MYCOLOGY THE FUNGUS AMONG US

Cell wall: chitin, glucan, mannan Cell membrane: phospholipid bilayer, β-(1,3)-glucan , β-(1,3)-glucan synthase, ergosterol Drug targets

Yeasts: unicellular, divide by budding or fission, daughter cells form pseudohyphae Molds: multicellular filaments/hyphae together as mycelium, septate or non, vegetative or aerial Dimorphism: exist in both forms (yeast at higher temps, molds in environment)

MYCOSES (fungal infections) Superficial

o Mild, little/no inflammatory response, mainly cosmetic, not painful, easy to treat o Malassezia furfur

Normal skin flora Causes tinea versicolor, hypo/hyperpigmentation, especially during puberty and in summer Can also cause dermatitis (dandruff), folliculitis, blepharitis

o Dx: through clinical appearance, under microscope looks like spaghetti & meatballs (KOH) o Tx: topical fluconazole, selenium sulfide shampoo

Cutaneous o Epidermis: skin, hair, nails, keratinized layers o Caused by dermatophytes (not normal skin flora) o Acute or chronic, mostly in tropical climates, gardeners/florists o Manifested as ringworm/tinea (on head, feet, body, groin, bearded area, nails) o Dx: clinical presentation, KOH prep o Tx: topical azoles, terbinafine, ciclopirax nail laquer

Subcutaneous o Associated with skin trauma, caused by environmental fungi, mimic bacterial infections o Tx: does not respond well to antifungals, may need surgery to excise lesion o Lymphocutaneous sporotrichosis: “rose handler’s disease” (Sporotrix schenckii)

Dx: culture, skin biopsy Tx: SSKI, azoles, terbinafine, amphotericin B, surgical excision

Systemic o Dx: culture, tissue biopsy, germ-tube test (differentiates between C. albicans and other Candida species) o Tx: fluconazole (drug of choice) or echinocandin (mod to severely ill, recent azole exposure, C. glabrata) o Molds that divide at acute angles are more severe than right angles

SYSTEMIC MYCOSES

YEASTS Candida species

Cryptococcosis o Cryptococcus neoformans o Ubiquitous; yeast found in soil, pigeon droppings o Candidates: patients with AIDS, cancer, or transplants o Clinical presentation: usually meningitis (although many other organ involvements) o Dx: culture, antigen detection o Tx: amphotericin B + flucytosine, fluocnazole as step-down therapy

MOLDS Aspergillosis (septate)

o Everyone’s been exposed from inhalation o Ubiquitous: soil, food, water, decaying vegetation o Angioinvasive: gets into blood vessels, invades tissues o Onset of disease: bimodal initial neutropenia + graft-vs-host disease o Typical host: stem cell transplant recipients (chemo kills cells)

Allogeneic>autologous Chemo >2 weeks, high dose steroids, graft-vs-host disease, immunosuppression

o Sx: pulmonary (most common), sinusitis, cerebral, cutaneous, osteomyelitis, dissemination o Dx: difficult to obtain (risky for pt), tissue/sputum culture, look for septate hyphae w/acute branching o Tx: amphotericin B (historic drug of choice), voriconazole (current drug of choice) o Fluconazole does not work

Zygomycosis (non-septate) o Ubiquitous: decaying matter o Non-septate, right angle branching o Rhizopus, Rhizomucor, Absidia, Cunninghamella o Risk factors: uncontrolled diabetes, corticosteroid use, trauma/burns, malignant hematological disorders o Clinical presentation: all of a sudden, tissue necrosis, rhinocerebral (most common) o Sx: face pain, unilateral headache, drainage, soft tissue swelling o Dx: tissue biopsy, doesn’t grow as well as Aspergillus in culture o Tx: reverse predisposing factors, surgical debridement, antifungal therapy (amphotericin B)

DIMORPHIC MOLDS (Endemic: regions of the US)

Dx: culture, tissue biopsy Tx: [severe] amphotericin B, [mild/mod] itraconazole, fluconazole

Histoplasmosis o Histoplasma capsulatum o Ohio/Mississippi river valleys (common at UIC) o Sx: chronic pulmonary infection, disseminated infection, mostly mild/asymptomatic

Blastomycosis o Blastomyces dermatitidis o Midwest, Canadian provinces bordering the Great Lakes o “Chicago Disease” o Not that common: histo > blasto o Sx: acute/chronic pulmonary infection, disseminated infection (like histo)

Coccidiodomycosis o Coccidioides immitis: California’s San Joaquin valley (“valley fever”) o Coccidioides posadasii: Southwest, Mexico, South America o Sx: most are mild/asymptomatic, some get respiratory infection pulmonary nodules/cavities