Fungal Infections

FUNGAL INFECTIONS
By kheyati.s
• Dermatophyte
• Superficial • Pityriasis versicolor
fungal infections • Candidiasis
• Mycetoma
• Sporotrichosis
Deep fungal • Chromoblastomycosis
infections • Subcutaneous phycomycosis
Systemic fungal • Histoplasmosis

infections
DERMATOPHYTE INFECTIONS
(RINGWORM)
• Keratinophillic fungi living on dead keratin (stratum corneum)

• They induce inflammation in skin due to:
• Permeation of their metabolic products into deeper layers.
• Induction of delayed hypersensitivity.
TINEA CAPITIS (TINEA OF SCALP)
• Discoid patch of partial alopecia from which the hair can easily and painlessly be
plucked.
Three patterns
Noninflammatory tinea Inflammatory tinea

Favus
capitis capitis(kerion)
NONINFLAMMATORY TINEA CAPITIS:
• Caused by anthropophilic organisms (e.g., T. verrucosum
• . Human to human spread occurs, so may occur in epidemics.
• Appear as partially bald areas with scaling most marked at the periphery.
• Hair present in the patch are lusterless, may break 3–4 mm from the scalp and can
easily be plucked
• The broken hair may appear as gray/black dots. There is very little inflammation
(erythema, papules, and pustules).
INFLAMMATORY TINEA CAPITIS (KERION)
• Caused by zoophilic dermatophytes (e.g., M. canis), which elicit intense
inflammation.
• Presents as a boggy swelling with pustulation. Often, the pus discharges from
multiple orifices.
• Hair from such a swelling is easily and painlessly pluckable. Lymphadenopathy
(especially occipital) invariable.
-FAVUS
• Caused by T. schoenleinii
• Characterized by presence of foul-smelling, yellowish cup-shaped crusts entangling
many scalp hair.
• Often results in cicatricial alopecia.
TINEA CORPORIS (TINEA OF TRUNK AND LIMBS)
• Annular/arcuate lesions with relative clearing in the center and an active periphery
• Infection of the glabrous skin
TINEA CRURIS (TINEA OF GROIN)
• Groins, genitalia, pubic area, perineal, and perianal areas.
• Morphology
• Seen on the inner aspect of thighs as arcuate, sharply demarcated plaques
• Peripheral scaling, papulovesiculation, and pustulation.
• Lesions expand centrifugally and center clears.
• Chronic lesions may show hyperpigmentation, nodulation, and lichenification in
center
TINEA PEDIS
• Causes:
• Occlusive foot wear.
• Hyperhidrosis of soles.
• Sharing of wash places.
• Presence of tinea unguium
• Interdigital variant: Interdigital scaling in the lateral two interdigital spaces of the
feet.
• Complicated by bacterial superinfection athlete’s foot.
• Hyperkeratotic variant: Well-defined scaly plaque on the sole, usually unilateral.

• Vesicular variant: Recurrent vesiculation of soles
TINEA MANUUM (TINEA OF HANDS)
• associated with tinea pedis. Lesions manifest as unilateral,
• well-defined plaques or as diffuse erythema of the palms with accumulation of fine

scales in the creases
TINEA UNGUIUM (TINEA OF NAILS)
• Also called as onchomycosis
• Toe nail(tinea pedis)>>finger nail(tinea cruris)
• Asymmetrical
• Begins at the free edge of the distal part of nail.
• Yellow-brown discoloration ,crumbling and tunneling of nail plate.
• Collection of friable debris under the nail (subungual hyperkeratosis).
• Separation of nail plate from nail bed (onycholysis).
DIAGNOSIS:
DIFFERENTIAL DIAGNOSIS:
INVESTIGATIONS:
• Potassium hydroxide (KOH) scraping
• Add 10% KOH (to dissolve the keratin). Keep for half an hour; nail clippings require
longer (2 h) and warming (not boiling).
• Cultures:
• when clinical suspicion is strong and KOH mount is negative.
• Send samples in a black paper envelope to the laboratory.
• cultured on Sabouraud’s dextrose agar.
• Growth may take up to 4 weeks
• Wood’s light(358nm):
• tinea fluoresces -green,
• pityriasis versicolor- yellow,
• erythrasma coral- pink
TREATMENT:
TREATMENT:
PITYRIASIS VERSICOLOR
• It is caused by Malassezia furfur, a commensal yeast

• PATHOGENESIS:
• PV represents a shift in the relationship between host and resident yeast flora, the
yeast overgrowing in hot and humid conditions.
• Releases carboxylic acid which causes hypopigmentation due to reduced tanning of
skin.
• Morphology:
• Hypopigmented, (less frequently erythematous or hyperpigmented, so called
versicolor) scaly, and perifollicular macules
• Frequently coalesce but invariably the perifollicular character of the lesions is
retained at the periphery of the lesions.
• Scaling is branny and can be accentuated, if the lesion is scratched
• Sites of predilection:
• Upper trunk, often spreading to the neck and upper arms
Hyperpigmented leisons
Perifollicular , hypopigmented macules with

branny scales
Perifollicular
leisons
• Investigations:
• KOH mount shows a mixture of short, branched hyphae and spores described as
spaghetti and meat ball appearance.
• Diagnosis:
• Hypopigmented, perifollicular macules that become confluent
• Lesions appear to be sitting on the skin.
• Branny scales, accentuated by scratching with glass slide.
• Upper trunk and neck involvement
• Differential diagnosis:
• Treatment:
• Topical agents
• Imidazoles: Ketoconazole, 2% applied daily for 4 weeks.
• Selenium sulfide: 2.5% lotion in a detergent base, used weekly for 4 weeks.
• Systemic agents:
• In extensive lesions or when recurrences are frequent:
• Ketoconazole, 200 mg daily for three consecutive days.
• Fluconazole, 400 mg single dose.
• Itraconazole, 200 mg daily for 7 days.
CANDIDIASIS
• Candida albicans, a normal commensal becomes pathogenic due to:
• Moisture
• Obesity
• Endocrinopathies
• Pregnancy and ocp
• Immunocompromised states
• Clinical Features:
• Candidal infection may present as:
Acute mucocutaneous candidiasis.

 Chronic mucocutaneous candidiasis.
Systemic candidiasis.
ACUTE MUCOCUTANEOUS CANDIDIASIS
1. Flexural candidiasis (candidal intertrigo):
• Predisposing factors: Obesity, moisture, wearing of occlusive clothing, and
diabetes.
• Morphology: in depth of fold (at sites of friction) as a moist glazed area of

erythema and maceration. The edges show frayed scaling and satellite subcorneal
pustules.
• Sites of predilection: Inframammary area (in women), axillae and groins, natal
cleft, and in between fingers and toes.
• Candidal paronychia
• Wet work, diabetes and presence of genital candidiasis.
• Cuticles are lost and proximal nail fold becomes red and rolled
• On pressing, small bead of pus can be expressed from under the proximal nail
fold.,the adjoining nail plate becomes yellow-brown and ridged
• Genital candidiasis:
• Diabetes, pregnancy, use of oral contraceptives and broad-spectrum antibiotics. May be
sexually transmitted.
• Candidal vulvovaginitis: intense itching in the vulva and presence of white curdy
vaginal discharge. When severe, the vulva becomes edematous and erythematous.
• Candidal balanoposthitis: Presents as fragile papulopustules on glans or coronal

sulcus. Rupture to form well-defined, erythematous erosions, which may show a
collarette of white scales.
• Oral candidiasis:
• Acute pseudomembranous candidiasis (thrush)
• Acute atrophic candidiasis:
• Angular stomatitis:in denture wearers
• Candidal leucoplakia
• Chronic mucocutaneous candidiasis:
• Associated with hypoparathyroidism, Addison’s disease and thymomas.
• infection in oral mucosa (all forms), skin and nails.
• Systemic candidiasis:
• Seen against a background of severe illness, leucopenia, and immunosuppression
(AIDS/ iatrogenic)
• Cutaneous and visceral infections.
• Investigations
• KOH mount shows budding yeasts and pseudohyphae.
• Culture from suspected lesion.
• Treatment :
• Stop long term broad spectrum antibiotic in diabetic patients, usage of gloves, avoid
contact with moisture
• Topical agents
• Imidazoles (broad spectrum), amphotericin, and nystatin are effective.
• Candidal intertrigo: Topical azoles (clotrimazole, miconazole, and ketoconazole) are
effective.
• Candidal paronychia: Topical azole lotions and a topical antibiotic. If acute paronychia is
superimposed, then a course of oral antibiotic therapy may facilitate response. Oral
candidiasis: Lotions and oral suspensions of azoles. Or nystatin.
• Genital candidiasis: Imidazole pessaries for vaginal infection. Topical azoles for
balanoposthitis
• Treatment :
• Candidal vulvovaginitis: Single dose fluconazole (150 mg) or itraconazole (400
mg). Weekly doses of fluconazole (150 mg) for recurrent problem.
• Recurrent oral candidiasis: In immunocompromised patients (e.g., HIV infection),
fluconazole, 150 mg weekly dose.
• Chronic mucocutaneous candidiasis: Requires prolonged therapy.
DEEP FUNGAL INFECTIONS
-MYCETOMA
• Habit of walking bare foot. Males > females
• Sites of predilection:
• Foot
• Less common-hands
• deeper tissues (bones of feet and hands) may cause deformities
• Clinical features:
• subcutaneous nodules, abscesses and draining sinuses
• the surrounding tissue becomes hard due to fibrosis.
• Discharge may be serosanguinous or seropurulent and contains granules
• dark eumycetoma pale actinomycetoma
• Treatment:
• Actinomycetoma--
• 6–9 months course of combination:
• Streptomycin + dapsone or co-trimoxazole.
• Co-trimoxazole + amikacin.
• Tetracyclines + streptomycin + rifampicin.
• Penicillins + gentamycin + co-trimoxazole.
• Eumycetoma--
• Ketoconazole
• Itraconazole.
• Amphotericin B in resistant cases.
• Surgical intervention: Deep debridement and even amputation may need to be done in
case of recalcitrant lesions.
SPOROTRICHOSIS
• Caused by Sporothrix schenckii.
• 2 types:
• Lymphangitic type: asymptomatic nodule which ulcerates.
• A chain of asymptomatic nodules appear along the lymph vessels draining the area
• Fixed: single infiltrated plaque
• Treatment: Saturated solution of potassium iodide. Or itraconazole.
CHROMOBLASTOMYCOSIS
• A painless warty papule, slowly enlarges to form a cauliflower-like hypertrophic

plaque .Characteristically, surface is studded with black
• Sites of predilection: Trauma prone sites.
• Treatment: Itraconazole, flucytosine, and amphotericin B.
SUBCUTANEOUS PHYCOMYCOSIS
• Causative agents: Basidiobolus ranarum and Conidiobolus coronatus.
• Slowly spreading, painless subcutaneous swelling with smooth edge which can be
raised by inserting a finger under it. Does not ulcerate .
• Sites of predilection: two common sites:
• Limbs.
• Centrofacial region.
• Treatment: Potassium iodide
BIBLIOGRAPHY
• Neena Khanna –chapter 14 infections

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FUNGAL INFECTIONS

Systemic fungal • Histoplasmosis

• Keratinophillic fungi living on dead keratin (stratum corneum)

Noninflammatory tinea Inflammatory tinea

• Hyperkeratotic variant: Well-defined scaly plaque on the sole, usually unilateral.

• well-defined plaques or as diffuse erythema of the palms with accumulation of fine

• It is caused by Malassezia furfur, a commensal yeast

Perifollicular , hypopigmented macules with

• Candidal infection may present as:

Acute mucocutaneous candidiasis.

• Morphology: in depth of fold (at sites of friction) as a moist glazed area of

• Candidal balanoposthitis: Presents as fragile papulopustules on glans or coronal

• Habit of walking bare foot. Males > females

• A painless warty papule, slowly enlarges to form a cauliflower-like hypertrophic

• Neena Khanna –chapter 14 infections

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