8/2/2019 Mycosis Systemik Opportunistik & Pathogens
1/41
MYCOSIS SYSTEMIK OPPORTUNISTIK
DAN PATOGEN
Oleh :
Dr. dr. Hj. Efrida Warganegara, M.Kes., Sp.MK
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
2/41
SYSTEMIC MYCOSIS : Pathogenic
Diseasea Agent
Blastomycosis Blastomycesdermatitidis
Histoplasmosis Histoplasmacapsulatum
Coccidioidomycosis Coccidioidesimmitis
Paracoccidioidomycosis Paracoccidoidesbrasiliansis
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
3/41
BLASTOMYCOSIS= Notrh American Blastomycosis= Gilchists disease
Etiologic agent :Blastomyces dermatitidis, a dimorphic fungus that grows as mold at
room temperature and as a yeast at 35 - 370C
Epidemiology :
B. dermatitidis is saprophytic in nature & grows in the mold form insoil
or decaying wood associated with soil, has been isolated severaltimes, but repeated isolation from the same sites were not succesful
most of the cases have been found in Noth America, but alsoprevalent in Africa & has been reported in India, occurs most often inadult males
the lack of a specific skin test antigen has prevented the
determination of the prevalence of asymptomatic Blastomycosis inlarge population
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
4/41
BLASTOMYCOSISCxlinical features :
the primary site of Blastomycisis is the lung, withmild infiltrat & few clinical symptoms
in severe disease, pulmonary infiltrate may be more
extensive & the patients will have fever, cough &weight lose, nodular pulmonary lesion may occur
some cases may progres to chronic disease withpulmonary fibrosis & the cavitation
the fungus may disseminate to any organ of thebody, mostly skin & bone
skin lesion are frequently a manifestationofdisseminated disease, with dry & scaly, extensive
granulomatous with vesicle or pustule
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
5/41
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
6/41
BLASTOMYCOSIS
Laboratory diagnosis :
Direct microscopic examination :
wet mount : B. dermatitidis appear as alarge, thick-walled single-budding yeast ( 8- 18 um ), the bud has a wide base
histophatology : the yeast form is usuallyeasily fount in infected tissue, are bestdetected with PAS or GMS stain
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
7/41
BLASTOMYCOSISLaboratory diagnosis :
Culture :
is the dimorphic fungus, that grows in the mycelial form(mold) at room temperature & as a yeast at 370C
the mold form grows slowly, became visible in 7 - 10days, the colony is usually white & cottony
the yeast-like colony grows on blood agar at 370C after 3- 4 days
Microscopic morpology :
the mold produces small, smooth walled conidia &attached to the conidiophores that arise directly from thehyphae
yaest are large, thick-walled, single-budding & the budhas a wide base (neck) the diagnostic
structure of B. dermatitidis
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
8/41
BLASTOMYCOSIS
Serology :
ID test is the most reliable, CFT notdetect antibodies in all cases, will
cross-react with antibodies to H.
capsulatum
Treatment : Amphoterisin B,
Ketoconazole
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
9/41
HISTOPLASMOSIS= reticuloendotheliosis= Darlings disease
Etiologic agent : Histoplasma capsulatum, adimorphic fungus, having a mold form at roomtemperature & yeast form at 370C
Epidemiology : H. capsulatum grows in soil, especially in soil
that esriched with bat or bird manure
often be isolated from old building/caves,where birds/chickens or bats have roosted
H. capsulatum grows in soil in the mycelialform & large number of conidia are produce
the disease is acquired by inhaling conidia &re orted from most area of the world
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
10/41
HISTOPLASMOSISClinical features :
is primarily a pulmonary disease; when conidia are inhaled,infections is established in the lungs; the disease may be mild,
with few or no symptom (95%)
may be severe with lung infiltrates, from mild to extensive
primary pulmonary histoplasmosis progresses to chronicpulmonary disease in about 5 % of those with disease; ischaracterized by fibrosis & cavitation,
symptoms includes : cough, fever, chills & weight lose (resemblesto toberculosis, sarcoidosis, & other systemic fungal disease)
the most severe form of histoplasmosis is disseminated disease;the fungus invade any organs of body
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
11/41
HISTOPLASMOSIS
Laboratory diagnosis :Direct microskopic examination : wet mount :
H. capsulatum may be seen in sputum, bronchialwashed, or in any body fluids as a small yeast, 4 -6 um
histopathology : the yeast form can be found intissue removed from the infected sites, ussuallyin the macrophage & in granulomas
GMS (gomori methenamine silver) stain shouldbe used ( the yeat dark-brown - black )
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
12/41
HISTOPLASMOSISCulture :
colony morphology : H. capsulatum grows slowly in the mold form
when incubated at room temperature, appear in 7 - 10 days butconidia is not form until later; on SDA ( sabouraud dextrose agar )the colony Is ussually white & cottony
microscopic morphology :
two types of conidia are prodeced by H. capsulatum small,pyriform smoth-walled conidia (microconidia, 4 - 6 um ) and large,round, thick-waled tuberculated conidia
( macroconidia, 8 - 18 um ) the diagnostic conidia
to prove the identification of H. capsulatum, convert the mold form- yeast form; be done by transferring the mold colony to blood agar& incubate at 370C in 3 - 5 days the yeast colony will be white
brown
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
13/41
HISTOPLASMOSIS
Serology :
antibodies to the fungus are produced within10 - 21 days after a person is infected by H.capsulatum
agglutination test, measures IgM antibodies, isa quantitative test
CFT, measures both IgM & IgG, is quantitativetest; ID test is a quantitative test
Treatment :
Amphotericin B, Ketoconazole
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
14/41
COCCIDIOIDOMYCOSIS= valley fever
Etiologic agent : Coccidioides immitis, a biphasic fungal pathogen
Epidemiology :
C. immitis grows in semi-acrid, solid, is known to exist in North,Central, & South American, especially California; its inhaled into thealveoli, where it produces disease, either benign ( resembles flu ), or
acute, depending on many factors ( race; inoculum )Clinical features :
most is a benign disease, prodeces only mild symptoms; amongcertain races ( Filipinos, Black ), immunosupressed or the used ofcorticosteroids, disseminated may occur
there is no site of predilection for this organism; any body tissue maybecome infected
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
15/41
COCCIDIOIDOMYCOSIS
Laboratory diagnosis :Direct microscopic examination :
wet mount : specimens in KOHmounts, C. immitis may be seen assporangia
( spherula ) filled with endospora histophatology : the sporangia stain
well with HE & PAS stain
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
16/41
COCCIDIOIDOMYCOSISCulture :Never work with culture on the laboratory bench
OUTSIDE of a biohazard hood !
C. immitis is a biphasic fungal phatogen, grows at roomtemperature repidly producing a dirty gray-white colony;at maturity, the hyphae develops arthroconidia wich
enlarged & barrel-shaped; alternate cells emptythehyphae break easilly into separate artrhoconidia float inthe air spread by the wind
Serology : used as diagnostic & prognostic tools; includeCFT, latex aglutination, ID test
Treatment : Amphotericin B, Ketoconazol
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
17/41
PARACOCCIDIOIDOMYCOSIS= South American blastomycosis
Etiologic agent :Paracoccidioidomycosisbrasiliaensis,
a dimorphic fungus that grows as mold at roomtemperature & as a yeast at 370C / in infected tissues
Epidemiology :
the saprophytic habitat of P. brasiliensis is not known;endemic mostly in South America
most cases of paracodioidomycosis are seen in adultmales; is rare in children
& adult women; appears to reflect a host-parasiterelasionship by sex hormones
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
18/41
PARACOCCIDIOIDOMYCOSIS
Clinical features :
the primarily site of infection is the lung; disease may bebenign, primary pulmonary form or may disseminate toproduce acute & chronic, progresive disease, includes lymphnodes & skin
the primary benign form may ultimately results with someresidual interstitial fibrosis
acute & chronic, progresive paracoccidioidomycosis,disseminated from of the disease, most prequently recognizedon the basic of lesion on oropharynx & gingivae
progresive chronic pulmonary disease may involve all lobes ofthe lung; produce extensive fibrosis
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
19/41
PARACOCCIDIOIDOMYCOSIS
Laboratory diagnosis :
Direct microscipic examination :
wet mount : appears a large, yeast-like cells ( 30 -360 um ), budding with one or more buds (multiple buds ) with narrow necks
histophatology : in infected tissue appears aslarge cells, multiple buds, connected to the
parent cell by narrow necks, it has been called apilot wheel or mickey mouse
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
20/41
PARACOCCIDIOIDOMYCOSIS
Laboratory diagnosis :
Culture :
colony morphology : P. brasiliensis is a dimorphicfungus, grows slowly in the mycelial form at roomtemperature; readily convert to the yeast phase when
grown at 370C on enriched media
microscopic morphology : the mycelial form is thin,septate hyphae, conidia, chlamydospora & arthroconidiamay be formed; yeast phase cultures will demonstrateboth mycelial element & yeast; the yeast arecharacterized by large ( 30 um or more ); multiple-thin-walled buds, with narrow necks
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
21/41
PARACOCCIDIOIDOMYCOSIS
Laboratory diagnosis :
Serology : CFT & ID test have been
shown to be reliable; howevercross reactions may occur
Tretment : Ketoconazole,Amphotericin B, Sulfadiazine
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
22/41
SYSTEMIC MYCOSES
SYSTEMIC MYCOSIS : Opportunistic
Disease Agents
Candidiasis Candida albicans; Candida sp.
Cryptococcosis Cryptococcus neoformans
Aspergillosis Aspergillus fumigatus;Aspergillus sp.
Zygomycosis Mucor, Rhizopus, Absidia
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
23/41
SYSTEMIC MYCOSES
Pathogenic Opportunistic
Agent dimorphic fungus non-dimorphic fungus
Port dentre lung (per inhalation ) lung & others
Disease usually chronic usually acute
Patients could be healthy patients usually illpatient
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
24/41
SYSTEMIC MYCOSESCANDIDIASIS = Candidosis
acute / chronic fungal infections, involving, the mouth,vagina, skin nails, bronchi / lung, alimentary tract,urinary tract, blood steam and less commonly, the heartor meningen
are caused by Candida albicans or other species
are predisposed by : extremes of age, wasting, &nutritional disease, excessive moisture, pregnancy,
diabetes, long-term antibiotics, & steroid use, indwellingcatheter, immunosupressed & AIDS
are generally treated with imidazoles, polyenes or both
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
25/41
CANDIDIASISCandida albicans : is part of the normal flora of the skin, mucous
membranes & GI tract along with other Candidasp.
normal colonization must be distinguised frominfection
form elongated budding forms calledpseudohyphae, which are often seen in clinicalmaterial along with true hyphae, blastoconidia &yaest cells
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
26/41
CANDIDIASIS
Clinical features : oral thrush is a yeast infectoins of the oral mucocutaneus
membranes
manifest as white curd-like patches in the oralcavity
occurs in premature infants; older infantsbeing treated with antibiotics,immunosuppressed patients, long-termantibiotics & AIDS patients
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
27/41
CANDIDIASIS
Clinical features : Vulvovaginitis is a yeast infection of the vagina; manifest with a
thick yellow-white discharge, a burning
sensation, curd-like patches on the vaginalmucosa & inflamation of perineum
is predisposed by diabetes, antibiotic therapy,
oral contraceptive use & pregnancy may be trasmitted to sexual partner as balanitis
CANDIDIASIS
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
28/41
CANDIDIASIS
Clinical features : Cutaneus candidiasis involves the nails ( onychomycosis; paronychis ), skin
folds ( intertriginosa ) or groin ( such as diaper rash )
may be eczematoid or vesicular / pustular; is
predisposed by moist condition
Clinical feature : alimetary tract disease :
is usually an extension of oral thrush & may includeesophagitis & ultimately the entire gastrintestinal tract
is found in patients with AIDS or otherimmunosuppressive disorder, particularly those patientson long-term antibiotics therapy
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
29/41
CANDIDIASIS
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
30/41
CANDIDIASISClinical feature :
Chronic mucocutaneus candidiasis
is a chronic, often disfiguring, infections of the epithelialsurfaces of the body
is diagnosed microscipically & by the lack of cellmediated immunity
Clinical feature :
Bronchopulmonary infections occurs in patient with chronic lung disease; its usually
manifested by persistent cough
CANDIDIASIS
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
31/41
CANDIDIASISClinical feature :
Candidemia / blood borne infections occurs most commonly in patients with indwelling
catheter; these infections are manifested by fever,macronodular skin lesion & endopthalmitis
Clinical feature : Endocarditis
occurs in patient who have manipulated or damagedvalves, or in IV drug abusers
Clinical feature : Cerebrospinal infections
may occur in compromised patients
CANDIDIASIS
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
32/41
CANDIDIASISLaboratory diagnosis :
direct microscopic examination : wet mount of the skin /nail scraping or exudate, demonstration of the presenceof pseudohyphae / hyphae, & yeast in the tissue
culture : of the specimens on to SDA at roomtemperature, Candida will grows as yaest-like colony
C. albicans be identified by :
* germ tube test -- yeast germination in serum at 370C
* culture on corn-meal-agar -- reveals chlamydospres
* culture on Eosin-methylen-blue-agar : reveals spidercolony
* fermentation test of : glucose, lactose, maltose,sacharose
serologic : high levels of Candida precipitins or antigens
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
33/41
SYSTEMIC MYCOSES : Opportunistic
CRIPTOCOCCOSIS
include subacute or chronic fungal infectionsinvolving the lungs, meninges, or lesscommonly the skin, bones & other tissues
most commonly occur as cryptococcalmeningtis; often occuring in AIDS patients
is caused by Cryptococcus neoformans; yeastthat posseses an antigenic polysaccharidaecapsule
is associated with pigeon feces; considered tobe an opportunist in the present of underlyingdisease in patients with Hodgkins disease,leukomias; or leucocyte enzyme deficiency
disease
CRYPTOCOCCOSIS Busse Buschkes disease
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
34/41
CRYPTOCOCCOSIS = Busse-Buschkes disease= European Blastomycosis
Clinical feature : pulmonary infections : are ussually
asymptomatic; & self resolving;
most common in pigeon breeder
meningitis ( most often ) or
meningoencephalitis occurs in AIDSpatients most commonly withheadache, ussually with fever,
followed by typical sign of meningitis
CRYPTOCOCCOSIS
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
35/41
CRYPTOCOCCOSISLaboratory diagnosis :
microscopic examination : wet mount,demonstration of encapsulated yeast in CSFsediment in india-ink
detection of the capsular material in the CSF (the cryptococcal antigen ) by latex agglutinationtest
culture : in SDA ( Sabouraud dextrase agar )revealyeast colony
Treatment : Amphotericin B, 5- fluorocytosisn or
fluconazol
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
36/41
SYSTEMIC MYCOSES : Opportunistic
ASPERGILLOSIS
caaused by Aspergillus fumigatus, an
opportunistic organism
is a ubiquitous filmentous fungus whose
airborne spores are contantly in the air
is recognized both in tissue & in culture by itscharacteristic septate hyphae with
dichotomous branching, produced conidial
heads with numerous conidia
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
37/41
ASPERGILLOSIS
Clinical feature :Aspergilloma = fungus ball :
is a roughly spherical growth of
Aspergillus in pre existing lung cavities &
does not invade the lung tissue
occurs clinically as reccurent hemoptysis& diagnosed by radiologig method
Treatment : surgical ( lobectomy )
ASPERGILLOSIS
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
38/41
ASPERGILLOSISClinical features : Invasive aspergillosis
occurs most commonly during severe neotropenic inleukemia & transplantm patients; most commonly occursas fever of unknown origin in patient with neutropenia
fewer than 500/mm3
& pneumonia
it may begin as sinusitis or lungs; it disseminate to anypart of the body, most frequently brain
is diagnosed by microscopy & culture of lung biopsymaterial
is trested with amphotericin B or intraconzole & has ahigh fatality rate
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
39/41
ASPERGILLOSIS
Clinical features :Allergic bronchopulmonary -aspergillosis
is an allergic disease, in which theorganism colonies the mucous plugs form
in the lung, but does not invade lungtissue
is diagnosed by finding of high titer of IgE
antibodies
SYSTEMIC MYCOSES O t i ti
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
40/41
SYSTEMIC MYCOSES : Opportunistic
ZYGOMYCOSIS = Mucormycosis + Phycomycosis
caused by the genera Rhizopus, Mucor & Absidia;non-septate fungi; phylum Zygomycota; grow repidly& predilection for invading blood vessels & the brain
Clinical features : thoracic infectoins
occur in leukemia & lymphoma patients
abdominal-pelvic infections occurs in malnourish
patients
cutaneus infections occurs in patients withleukemia30
ZYGOMYCOSIS
8/2/2019 Mycosis Systemik Opportunistik & Pathogens
41/41
ZYGOMYCOSISClinical features : Rhinocerebral infections
is the common form; occurs in patients with acidoticdiabetes
presents with facial swelling & blood tinged exudate inthe turbinate bones & eyes; lethargy & fixated pupil
is a fatal infections & spreads rapidly
must be diagnosed rapidly; ussually by a KOH mount of
necrotic tissue or exudate from the eye, nose, or ear
Treatment : control of diabetes; Surgical debridement;
amnphotericin B