by an actinomycete; A Eumycetoma is a mycetoma caused by fungus. It occurs worldwide but more often among impoverished people who reside in tropical areas and wear less protective clothing. Mycetoma develops after traumatic inoculation with soil contaminated with one of the agents. Subcutaneous tissues of the feet, lower extremities, hands , and exposed areas are most often involved Untreated lesions persist for years and extend deeper and peripherally, causing deformation and loss of function.

36. Mycetoma The management of eumycetoma is difficult. Involving surgical debridement or excision and chemotherapy. P. boydii is treated with topical nystatin or miconazole, Itraconazole, and even smphotericin B can be recommended for Madurella infections and flucutosine for E. jeanselmei. Chemotherapeutic agents must be given for long periods to adequately penetrate these lesions. Properly cleaning wounds and wearing shoes are reasonable control measures.

37. ENDEMIC MYCOSES The fungi that cause coccidioidomycosis and histoplasmosis exist in nature in dry soil or in soil mixed with guano, respectively.The agents of blastomycosis and paracoccidioidomycosis are presumed to reside in nature, but their habitats have not been clearly defined. Each of these four mycoses is caused by a thermally dimorphic fungus, and the infections are initiated in the lungs following inhalation of the respective conidia. With rare exceptions, these mycoses are not transmissible among humans or other animals.

38. Coccidioidomycosis Coccidioidomycosisis caused C.posadasii or C.immitis. Endemic in well-circumscribed semiarid regions of the southwestern United States, Central America, and South America. Infection is usually self-limited, and dissemination is rare but always serious, and it may be fatal. Inhalation of arthroconidia leads to primary infection that is asymptomatic in 60% of individuals. The only evidence of infection is the developmenti of serum precipitins and conversion to a positive skin test within 2-4 weeks. The other 40% of individuals develop a self-limited influenza-like illness with fever, malaise, cough, arthralgia, and headache. This condition is called valley fever. San Joaquin Valley fever, or desert rheumatism.

39. Coccidioidomycosis After 1-2 weeks, about 15% of these patients develop hypersensitivity reactions, which is present as a rash, erythema nodosum, or erythema multiforme. Symptomatic primary infection is self-limited and requires only supportive treatment, although itraconazole may reduce the symptoms. Patients who have severe disease require treatment with amphotericin B, which is administered intravenously. This regimen may be followed by several months of oral therapy with itraconazole. The disease is not communicable from person to person, and there is no evidence that infected rodents contribute to its spread. Some measure of control can be achieved by reducing dust, paving roads and airfields, planting grass or crops, and using oil sprays.

40. Histoplasmosis Is a dimorphic soil saprophyte that causes histoplasmosis, the most prevalent pulmonary fungal infection in humans and animals. In nature, H. capsulatum grow as a mold in association with soil and avian habitats, being enriched by alkaline nitrogenous substrates in guano. Some individuals, such as immunocompetent persons who inhale a heavy inoculum, develop acute pulmonary histoplasmosis, which is self-limited flu-like syndrome with fever, chills, myalgias, headaches, and nonproductive cough. These symptoms resolve spontaneously without therapy, and the granulomatous nodules in the lungs or other sites heal with calcification.

41. Histoplasmosis Acute pulmonary histoplasmosis is managed with supportive therapy and rest. Itraconazole is the treatment for mild to moderate infection. In disseminated disease, systemic treatment with amphotericin B is often curative, though patients may need prolonged treatment and monitoring for relapses. AIDS patients require maintenance therapy with itraconazole. Histoplasmosis is not communicable from person to person. Spraying formaldehyde on infected soil may destroy H. capsulatum .

42. Blastomycosis B. dermatitidis is a thermally dimorphic fungus that grows as a mold culture, producing hyaline, and branching septate hyphae and conidia. B. dermatitidis causes blastomycosis, a chronic infection with granulomatous and suppurative lesions that is initiated in the lungs, whence dissemination may occur to any organ but preferentially to the skin and bones. The most common clinical presentation is a pulmonary infiltrate in association with a variety of symptoms indistinguishable from other acute lower respiratory infections (fever, malaise, night sweats, cough, and myalgias). Patients can also present with chronic pneumonia.

43. Blastomycosis Severe cases of blastomycosis are treated with amphotericin B. In patients with confined lesions, a 6-month course of itraconazole is very effective. Blastomycosis is a relatively common infection of dogs and rarely other animals in endemic areas. It cannot be transmitted by animals or humans. However, the occurrence of several small outbreaks has linked B. dermatitidis to rural river banks.

44. Paracoccidioidomycosis P. brasiliensis is the thermally dimorphic fungal agent of paracoccidioidomycosis which is confined to endemic regions of Central and South America. P. brasiliensis is inhaled, and initial lesions occur in the lung. After a period of dormancy that may last for decades, the pulmonary granulomas may be active, leading to chronic, progressive pulmonary disease or dissemination. Most patients are 30-60 years of age, and over 90% are men. A few patients, typically less than 30 years of age, develop an acute or subacute progressive infection with a shorter incubation time .

45. Paracoccidioidomycosis Many patients present with painful sores involving the oral mucosa. Skin test surveys have been conducted using an antigen extract, paracoccidioidin, which may cross-react with coccidioidin or histoplasmin Serologic testing is most useful for diagnosis. Itraconazole appears to be most effective against paracoccidioidomycosis, but ketoconazole and trimethoprim sulfamethoxazole are also efficacious. Severe disease can be treated with amphotericin B. Paracoccidioidomycosis occurs mainly in rural areas of Latin America, particularly among farmers. Since P. brasiliensis has only rarely been isolated from nature, its natural habitat has not been definitively determined. As with the other endemic mycoses, paracoccidioidomycosis is not communicable.

46. OPPORTUNISTIC MYCOSES

47. Opportunistic mycoses are known to be fungal infections of the body that nearly always develop in debilitated patients whose natural defense mechanisms are compromised. WHAT CAUSES OPPORTUNISTIC MYCOSES? Cosmopolitan fungi which have a very low inherent virulence. Exogenous fungi that are globally present in soil, water, and air. Neutropenia Organ transplantation Use of steroids Broad spectrum Antibiotics Antineoplastic chemotherapy

48. Parenteral nutrition Prolonged intravenous infusions Extensive surgery MAJOR PROBLEMS CAUSED BY OPPORTUNISTIC MYCOSES Clinical resistance Microbial resistance Emergence of new pathogens Involvement of more susceptible patients

49. DISEASES CAUSED BY OPPORTUNISTIC MYCOSES CANDIDIASIS Caused by several species of the yeast genus Candida including Candida albicans, Candida parapsilosis, Candida glabrata, Candida tropicalis, Candida guilliermondii, and Candida dubliniensis. It is an opportunistic pathogen for some immunologically weak and immunocompromised people. Involvement may be localized to the mouth, throat, skin, scalp, vagina, fingers, nails, bronchi, lungs, or the gastrointestinal tract, or become systemic as in septicemia, endocarditis and meningitis.

50. Candida infections are most common in newborns and the elderly, and are usually caused by compromised epithelial barrier functioning. Patients with cell-mediated immune deficiency, as well as those undergoing rigorous cancer treatment, immunosuppression, or transplantation therapy, are more likely to develop systemic candidiasis.

51. Cutaneous and Mucosal Candidiasis When an overgrowth of Candida develops on the skin, an infection can occur which is known as cutaneous candidiasis or candidiasis of the skin. Candidiasis of the skin causes a red, itchy rash in the folds of the skin, which can spread to other areas of the body which can be treated with improved hygiene and antifungal creams or powders. The main symptom of candidiasis of the skin is a rash, which can cause redness and intense itching. Blisters and pustules may also occur. The rash can affect various parts of the body, but is most likely to develop in the folds of the skin. Candida can also cause infections in the nails, edges of the nails, and corners of the mouth.

52. Candida fungi thrive in warm, moist areas, which can lead to candidiasis of the skin. Babies can also develop candidiasis of the skin, especially on the buttocks. It is usually not contagious, but people with weakened immune systems may develop the condition after touching the skin of an infected person. Those with compromised immune systems are more likely to develop a severe infection.

53. Mucosal candidiasis is also known as oral candidiasis which is an infection of the oral cavity by the Candida albicans. Candidiasis in the mouth and throat is also called thrush or oropharyngeal candidiasis. Candidiasis in the esophagus is called esophageal candidiasis or Candida esophagitis and is considered to be one of the most common infections in people living with HIV/AIDS. Candidiasis in the mouth and throat can have many symptoms, such as white patches, redness, soreness, cotton-like feeling, loss of taste, pain while eating or swallowing, and cracking and redness at the corners of the mouth. Symptoms of candidiasis in the esophagus usually include pain when swallowing and difficulty swallowing. Candidiasis in the mouth, throat, or esophagus is uncommon in healthy adults, but is more common in babies and people who wear dentures, have diabetes, cancer, HIV/AIDS, taking antibiotics or corticosteroids, taking medications that cause dry mouth, or smoking.

54. People with weakened immune systems, such as those living with HIV/AIDS and blood cancers, are more likely to get candidiasis in the esophagus which can lead to candidiasis in the mouth and throat. Candidiasis in the mouth, throat, or esophagus is usually treated with antifungal medicine. For mild to moderate infections, an antifungal medicine is applied to the inside of the mouth for 7-14 days. For severe infections, fluconazole is the most common treatment. If the patient does not get better after taking fluconazole, healthcare providers may prescribe a different antifungal. Other types of prescription antifungal medicines can also be used for people who can't take fluconazole or don't get better after taking fluconazole.

55. b . Systemic Candidiasis . Candidemia, or bloodstream infection, is the most common form of systemic candidiasis caused by Candida species. However, Candida organisms may be disseminated to multiple sites, notably retina, kidney, liver and spleen, bones, and the central nervous system. Symptoms of systemic candidiasis include abdominal pain, fever, muscle aches, skin rash, and weakness . Untreated Candida infection carries the risk of leading to a systemic infection in which other organs can become involved and may lead to sepsis. People with surgery, hospital stay, and premature babies are at risk of systemic candidiasis. Systemic candidiasis is treated with amphotericin B. sometimes in conjunction with oral flucytosine, fluconazole, or caspofungin.depends on age, immune status, location, and severity of infection.

56. c . Chronic Mucocutaneous Candidiasis CMC is a group of disorders characterized by recurrent or persistent superficial infections of the skin, mucous membranes, and nails with Candida albicans. Chronic Mucocutaneous Candidiasis is characterized by thickened, cracked, and discolored nails, skin lesions, crusted, pustular, erythematous, and hyperkeratotic skin lesions, and scarring alopecia on the scalp. Chronic mucocutaneous candidiasis is caused by a mutation in specific genes, which can be caused by one or two mutations from each parent. Chronic mucocutaneous candidiasis responds well to oral ketoconazole, but patients with a genetic cellular immune defect often require lifelong treatment.

57. 2. CRYPTOCOCCOSIS Cryptococcus neoformans and Cryptococcus gattii are environmental, basidiomycetous yeasts which considered to be the principle pathogenic species. Cryptococcosis is a chronic, subacute to acute pulmonary, systemic or meningitic disease, initiated by the inhalation of infectious propagules from the environment. In humans, C. neoformans affects immunocompromised hosts predominantly and is the commonest cause of fungal meningitis. Meningitis is the predominant clinical presentation with fever and headache as the most common symptoms. C. neoformans usually infects the lungs or the central nervous system (the brain and spinal cord), but it can also affect other parts of the body. The symptoms of the infection depend on the parts of the body that are affected.

58. a. Lungs (Pulmonary cryptococcosis) Cryptococcus neoformans is a fungus that lives in the environment throughout the world . People can become infected with C. neoformans after breathing in the microscopic fungus, although most people who are exposed to the fungus never get sick from it. A C. neoformans infection in the lungs can cause a pneumonia-like illness and its symptoms are often similar to those of many other illnesses such as cough, shortness of breath, chest pain and fever. Pulmonary cryptococcosis is an emerging disease in immunocompromised and immunocompetent patients, with 11% of hospitalized patients with HIV having it as a secondary infection. Cryptococcosis is a pulmonary or disseminated infection caused by inhalation of soil contaminated with Cryptococcus neoformans or C. gattii.

59. Pulmonary cryptococcosis resolves without specific therapy in most immunocompetent patients, patients with infections who fall under the categories of infection with pulmonary cryptococcosis in immunocompetent host and pulmonary cryptococcosis in immunosuppressed hosts require antifungal therapy. The therapeutic objective for individuals with HIV and C neoformans co-infection may be different from that for patients with cryptococcal infection that is not exacerbated by HIV infection.

60. b . Central Nervous System (Cryptococcal meningitis) Cryptococcal meningitis is an infection caused by the fungus Cryptococcus after it spreads from the lungs to the brain. It is specifically caused by the fungus Cryptococcus neoformans which is a type of fungi that is found in soil around the world. C. neoformans is thought to invade the brain and cerebrospinal fluid via circulating blood in most clinical situations. In order to penetrate into the brain, C. neoformans must cross the endothelium of the BBB or the epithelium of the blood-cerebrospinal fluid barrier. Cryptococcus gattii can also cause meningitis, but this form can cause disease in patients with a normal immune system as well. A person with cryptococcal meningitis may experience symptoms such as headache, fever, neck pain, nausea and vomiting, sensitivity to light, If left untreated, more serious symptoms may develop such as brain damage, coma, hearing loss, and hydrocephalus.

61. This type of meningitis spreads through the bloodstream to the brain from another place in the body that has the infection and it is not spread from person to person. People become infected with cryptococcal meningitis when they breathe in fungal spores from the environment, often from bird droppings In order to diagnose cryptococcal meningitis, a sample of cerebrospinal fluid is taken by lumbar puncture which is then tested using a rapid antigen test, or an India ink test if a rapid antigen test is not available. If a lumbar puncture is not possible, a sample of blood is taken for testing. Cryptococcus meningitis often affects people with a weak immune system including those people suffering from AIDS, cirrhosis, diabetes, leukemia, lymphoma, sarcoidosis and people who had an organ transplant. The principal antifungal agents for the treatment of cryptococcal meningitis are intravenous amphotericin B deoxycholate and its lipid formulations, oral flucytosine, and oral fluconazole.

62. 3. Aspergillosis Aspergillosis is a spectrum of diseases of humans and animals caused by members of the genus Aspergillus. The type of disease and severity depends upon the physiologic state of the host and the species of Aspergillus involved. The etiological agents are cosmopolitan and include Aspergillus fumigatus complex, A. flavus complex, A. niger complex, A. nidulans and A. terreus complex. Pulmonary Aspergillosis Allergic aspergillosis Allergic bronchopulmonary aspergillosis (ABPA) is a fungal infection of the lung due to a hypersensitivity reaction to antigens of Aspergillus fumigatus after colonization into the airways.

63. Symptoms of a llergic bronchopulmonary aspergillosis (ABPA) is similar to asthma symptoms which includes wheezing, shortness of breath, cough and fever in rare cases. Aspergillus fumigatus is a species of fungus which can be found throughout the environment, including in soil, plant matter, and household dust. The fungus can also produce airborne spores called conidia. The spores of Aspergillus fumigatus that are inhaled and develop as hyphae in bronchial mucus are the cause of allergic bronchopulmonary aspergillosis (ABPA), which affects people with cystic fibrosis and asthma. .Normal hosts exposed to massive doses of conidia can develop extrinsic allergic alveolitis. Allergic forms of aspergillosis are treated with corticosteroids or disodium cromoglycate.

64. b . Aspergilloma and Extrapulmonary Colonization Aspergilloma occurs when inhaled conidia enter an existing cavity, germinate, and produce abundant hyphae in the abnormal pulmonary space. Patients with previous cavitary disease including tuberculosis, sarcoidosis and emphysema are at risk of catching this disease. Some patients suffering from this disease are asymptomatic while others are experiencing symptoms such as cough, dyspnea, weight loss, fatigue and hemoptysis. Localized, noninvasive infections (colonization) caused by Aspergillus species can affect the ear canal, cornea, nails, and sinuses of the nose. Most people breathe in Aspergillus spores every day without getting sick but people with weakened immune systems or lung diseases are at a higher risk of developing health problems due to Aspergillus spores.. Aspergilloma is treated with itraconazole or amphotericin B and surgery.

65. c . Invasive Aspergillosis After inhalation and germination of the conidia, an acute pneumonic process with or without invasive disease develops. Patients at risk are those with lymphocytic or myelogenous leukemia and lymphoma, stem cell transplant recipients, and especially individuals taking corticosteroids. The risk is much greater for patients receiving allogeneic (rather than autologous) hematopoietic stem cell transplants. People suffering from this disease may experience symptoms such as fever, cough, dyspnea, and hemoptysis. Persons with less compromising underlying disease may develop chronic necrotizing pulmonary aspergillosis, which is a milder disease. Rapid delivery of either the native or lipid formulation of amphotericin B or voriconazole, along with cytokine immunotherapy, is necessary for invasive aspergillosis.

66. .Invasive aspergillosis requires rapid administration of either the native or lipid formulation of amphotericin B or voriconazole, often supplemented with cytokine immunotherapy.

67. 4. MUCORMYCOSIS (Zygomycosis) an opportunistic mycosis caused by a number of molds classified in the order Mucorales of the Phylum Glomerulomycota and Subphylum Mucoromycotina. These fungi are ubiquitous thermotolerant saprobes. The leading pathogens among this group are species of the genera Rhizopus,, Rhizomucor , Lichtheimia, Cunninghamella and Mucor . The most prevalent agent is Rhizopus oryzae. The conditions that place patients at risk are those who are suffering from diabetes, leukemia, lymphoma, corticosteroid treatment, severe burns, immunodeficiencies and those who are undergoing dialysis.

68. a. Rhinocerebral mucormycosis an infection in the sinuses that can spread to the brain. People with uncontrolled diabetes and who have had a kidney transplant are at risk of this kind of disease. Symptoms a patient may experience include one-sided facial swelling, headache, nasal or sinus congestion, fever and Black lesions on nasal bridge or upper inside of mouth that quickly become more severe.. Fungal hyphae invade blood vessels, damaging the endothelium and leading to ischemia and necrosis of surrounding tissue. In Rhinocerebral mucormycosis, the invasion of brain and orbit is through the involvement of sphenopalatine and internal maxillary arteries, while the involvement of the internal carotid artery and cavernous sinus thrombosis is common only in long-standing cases.

69. Amphotericin B is the only reliable systemic antifungal agent approved for the treatment of mucormycosis, and the highest possible tissue levels should be achieved.