Lecture 20

Fungal diseases and antifungals

Objectives
Describe the major classes of fungal diseases superficial, cutaneous, subcutaneous, systemic, mycotoxicoses Differentiate superficial from cutaneous fungal infections lesions, causative agents Define dermatophytes and name the 3 genera of fungi grouped together as dermatophytes Describe the nature of tinea, ringworm Briefly indicate the steps used to identify fungi in the laboratory Appreciate the importance of subcutaneous mycoses and how they occur Briefly describe infections associated with Sporothrix schenkii Differentiate systemic mycoses caused by pathogenic fungi from those caused by opportunist fungal pathogens Understand the geographic associations of pathogenic fungi] Briefly describe infections associated with Histoplasma capsulatum Understand the importance of Candida albicans as an opportunist pathogen and describe infections it causes Briefly describe infections caused by Aspergillus spp Cryptococcus neoformans zygomycetes spp, neoformans, including Penicillium marneffei Briefly desribe non-infectious fungal diseases, particularly mycotoxicoses Describe the anti-fungal activity of disinfectants Describe the sites of action of anti-fungal drugs Describe the modes of action of griseofulvin, polyenes, azoles, allylamines, echinocandins, nikkomycin, sordarins Have an appreciation of the chemical structure of antifungal drugs 2

Fungal infections - myocoses

For many years considered trivial rather than life th t i th lif threatening In recent years fungal infections have become much more important immunocompromised people (transplant patients on immunosuppressive drugs, leukaemia, other cancer patients, diabetics, AIDS
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Fungal diseases of man & animals

Types of fungal diseases 1. 1 Superficial mycoses 2. Cutaneous mycoses 3. Subcutaneous mycosis 4. Systemic mycoses 5. Mycotoxins Fungi can be true pathogens or opportunistic pathogens.
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Superficial fungal infections

Pityriasis versicor caused by Melassezia furfur (a yeast) Mild infection of the skin ranging from white or nonpigmented (darker-skinned people) through to brown (fairer skinned people) No inflammatory response lesions are cosmetic

Cutaneous mycoses
Tinea or ringworm Caused by fungi called dermatophytes Dermatophytes invade the keratinised layers of the skin (superficial epidermis, hair and nails) Most important species are:
Microsporum spp Trichophyton spp Epidermophyton spp Dermatophytes differ in ecological niche and preferred site of infection Geophilic - Microsporum gypseum Zoophilic - Microsporum canis (dogs, cats/scalp, smooth skin) Anthropophilic - Epidermophyton floccosum (foot, groin, nail); Trichophyton p p p p y ( ,g , ); p y rubrum (trunk, foot, groin, nail); Microsporum audounii (scalp); Trichophyton tonsurans (scalp)

Anthropophilic organisms are associated with chronic infections Zoophilic and geophilic organisms are associated with more intense inflammatory reactions.
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Cutaneous infections
Dermatophyte infections are transmitted by p person-to-person contact or by contact with shed p y skin scales or hair clippings (communal showers, sharing hats ) Tinea pedis athletes foot Tinea corporis ringworm anywhere on the body j g Tinea cruris jock itch groin Tinea capitis scalp infections Onchomycosis infection of the nail (can also be caused by other fungi)
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Tinea pedis

Tinea pedis
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Onychomycosis

http://medocs.ucdavis.edu/mmi/

Tinea corporis - Ringworm

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Laboratory diagnosis
Diagnosis based on direct exam of scrapings, culture on selective media

Examine for fungal hyphae and characteristic asexual spores macroconidia Culture colonies also characteristic
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Microsporum canis

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Subcutaneous mycoses
Disease sporotrichosis chromoblastosis h bl t i phaeohyphomycosis mycotic mycetoma subcutaneous zygomycosis i rhinosporidiosis lobomycosis Fungus Sporothrix schenkii Fonsecaea, Cladosporium, Phi l h F Cl d i Phialophora etc, t Cladosporium, Exophiala, Wangiella, Bipolaris, Exserophium, Curvularia, etc, Pseudallescheria, Madurella, Acremonium, Exophiala etc. Basidiobolus ranarum, Conidiobolus coronatus; Rhizopus, M t Rhi Mucor, Rhi Rhizomucor, Absidia, Saksenaea etc Rhinosporidium seeberi Loboa loboi
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http://www.mycology.adelaide.edu.au/Mycoses/Subcutaneous/

Subcutaneous mycoses
Rare in Australia Occur when a fungus penetrates under the skin & establishes an infection Usually caused by soil or plant fungi Introduced when the skin is broken or damaged thorn or splinter gardening Sporothrix schenkii lives on wood & plants Dimorphic fungus mould form in environment; yeast in tissues Causes a chronic granulomatous infection that can spread along lymphatic system

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Systemic mycoses
Caused by pathogenic fungi or opportunistic fungi infecting an immunocompromised host Tend to be free-living dimorphic soil associated Diseases causes by pathogenic species tend t b t d to be restricted to particular ti t dt ti l geographic areas
Many confined to the Americas
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Systemic mycoses pathogenic fungi

Fungus Blastomyces Bl t dermatidis Coccidioides immitis Histoplasma capsulatum Disease Blastomycosis Bl t i Distribution North America N th A i

Coccidioidomycosis Soil; south-west USA; Mexico Histoplasmosis

Central & Eastern USA; South America; ; ; Africa; Australia, parts of East Asia (India & Malaysia

Paracoccidioides Paracoccidioidomycosis brasiliensis

Soil; Latin America

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Histoplasmosis
Histoplasma capsulatum has been reported i A t li t d in Australia
Infections more common in USA (Mississippi Ohio river valley) Associated with inhalation of dust from bat droppings in caves Mycotic infection of the RE system 95% cases inapparent or benign 5% progressive lung disease may be fatal
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 Filamentous mould in environment Budding yeast (2-4 m) in tissue

H. capsulatum - Dimorphism
Thin septate hyphae, microconidia, and tuberculate macroconidia (8 14 m) (8-14 Dimorphic transition is thermally dependent and reversible (25C 37C).

Hyphae, micro- and macroconidia

Yeast within histiocyte

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Opportunistic fungal infections

Fungus Candida spp Aspergillus spp Disease candidiasis aspergillosis Cryptococcal pneumonia & meningitis zygomycosis penicilliosis Distribution/ habitat Human normal flora Ubiquitous; soils. grains birds

Cryptococcus neoformans Rhizopus, Mucor

Soil, plants SE Asia (China, Thailand, India); bamboo rat

Penicillium marneffii

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Candidiasis
Genus Candida - diverse group of yeasts Budding yeast, stain Gram-positive ID based on biochemical tests and morphology (corn meal agar) C. albicans - most important pathogen Multiple forms: budding yeast, true hyphae. Forms germ tubes (pseudohyphae) in presence of serum.

Other Candida spp: C. tropicalis, C. parapsilosis C. lusitaniae, C. krusei, C. glabrata, C. guilliermondii, and C. dubliniensis
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Candidiasis

commonest species is Candida albicans.

Commensal of human mucosal surfaces mouth, vagina, intestinal tract. Can become pathogenic if bodys defence mechanisms are impaired or body s balance of microbial flora upset. Infections can affect skin & mucous membranes (mucocutaneous = thrush) or be systemic.

Oral thrush neonates, corticosteroid puffers, prolonged treatment with antibiotics; Skin folds of obese people, nappy rash in infants Vaginal thrush diabetes, pregnancy, hormonal imbalance, prolonged antibiotic treatment.
Destruction of lactobacilli (normal vaginal flora) allows pH to rise and Candida spp can invade invade.

Systemic candida infection candidaemia

generally in association with severe underlying disease (leukaemia, other cancers; organ transplantation. neutropaenia makes people more susceptible
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Candidiasis

http://www.edison.edu/course_material/

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Figure 21.17

Candida infections

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Aspergillus spp.
More than 100 species of Aspergillus. Septate hyphae branching at 45 angle 45 angle. Omnipresent in environment. A. fumigatus is thermotolerant (up to 55oC) and is found in high concentrations in compost sites. Most human disease caused by A. fumigatus, A. flavus, and A. niger. Opportunistic pathogen, airborne spread

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Aspergillosis
Almost any organ or system in the human body b d may b i be involved l d Spores inhaled lung infection in susceptible patient spread to other parts of the body via the bloodstream potentially fatal abscesses in various organs Major problem in bone marrow recipients
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Cryptococcosis
Cryptococcus neoformans var neoformans encapsulated yeast found in pigeon droppings & other birds; bi d most parts of the world t t f th ld Enters body via respiratory tract mild asymptomatic pneumonitis in most people In immunosuppressed people severe pneumonia
Can spread to brain causing meningitis Occurs in about 80% AIDS patients

Cryptococcal infections more frequently seen in patients receiving steroids or i i i t id immunosuppressive th i therapy Note also Cryptococcus neoformans var gattii associated with flowering Red River gums; infections in Indigenous Australians associated with living in dry river beds
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Cryptococcus neoformans in CSF

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Zygomycosis
Infections caused by Mucoraceae
Mucor, Rhizopus, Absidia Broad nonseptate hyphae, sporangia (rhizoids in some species).
Widespread in environment; found in decaying vegetables and fruits, soil, old bread; grow and sporulate on materials containing carbohydrates. Rhizopus oryzae is most common clinical isolate isolate.

Invasive infections assoc with diabetes, leukopenia and patients treated with steroids or deferoxamine Predilection for blood vessel invasion, thrombosis, infarction

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Only dimorphic species in genus Penicillium Distribution limited to SE Asia, isolated from healthy bamboo rats and surrounding soil Infection probably occurs through inhalation Major cause of opportunistic infections in HIV pts in Thailand - Chronic illness, low-grade fever, wt loss, skin lesions, disseminated infection Intracellular forms resemble H. capsulatum; extracellular forms exhibit septa (cells divide by fission, not budding) Grows as mold at 25-30C Produces soluble red pigment Converts to yeast phase at 37C

Penicillium marneffei

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Penicillium marneffei
http://www.pmarneffei.hku.hk/

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Non-infectious fungal diseases

Allergies - associated with spores of moulds ld Fungal toxins
Ergotism Claviceps purpurea Aflatoxins etc (see table)
Human disease associated with contaminated food often grains and cereals

Poisonous mushrooms
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Mycotoxins and Their Biological Effects

Mycotoxin Aflatoxins Trichothecenes (T-2, nivalenol, deoxynivalenol, satratoxins, DAS*) , ) Biological Effect Hepatocarcinogen Dermal toxicity; impairment of immune system; inhibit p protein synthesis, teratogen* y , g Organism A. parasiticus, A. flavus Fusarium, Acremonium, Stachyobotris, Trichoderma, Trichothecium, , Verticimonosporium

Anthraquinones (luteoskyrin, Hepatotoxic, Penicillium, Aspergillus rugulosin, iridoskyrin, emodin) hepatocarcinogen or mutagen Citreoviridin Neurotoxin; inhibits mitochondrial ATPase activity, reduces glycogen synthetase activity Hepatotoxic Inhibit phe-tRNA synthase Estrogenic, teratogenic Hepatotoxin, decreases hepatic glycogen synthase activity Penicillium

Naphtoquinones (xanthomeganin, viomellein) Ochratoxins Zearalenone (F-2) Chloropeptide (islandi-toxin)

Trychophyton, Penicillium viridicatum Aspergillus, Penicillium Fusarium graminearum Penicillium islandicum

33 *DAS = diacetoxy-12, 13-epoxytrichotece-9-ene

http://medocs.ucdavis.edu/

Treatment of fungal infections

Australian Guidelines for the use of antifungal drugs in the t t tif ld i th treatment of t f invasive fungal infections (July 2003) http://www.racp.edu.au/asid/antifungal/ind ex.htm

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Antifungal activity of disinfectants & antiseptics time to give 99.99% kill

Agent A niger T C albicans mentagrophyte s <2 <2 <2 <2 20 > 20 <2 <2 <2 5 <2 <2
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Phenolic (0.36% < 2 Chlorhexidine (0.02%) Iodine (1%) hypochlorite cetrimide chlorhexidine <2 <2 10 <2 20

Sites of action of antifungal drugs

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History of antifungal drugs

1950s Griseofulvin First azole 1960s Amphotericin B Miconazole Clotrimazole Flucytosine 1970s Econazole Miconazole (IV) 1980s Ketoconazole (po)

1990s Fluconazole Itraconazole Terbinafine Lipid Ampho formulations

2000s Caspofungin Voriconazole

Micafungin Anidulafungin Posaconazole Ravuconazole Sordarins...

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http://www.doctorfungus.org/l

Antifungals
Griseofulvin Inhibits mitosis. Activity limited to dermatophytes. Polyenes (Amphotericin B, nystatin) Bind to ergosterol, disrupt membrane integrity (lower affinity for cholesterol). Active against most fungi; significant toxicity. Azoles (fluconazole, itraconazole) Inhibit P450-dependent demethylase required for synthesis of ergosterol. Active against many fungi. 5-Fluorocytosine Converts to 5-FU, inhibits RNA/DNA synthesis. Resistance develops readily. Used in combinations. Allylamines (terbinafine) Inhibits squalene epoxidase (sterol synthesis). Treatment of nail infections and dermatophytes. p y Echinocandins (caspofungin) Inhibit synthesis of glucans in cell wall. Active against major opportunist infections eg Aspergillus and Candida. Nikkomycin Chitin synthetase inhibitor treatment of Blastomyces and Histoplasma Sordarins - specifically inhibit protein synthesis elongation cycle in yeasts but do not affect protein synthesis machinery in mammalian systems 38

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Antifungal Agents
Spectrum of Activity
http://www.lumen.luc.edu/lumen/MedEd/USMLE/104

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Structure of some important antifungal drugs

Amphotericin B

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Examples of azoles
fluconazole ketoconazole

itraconazole

voriconazole

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Structure of some important antifungal drugs

caspofungin
5 fluorocytosine

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Some important antifungal drugs

griseofulvin

terbinafine

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