Subcutaneous mycosis

subcutaneous fungal infections in brief

1. Presenter: Dr Rohini Soni Moderator: Dr Sundeep Chowdhry Subcutaneous mycosis

2. Introduction Subcutaneous mycoses, or mycoses of implantation, are sporadically occurring infections caused by fungi present in the natural environment, which are directly inoculated into the dermis or subcutaneous tissue through a penetrating injury.

3. Eumycetoma Sporotrichosis Chromoblastomycosis Rhinosporodosis Phaeohyphomycosis Lobomycosis Subcutaneous zygomycosis

4. Mycetoma (madura foot) Chronic, slowly progressive granulomatous infection of skin & subcutaneous tissues with the involvement of underlying fasciae & bones commonly affecting the extremities. Reported by Gill from Madurai, S.India. Maduramycosis or Madura foot. Tropical & subtropical countries of Asia , Africa, Central & S.America Fungi associated with fungal mycetoma are opportunistic. Mycotic mycetoma - usually more common in men (3:1 to 5:1) than in women Usually results from trauma or puncture wounds to feet, legs, arms and hands (usually on the feet)

5. Mycetoma Eumycetoma Actinomycetoma

6. Clinical features Site : foot and lower leg The earliest stage is a firm, painless nodule but, with time, papules, pustules which break down to form draining sinuses, appear on the skin surface. The whole area becomes hard and swollen, often without significant pain. Extension to underlying bones and joints gives rise to periostitis, osteomyelitis and arthritis There are usually multiple sinus tracts draining pus The discharge may be purulent or seropurulent. The condition is painless and usually develops slowly Lymph node involvement is rare Madurella mycetomatis causes the majority of the cases with the black grains.

7. Characterized by a clinical triad of: Tumefaction – tumor like swelling Multiple draining sinuses Presence of grains or granules in sinuses.

8. Differences between eumycetoma and actinomycetom

9. Lab diagnosis Specimen : pus, fluids, scrapings of sinuses, grains, biopsy specimen. Color of grain : Black grains are always eumycotic whereas red grains are due to Actinomadura pelletierri. KOH : eumycotic cells consists of broad septet hyphae with well defined walls and chlamydospores. Gram stain AFB to identify Nocardia. Culture on SDA media to identify the species.

10. FNAC smear showing PAS positive fungal hyphae Actinomycetoma-neutrophilic infiltrate surrounding the actinomycotic colony with occasional giant cell (H and E, ×250) Histology The causal organisms produce a chronic infammatory reaction leading to focal neutrophil abscess formation, with scattered giant cells and fibrosis.

11. Xray Soft tissue swellings Irregular destruction from without or around the periphery of the affected bones: osteolysis A periosteal reaction Sclerosis of the affected bones and the absence of true sequestra The shaggy periostitis, reactive sclerosis and resorption of bone gives a melting snow appearance

12. Treatment of eumycetoma Oral Ketoconazole (200- 400 mg) daily for several months A trial of therapy with terbinafine , itraconazole, Voriconazole, Posaconazole is worth attempting. AMB (1mg/kg) for Madurella & Fusarium species. Protracted case – Surgery (debridement with skin graft)

13. SPOROTRICHOSIS Chronic infection involving cutaneous, subcutaneous and lymphatic tissue. Frequently encountered in gardeners, forest workers and manual labourers, urban alcoholics ,particularly homeless. Rose gardener’s disease Caused by the thermally dimorphic fungus Sporothrix schenckii 25˚C – mold, 37°C – yeast. Saprophytic fungus – grows on decaying vegetation, soil, thorns.

14. SPOROTRICHOSIS Cutaneous Extra cutaneous Fixed/localised Lymphocutaneous Pulmonary Disseminated

15. Clinical presentation Spore is the infective stage of the fungus. It causes infection primarily on the hand or the forearm through direct contact of the skin by spores. Typically, infection is introduced in skin through a penetration of thorn. At the site of thorn injury, it causes a local pustule or a nodules that breaks down to form a ulcer. Frequently , the regional lymph nodes draining the ulcer enlarge, suppurate and may ulcerate. (lymphocutaneous form)

16. The primary lesion may remain localized (fixed sporotrichosis) or in the immunocompromised individuals may disseminate to involve the bones, joints, lungs and rarely the central -nervous system (meningitis). Pulmonary forms results from inhalation of conidiaand presents as chronic cavitary fibronodular disease. Patient presents with the features of pneumonitis or bronchitis.

17. HISTOLOGY The fungus provokes a mixed granulomatous reaction with neutrophil foci. The fungus is present in the tissue, usually in the form of small (3–5 μm) cigar-shaped or oval yeasts These may be surrounded by a thick, radiate, eosinophilic substance, which forms the distinctive asteroid bodies ( a rounded oval, basophilic, yeast-like body, with of an eosinophilic substance radiating from the yeast cell). This is called “ Splendore-Hoeppli ” phenomenon : due to immune complex deposition around the organism The characteristic formation of the perifungal Splendore-Hoeppli reaction probably prevents phagocytosis and intracellular killing of the insulting agent leading to chronicity of infection

18. 3 granulomatous patterns: Sporotrichoid type -concentric zones with necrotic material in the centre surrounded by epitheloid histiocytes, neutrophils, plasma cells. Tuberculoid type - merges into the area of epitheloid cells Foreign body type without pyogenic reaction may be seen.

19. Lab investigations Specimens – pus, exudate & aspirate from nodules, curettage or swabs from open lesions. Direct microscopy usually negative or few organisms may be seen. Others : serology/sporotrichnin test. Culture on SDA media

20. Microscopic morphology of the saprophytic or mycelial form of Sporothrix schenckii when grown on Sabouraud's dextrose agar at 25oC. Note clusters of ovoid conidia produced sympodially on short conidiophores arising at right angles from the thin septate hyphae. The arrangement of the conidia at the apex of the conidiogenous cell is often described as palmate or flower-like, with each conidium attached by a denticle to the small vesicle Yeast phase of sporothrix

21. Treatment Treatment ladder First line Itraconazole 100–200 mg/day until clinical recovery (at least 3 months) Or Terbinafine 250 mg/day until clinical recovery (at least 3 months) Second line Potassium iodide at an initial dose of 5 drops daily of saturated solution increasing slowly to 4–6 mL daily AMB – disseminated & CNS disease. Thermotherapy

22. Lobomycosis Also called Keloidal blastomycosis or Lobo’s disease Caused by Lacazia loboi (Hydrophilic fungus) : exists only as yeast cells. May occur anywhere but mainly involves exposed parts- legs, arms and face, ear. Chronic, localized, subepidermal infection characterized by the presence of keloidal, verrucoid, nodular lesions or sometimes by vegetating crusty plaques and tumors. The lesions contain masses of spheroidal, yeast- like organisms tentatively referred to as Loboa loboi. Painless, occasionally pruritic, dysesthetic or anesthetic. No systemic spread. The disease has been found in humans and dolphins and is restricted to the Amazon Valley in Brazil.

23. LAB DIAGNOSIS KOH spheroid, yeast - like cells, 5 -12µ thick - walled & multinucleate. Form chain with cells joined by bridges. HE –dense granulomatous infiltrate with epithelia cells and multinucleate giant cells. May show ‘asteroid bodies’. Culture- cannot be cultured Fungal elements can be stained with PAS, Gomori, Grocott stains.

24. Diagnosis is made by skin biopsy and there is a characteristic appearance of the fungal spores which line up like “chains of lemons Multiple, confluent, keloid-like, hyperchromic nodules with at shiny surfaces involving the entire free border, posterior aspect, and lobule of the left ear of a sherman, Venezuela. B) Numerous Lacazia loboi tissue-phase organisms within the stroma. Note the typical chain pattern showing simple gemation budding (Gomori-Grocott stain, magni cation ×100). C) Yeast cells showing typical double refraction of the membrane and protoplasmic bodies within cells (periodic acid–Schiff stain, magni cation ×600)

25. Treatment No effective medical treatment Complete excision Cryosurgery. Clofazimine at the dose of 300mg/day can be used with maintenance dose of 100 mg for unto 2 years. Clofazimine can be combined with itraconazole or posaconazole.

26. Rhinosporidiosis Caused by a hydrophilic protist, Rhinosporidium seeberi 1 st identified in Argentina, but majority of cases occur in India and Sri lanka. It has high incidence among people who frequently bath along with domestic animals in ponds, tanks, lakes. A chronic granulomatous disease characterized the development of friable polyps, usually confined to nose, mouth or eye but rarely seen on the genitalia or other mucous membranes.

27. Rhinosporidiosis Mucosa Friable, vascular polyp Cutaneous Friable wart like growth with crenated surfaces Disseminated (livers,lungs,spleen, brain)

28. Nasal polyp : Obstruction to breathing is usually the chief complaint. Eye: If the eye is involved there is conjunctivitis and photophobia Miscellaneous forms: Buccal cavity, vagina, vulva, penis, urethra or rectum

29. Large (100 - 450 microns), thick walled sporangia with 1000+ endospores, each 6 - 10 microns, accompanied by a mixed inflammatory infiltrate (h/e), GMS stain Lab diagnosis Direct microscopy can be done with KOH to demonstrate sporangia,H/E & PAS/GMS are diagnostic if sporangia is visible .

30. Treatment options Radical Surgery:- Excision/ Electrocautery Dapsone (widely used) Recurrence common

31. CHROMOBLASTOMYCOSIS A chronic granulomatous fungal infection of the dematiaceous (pigmented fungi), which produce thick walled single- or multicelled clusters (sclerotic or muriform bodies) Commonest fungi - Fonsecaea Species Phialophora verrucosa Cladosporium carrionii Fonsecaea compacta Rhinocladiella aquaspersa- rare Also called as Verrucous dermatitis Fungi is isolated from wood and soil Adult male agricultural workers are most often affected

32. Presentation Enter the skin by traumatic implantation and lesions develop slowly around the site of implantation Warty cutaneous nodules which resembles flouts of cauliflower . Frequently ulcerate Confined to the subcutaneous tissue of the feet and lower legs Satellite lesions are produced by scratching. Presence of secondary infection causes itching and pain. Haematogenous spread has occurred but is rare, and brain abscesses have reported. Complications of chromoblastomycosis include local lymphedema, leading to elephantiasis and squamous carcinomas

33. Lab investigations Specimen: scraping, crust, aspirated material, biopsy tissue. KOH: thick walled dark brown sclerotic bodies or muriform cells. H/E: variably pigmented fungal cells called muriform/sclerotic/copper penny bodies. sclerotic/medlar bodies in KOH shows mononuclear cell infiltrate and a dark-brown, round sclerotic body resembling a “copper penny” (arrow), consistent with chromoblastomycosis

34. Culture: SDA medium at 26 C for 6 weeks. Typical velvety brown colored colony Multiplication in vivo is by fission rather than budding, and this results in the production of single, two- or multiple-celled clusters giving a chest-nut appearance Fonsecaea pedrosoi – conidia is confined to the upper part of the cell, produced by acropetal budding Phialophora verrucosa - flowers in the vase conidiation) phialophora Fonsecaea

35. Treatment Itraconazole (100–200 mg daily) or terbinafine (250 mg daily) is often successful, although responses to both are thought to be better if the causative organism is C. carrionii . Flucytosine used on its own or combined with amphotericin B may also be effective, but resistance to flucytosine may develop if used alone. Other approaches to treatment: cryotherapy or the local application of heat The use of surgery is contentious; in larger plaques there is a risk in pursuing this approach as satellite lesions may develop around the excision site. Surgery is really only indicated in very small lesions combined with chemotherapy.

36. Subcutaneous zygomycosis Zygomycota Zygomycetes Mucorales Entomophthorales phylum Subcutaneous zygomycosis Usually infect immunocompetent Traumatic implantation s/c mycosis and sinusitis Dissemination rare

37. Entomophthorales Name is derived from Greek word (‘ Entomon ’ = insect; phthoro = destroyer) slow -growing tumoral -like masses in infected tissues SITES AFFECTED: Conidiobolus spp - Face ( generally around nose ) Basidiobolus - limbs, intestinal tract, and rarely other body areas. A typical feature of these pathogens: Splendore – Hoeppli phenomenon Basidiobolomycosis Conidiobolomycosis B. ranarum B.haptosporus C. coronatus C. incongrus C. lampragues

38. Pathogens .. plant detritus, where they could associate with insects or mammals by producing forcibly ejected sticky conidia Both Conidiobolus spp. and Basidiobolus spp. are thermophilic fungi . Affected patients are apparently healthy without predisposing factors. Fungal spores on Bristles of insect Eaten up by reptiles Faeces of reptiles in soil People using toilet leaves

39. Mainly afflicts children PORTAL OF ENTRY: Insect bite, ingestion, and inhalation Frequently in tropical Africa and Southeast Asia and occasionally in India, Costa Rica, and Brazil Usually adults Inhalation or through trauma to nasal mucosa Rainforests of tropical Africa , South or Central America and Southeast Asia and India Basidiobolomycosis Conidiobolomycosis

40. Basidiobolomycosis Patients present with a single painless, unilateral, well- circumscribed subcutaneous mass on the buttock or thigh. Initial single nodule is hard and woody and progressively grows into contiguous subcutaneous tissues. It may be single, or there may be multiple satellite lesions. The disc shaped masses have a uniform hard consistency, and they do not pit. Hematogenous spread typically does not occur. The subcutaneous nodule is anchored to underlying muscle fascia and is not attached to the overlying skin The smooth rounded edge, which may be lobulated, can be raised up by inserting the fingers underneath it . Pain and tenderness may be absent. The overlying skin may be tense, oedematous, desquamating, hyperpigmented or normal. Ulceration does not occur.

41. Conidiobolomycosis Over an extended period of time, infection undermines the mucosa of the nasal cavity. Expansion of the nasal mass produces painless swelling of overlying tissue of forehead , upper lip, and about the eye with intact dermal layer without ulceration. Signs of nasal obstruction may be present. Long standing cases hippopotamus look may be present. Does not usually disseminate, may involve lymph nodes

42. Lab diagnosis Specimen : scrapings ,biopsy tissue. KOH : Ribbon-like broad, aseptate or sparsely septate hypha ( 3.5 to 10μm ) with right or wide-angle branching and covered by a hyaline material. Presumptive infection by members of the Entomophthoromycota. CULTURE : SDA media at 30 C & 37 C: yellowish to grey colonies in case of basidiomycosis and white colonies in coniobolus

43. few broad fungal hyphae with right angle branching (black arrow) and surrounding Splendore — Hoeppli reacti on (green arrow). Adjacent soft tissue shows dense infiltrate of eosinophils and fibrosis (a) (H and E, ×100). High power photomicrograph shows a few transverse septae (black arrows) in these fungal profiles (b) (H and E, ×400). Silver methinamine stain shows clearly identifiable transverse septae (black arrow) (c and d) (Grocott 's methinamine silver

44. Treatment Treatment for entomophthoramycosis : both medical and surgical. Systemic prolonged antifungal therapy coupled with surgical debridement is the cornerstone treatment. SSKI( Supersaturated solution of Potassium iodide) used to treat. Oral dosage for adults: Therapy is usually initiated at 600 mg (roughly 12 drops of SSKI) PO three times daily. This dosage is often gradually increased up to 4—6 g/day (127 drops/day of SSKI) if tolerated. The duration of therapy is often 6—10 weeks. Amphotericin B (0.5 mg/d) for 2 weeks or 1 month, dapsone , (1-2 mg/kg of body weight daily), and ketoconazole (400 mg/d), itraconazole (300 mg/d), or fluconazole (300 mg/d) for 6 months have been used.

45. PHAEOHYPHOMYCOSIS A mycotic infection of humans and lower animals caused by a number of dematiaceous (brown-pigmented) fungi where the tissue morphology of the causative organism is mycelial. This separates it from other clinical types of disease involving brown- pigmented fungi where the tissue morphology of the organism is a grain (mycotic mycetoma) or sclerotic body (chromoblastomycosis). Etiological agents: Wangiella dermatitidis Exophiala jeanselmei Cladophilophora bantiana Nattrassia mangiferae Alternaria species Ulocladium species Bipolaris species Chaetomium species Curvularia species Exserohilum species etc

46. Phaeohyphomycosis Superficial Piedra Cutaneous Deramatomycosis Invasive Systemic Cerebral Subcutaneous Keratitis

47. Subcutaneous or intramuscular lesions with abscess or cysts - single circumscribed lesion with a central cavity filled with pus and surrounded by a fibrous wall. Apart from classical forms, papulonodules, pustules, eschars, verrucous lesions have also been described. Unlike in chromoblastomycosis, these organisms form short, irregular, pigmented hyphae in tissue. Brain abscess is caused by Cladosporium Cystic lesions caused by non-pigmented fungi are also found called hyalohyphomycotic cysts

48. Lab investigations Specimen Aspirates from cysts Curreting from plaques, nodules and drained abscess KOH: septet hyphae seen SDA: olivaceous to brown or black colony Dematiaceous septate fungi

49. Intra and extracellular, round to oval, thick walled brown cells with septate hyphae (H and E, ×40 (H and E, ×10) Granuloma in the dermis composed of epithelioid cells, lymphocytes, and fibroblasts. (b) (H and E, ×100) closer view

50. Treatment Local excision for subcutaneous forms Invasive infections – I.V. AMB + Oral Flucytosine.

51. Thank you

52. Case scenario 1 A 29 year-old man (forest ranger) who was a native of the Peruvian jungle noticed a painless but pruriginous papular lesion on his left earlobe at the age of 12 years. He did not recall previous trauma. At the age of 23, he was given a misdiagnosis of cutaneous leishmaniasis on the basis of clinical findings and was treated with meglumine antimoniate (Glucantime™) for five days with no improvement After 17 years of slow disease progression, the patient came to the hospital for clinical evaluation. At physical examination, the entire left earlobe was involved, presenting diffuse infiltration, as well as multiple nodules and ulcers. At that time, direct examination and pathologic findings of a skin biopsy specimen showed multiple, round yeast-like cells in chains of 3–4 elements.

53. LOBOMYCOSIS

54. CASE SCENARIO 2 A 30-year-old gentleman was referred for a nonresolving cellulitis of the right hand and forearm for a 6-week duration. The patient gave a history of a motorbike accident before the onset of his problem. The patient did not sustain any other injury apart from a minor superficial wound over the dorsum of his right hand. After 3 days, he developed pain and redness over the dorsum of his right hand. In addition, he claimed that there was an on-off serous discharge from his wound associated with the swelling. After the injury, he denied contact with soils, untreated water source, or any other dirty environment. He does not have pets in his house.

55. Examination of the patient's right hand revealed a 1 cm × 3 cm healing wound over the dorsal region. There was no active discharge noted. His right hand, as well as his forearm was erythematous almost up to the elbow level. The erythema over the forearm followed a distinctive pattern. It spread along the lymphatic channels of the forearm. There was no other skin lesion or ulcer noted. There was tenderness over the erythematous area associated with multiple discrete swellings with sizes ranging from 2 mm to 5 mm

56. Sporotrichosis Mature blackish fungal colony growth noted on the Sabouraud agar media

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