Vous êtes sur la page 1sur 92

Dermatophytes (1)

Dermatophytes
The outer portion of the skin, called the epidermis,
contains keratin-filled keratinocytes with a
glycolipid intercellular "sealant", which provides a
waterproof coating.
The inner portion of the skin, the dermis, contains
hair follicles, sweat ducts, and oil glands that
provide passageways for microorganisms.
Sebum and perspiration are secretions of the skin
that can inhibit the growth of microorganisms.
Sebum and perspiration provide nutrients for some
microorganisms.
Body cavities are lined with epithelial cells. When
these cells secrete mucus, they constitute the
mucous membrane.

Dermatophytes
Fungi (filamentous) that colonize the skin{ the
outer layer (stratum corneum) of the epidermis}
hair, and nails are called dermatophytes; they grow
on the keratin present in those locations.
Dermatophytes break down and utilize keratin as a
source of nitrogen i.e. they have a unique enzymatic
capacity [keratinase]. (but unable to penetrate the
subcutaneous tissue)
Termed dermatophytes these fungal infections are
more informally known as tineas or ringworm.
Tinea
Ringworm
Clothes moth

Dermatophytes
The disease process dermatophytosis ( is not lifethreatening disease) is unique for two reasons:
Firstly, no living tissue is invaded, the keratinised
stratum corneum is simply colonised.
However, the presence of the fungus and its metabolic
products usually induces an allergic and inflammatory
eczematous response in the host.
The type and severity of the host response is often
related to the species and strain of dermatophyte
causing the infection.
Secondly, the dermatophytes are the only fungi that
have evolved a dependency on human or animal
infection for the survival and dissemination of their
species.

Dermatophytes

The infection is usually


transmitted by contact with
fomites .
Dog and cats are frequently
infected.
Dermatophy
Skin
Hair
Nail
Three
genera
of
fungi
are
tes
involved in
mycosis:
Microsporu
X cutaneous
X
m
Trichophyto
n

Dermatophytes
Basic Characteristics

A. Growth rate
1. 1-4 weeks (medium rate)
B. Identification
1.Clinical: site of infection, UV light.
2. Colony morphology (culture)
3. Microscopic morphology:
Septate hyphae, presence or absence of
macroconidia and microconidia.
Macroconidia: Long, spindle shape, thick wall &
multicellular (microsporum)
M. audouinii , rarely produce Mac/micro.
Trichophyton few Mac/ many micro.
Epidermophyton many Mac/ no micro

Macroconidia and
macroconidia
Macroconidia
and
macroconidia of
dermatophytes

Macroconidia of the dermatophyte


Microsporum (arrows)

Identification of Common Dermatophytes.

Microscopic morphology of the micro and/or macroconidia


is the most reliable identification character, but you need a
good slide preparation and you may need to stimulate
sporulation in some strains.

Culture characteristics such as surface texture, topography

are variable

and pigmentation
and are therefore
the least reliable criteria for identification. Clinical
information such as the site, appearance of the lesion,
geographic location, travel history, animal contacts and
race is also important, especially in identifying rare nonsporulation fungi.
Three genera are recognized:
Epidermophyton: E. floccusum
Smooth thin-walled Macroconidia only present, no
microconidia, colonies a green-brown to khaki color.
Microsporum:

Lactophenol cotton blue staining


of M. canis macroconidia.

Dermatophytes
Epidemiology

World wide disease.


Mora common in tropical & subtropical countries due to
the heat & humidity.
Affect any age
1. Anthropophilic found primarily in man. The common
anthropophilic species are primarily parasitic on man .
They are unable to colonies other animals and they have
no other environmental sources. (e.g. Trichophyton
rubrum).
2. Zoophilic found primarily in animals such as cats and
dogs (man easily infected) Some species may cause
infections in animals and man following contact with soil.
Zoophilic species are primarily parasitic on animals and
infections may be transmitted to humans following contact
with the animal host. (e.g. Microsporum canis).
Zoophilic infections usually elicit a strong host response
and on the skin where contact with the infective animal
has occurred i.e. arms, legs, body or face.

Dermatophytes
Epidemiology
3. Geophilic found primarily in soil , geophilic
species normally inhabit the soil where they are
believed to decompose keratinaceous debris.
Some species may cause infections in animals and
man following contact with soil (e.g. Microsporum
gypseum).
NOTE: Anthropophilic fungi such as Microsporum
audouinii, Trichophyton rubrum, Trichophyton
schoenleinii, Trichophyton tonsurans and
Trichophyton violaceum are unable to colonize
animals, other than man.
They are the only fungi that have developed a
dependency on man for the maintenance and
dissemination of their species.

Mode of transmission
&
Pathogenesis

Dermatophyte infections are usually spread


through direct contact with an infected person or
animal. Clothing, bedding and towels can also
become contaminated and spread the infection.
Symptoms typically appear between 4 and 21
days following exposure.(spores)
Pathogenesis
Spores get access to the skin (stratum corneum),
Germinate, multiply (keratinase) break the
keratin into simple substances.

SKIN
characteristic pattern
of inflammation,
termed an active
border. The
inflammatory response
is usually characterized
by a greater degree of
redness and scaling at
the edge of the lesion
or, occasionally, blister
formation.
Central clearing of the
lesion may be present
and distinguishes
dermatophytoses from
other infections, in
which the inflammatory

Tinea corporis
of the axilla,
with an active
border and

lesion on the
elbow, with a
silvery scale
and no
central
clearing

HAIR AND /OR SCALP


Ectothrix hair invasion
Chains of arthroconidia outside the hair
shaft( spores grow between the hair
sheath and the shaft), Microsporum
Endothrix hair invasion
Chains of arthroconidia inside the hair
shaft(spores grow inside the hair shaft)
Alopecia, or break down keratin
rendering hair brittle

Sites of Infection
Dermatophytes infect different sites of the body, given
the prefix Tinea followed by the Latin name of the site
of infection:
A. Skin
i.Tinea corporis (ringworm of the glabrous (Free from
hair ) skin of the body), excluding feet, groin and hands
ii. Tinea pedis (ringworm of the feet, interdigitale
space) athletes foot
iii. Tinea cruris (ringworm of the groin area) jock itch
B. Hair
i. Tinea capitis (ringworm of hair and/or scalp)
ii. Tinea barbae (ringworm of beard hair)
Iii.Tinea unguium (ringworm of the nails)
Onychomycosis: infection of the nails by any type of
fungi.

Dermatophytes (2)
Host preference
Microsporum -children, rarely
adults
Trichophyton - both children and
adults
Epidermophyton - adults, rarely
children

Tinea pedis
Infections by anthropophilic dermatophytes are
usually caused by the shedding of skin scales
containing viable infectious hyphal elements
[arthroconidia] of the fungus. Athlete's foot
Desquamated skin scales may remain infectious
in the environment for months or years.
Therefore transmission may take place by
indirect contact long after the infective debris
has been shed.
Thus, transmission of dermatophytes like:

Trichophyton rubrum
T. interdigitale
Epidermophyton floccosum is

Tinea pedis
Substrates like carpet and
matting that hold skin scales
make excellent vectors.
Bathrooms, Boots (soldiers),
swimming pools
Tinea is transmitted
via the feet by
desquamated skin
scales in substrates
like carpet and
matting

Tinea pedis
In this site, (foot & interdigitale space) infection is frequently
asymmetrically , and particularly between the third and the
fourth &the fourth and fifth toes.
Are often chronic and may remain subclinical for many years, or
form hyperkeratosis ( excessive scaling of the skin) and spread
to another site, usually the groin or skin.
Infection could also be Acute with formation of vesicles (contain
fluids which contain fungal elements). Uncomfortable.
On of the most common fungal infection , and can be caused by
many microorganisms.
It is important to recognise that the toe web spaces are the
major reservoir on the human body for these fungi and therefore
it is not practical to treat infections at other sites without
starting treatment of the toe web spaces in the same time.
This is essential if a "cure" is to be achieved. (difficult to treat)
It should also be recognised that individuals with chronic or
subclinical toe web infections are carriers and represent a public
health risk to the general population, in that they are constantly
shedding infectious skin scales.

Tinea
pedis

Tinea pedis caused by T. rubrum. Sub-clinical infection (left)


showing mild maceration under the little toe and more severe
infection showing extensive maceration of all toe web spaces

E. floccosum
vesicular type tinea pedis caused by T.
Tinea pedis caused by

(left) and

Tinea capitis
Tinea capitis refers to dermatophytosis of the scalp.
Host preference children.
Source of infection, fomites, poor hygiene &
crowding.
Infection is anthrophilic or Zoophilic.
Three types of in vivo hair invasion are recognised:
1. Ectothrix invasion is characterised by the
development of arthroconidia on the outside of the
hair shaft.
The cuticle of the hair is destroyed and infected
hairs usually fluoresce a bright greenish yellow color
under Wood's ultraviolet light.
Common agents include M. canis, M. gypseum,
(common)
T. equinum and T. verrucosum. (rare)

Tinea capitis
2. Endothrix hair invasion is characterised by the
development of arthroconidia within the hair shaft
only.
The cuticle of the hair remains intact and infected
hairs do not fluoresce under Wood's ultraviolet light.
All endothrix producing agents are anthropophilic e.g.
T. tonsurans (common)and T. violaceum (not common).
3. Favus usually caused by T. schoenleinii, produces
favus-like crusts or scutula (scutulum is a yellow,
saucer like or cup-shaped crust with a cheesy odor,
composed of dense mats of mycelia and epithelial
debris).
Scutula often occur on the scalp and are characteristic
of favus )and corresponding hair loss.(alopecia)

Tinea capitis
Tinea capitis
showing extensive
hair loss caused by
M. canis. .

"Kerion" lesion
caused by M.
A canis.
severe, painful
inflammation of the
scalp. Kerion appears
as soft, raised
swellings that drain

Tinea
capiti
s
caus
ed by
M.
canis
.

Tinea capitis

"Kerion" lesion caused by T. verrucosum


following contact with cattle.

Endothrix tinea capitis (left) caused by T.


tonsurans and "black dot" tinea capitis (right)

Tinea cruris

Tinea cruris refers to dermatophytosis of the


proximal medial thighs (groin), buttocks and
external genitalia.
It occurs more commonly in males and is
usually due to spread of the fungus from the
feet (autoinfection).
Thus the usual causative agents are T.
rubrum, T. interdigitale and E. floccosum,
sharing clothes or sexually transmitted.
Tinea of the groin (jokes itch) showing typical
1-Erythematous (red),
2- itchy lesions on the inner thighs, which can
be spread by nail scratching.

Tinea cruris

Tinea corporis
Tinea corporis refers to dermatophytosis of
the glabrous skin. Non-Hairy areas of the: Trunk, Back, arm, and thigh and may be
caused by anthropophilic species such as T.
rubrum usually by spread from another body
site Lesions are usually round (annular
rings), few, dry, scaly, itchy and difficult to
treat or by geophilic and Zoophilic species
such as M.gypseum andM. Canis, contact
with either contaminated soil or an animal
host, and the lesions are multiple, red,
aggressive (inflamed), but can be treated.

Tinea corporis

Tinea corporis is a dermatophyte


infection of the face, trunk, and
extremities.
In its most common form, it
manifests as pink-to-red annular
patches and plaques with raised
scaly borders that expand

Tinea
corporis,
caused by
M. canis

Tinea unguium
(Dermatophyte Onychomycosis)
Trichophyton rubrum and T. interdigitale are the dominant
dermatophyte species involved.
The use of communal showers and changing rooms. Toe nail fungal
dystrophy is very common in adults
It is important to stress that only 50% of dystrophic nails have a
fungal etiology, therefore it is essential to establish a correct
laboratory diagnosis by either microscopy and/or culture, before
treating a patient with a systemic antifungal agent.
The great toe nails are often the first to be affected.
Dermatophyte onychomycosis may be classified into two main types;
(1) superficial white onychomycosis ,a less common pattern is white
patches or pits on the surface of the nail, and T. interdigitale is
usually responsible for this.
(2) invasive, the involvement usually starts laterally as yellowish
streaks in the nail plate, but gradually the whole nail becomes
thickened, discolored and friable( establishment of the infection
beneath the nail plate), T. rubrum is usually the cause
The fungus invades the distal nail bed causing hyperkeratosis of the
nail .

Tinea unguium

Tinea of the nails caused by


T. rubrum.

Tinea barbae
Tinea barbae (ringworm of beard,
& mustache
Tinea verrucosum
Cause inflammation of the hair
follicles, leads to pus formation
and loss of hair.
Sycosis barbae- staphylococcus

Tinea Manum
Ring worm of the hand is usually
unilateral.
On the palm the appearance is of
mild scaling, and erythema, where
as on the dorsum there is more
obvious inflammatory changes.
The source of infection
is almost the patient feet.

Laboratory Diagnosis
Dermatophyte
s

Skin

Hair

Nail

Microsporu
m

EXCLUDE

Trichophyto
n

EXCLUDE

X
Epidermoph
SAMPLES
ARE:
yton

1- SKIN
SCRAPING
2- SCALPE
SCRAPING

Laboratory Diagnosis
Clinicians should be aware of the need to generate an
adequate amount of suitable clinical material.
Unfortunately many specimens submitted are either of an
inadequate amount or are not appropriate to make a
definitive diagnosis. The laboratory needs enough specimen
to perform both microscopy and culture.
Routine turn around times for direct microscopy should be
less than 24 hours, however culture may take several weeks .
In patients with suspected dermatophytosis of skin [tinea or
ringworm] any ointments or other local applications present
should first be removed with an alcowipe. Using a blunt
scalpel, tweezers, or a bone curette, firmly scrape the lesion,
particularly at the advancing border.
In cases of vesicular tinea pedis, the tops of any fresh
vesicles should be removed as the fungus is often plentiful in
the roof of the vesicle. In patients with suspected
dermatophytosis of nails [onychomycosis] the nail should be
pared and scraped using a blunt scalpel until the crumbling
white degenerating portion is reached.

Laboratory Diagnosis
Any white keratin debris beneath the free edge of the
nail should also be collected.
Skin and nail specimens may be scraped directly onto
special black cards which make it easier to see how
much material has been collected and provide ideal
conditions for transportation to the laboratory.
It must be stressed that up to 30% of suspicious
material collected from nail specimens may be negative
by either direct microscopy or culture.
A positive microscopy result showing fungal hyphae
and/or arthroconidia is generally sufficient for the
diagnosis of dermatophytosis, but gives no indication as
to the species of fungus involved.
Culture is often more reliable and permits the specie of
fungus involved to be accurately identified. Repeat
collections should always be considered in cases of
suspected dermatophytosis with negative laboratory
reports.

Laboratory Diagnosis - Clinical Material


A. Specimen collection

1. Hair: should be plucked, not cut, from the edge


of the lesion.
Choose hairs that fluoresce under a Wood's
lamp or, if none
fluoresce, choose broken or scaly ones (contain
organism). Place infected hair into Petri dish.
Scalp scraping done by using blunt scalpel,
brush, and forceps.
2. Skin: should be washed well (gauze with
alcohol)and then scraped from the margin of the
lesion use a blunt scraper onto folded black
paper. Place skin scrapings into Petri dish
3. Nails: scrapings are obtained from the nail bed
or from infected

B. Direct examination of clinical material

1. 10-20 % KOH
Slide- coverslip, heat

a. For hair, skin and nails


b. Detect presence of fungal elements.
[Look for spores (arthrospores-if produced),
hyphae, mycelium- between epithelial cells in
skin &nails) , in hair spores ].
2. Gram stain
3. LPCB
4. Calcofluor white stain
a. For hair, skin and nails
b. Detect presence of fungal elements

Calcofluor white: fungal


hyphae

Calcofluor white: septate


fungal hyphae

B. Direct examination of clinical


material
3. Woods Lamp
a. For hair only
b. Positive bright yellow-green fluorescence
Microsporum canis Small spored
ectothrix hair invasion.
Microsporum audouinii
c. Negative no fluorescence
Microsporum gypseum
(Large spored ectothrix hair invasion).
Trichophyton species
(endothrix- fungal hyphae inside- T. schoenleinii )

Hyphal elements of Epidermophyton


floccosum in skin scales mounted in
10% KOH

Wood's ultra-violet light. Note simulated greenish-yellow fluorescence in small beaker.

Culture of clinical material

1. Specimen processing
a. Nails are scraped or minced into small
pieces
b. Hair is cut into short segments
2. Media
Generally tube media is used rather than plated
media because:
(1) There is less chance for spore release into the
environment.
(2)Less chance for dehydration.
(3)Ease of storage.
a. Sabouraud's dextrose agar (Sab-Dex)
Classic medium, recommended for most
studies.

Culture of clinical material


1- Rate of growth
2- Colony Morphology (macroscopic features)
Scotch tape preparation
Slide culture
Needle mount
c. Potato dextrose and Cornmeal dextrose
Encourages sporulation & Enhances pigment
production
Pigmentation is due to the color of the
sporulating apparatus. The pigment can be
diffused into the agar
Trichophyton rubrum: red
Trichophyton schoenleinii : yellow
Trichophyton soudanense: yellow

Culture of clinical material


3. Growth requirements
a. Generally 25-30 C
Exception: Trichophyton verrucosum requires 35
C
b. Ambient air
c. Visible growth can occur as soon as 3-4 days,
with mature growth between 1-4 weeks
d. Routine cultures are kept for 4 weeks &
should be examined every other day.
e. Most systemic pathogens require 10 days to
2 weeks, while saprophytic fungi grow usually
grow within 1 week.

Physiologic tests
a. Able to speciate the molds
b. Urea hydrolysis
Incubate 2-3 days on Christensens Urea Agar.
Used to differentiate between Trichophyton rubrum
(negative) and Trichophyton mentagrophytes (positive)
c. Hair perforation test
Sterile hair is incubated at 25C with mold for 10-14 days
in moist chamber
Observe hair microscopically for presence or absence of
conical perforations of the hair shaft Used to differentiate
between Trichophyton rubrum (negative) and
Trichophyton mentagrophytes (positive)
d. Growth on rice grain media
Microsporum audouinii will not grow. All other
Microsporum species will grow
e. Vitamin requirements

Microsporum canis
(LPCB)

Microsporum canis macroconidia


showing rough surface with knob-like
end
(LPCB X1000 Adhesive Tape
Preparation)

Kno
b

Spicule
s

M.gypseum macroconidium showing


rounded apical end and truncated end
where once attached to conidiophore.
Six internal cells or compartments
visible
apical
end

truncat
ed end

M.gypseum clavate
microconidia

Epidermophyton macroconidium

Hyphae may have some specialised


structure or appearance that aid in identification .
Some of these are:

Treatment
Infected skin may be treated with
topical application of antifungal
agents;
Miconazole, Nystatin and
Clotrimazole.
Refractory lesions oral Griseofulvin
and Itraconazole, Terbinafine.
Systemic ( oral) Griseofulvin therapy
is required if it is chronic or
recurrent.
Infections of hair and nails usually

Aspergillus
Aspergillosis is a spectrum of diseases of humans
and animals caused by members of the genus
Aspergillus.
They are ubiquitous in nature and play a significant
role in the degradation of plant material as in
composting.
Similar to Candida The organism is distributed worldwide and is commonly found in soil, food, paint, air
vents.
There are more than one hundred species of
aspergilli, but few have been implicated in human
disease.
The most common etiologic agents of aspergillosis :
Aspergillus fumigatus
A. niger
A. flavus
A. nidulans
A. terreus.

Aspergillus
All grow in nature and culture as mycelial fungi with septate
hyphae and distinctive sporing structures.
Ascomycota
The spore bearing hypha (conidiophore) terminate in a
swollen cell (vesicle) surrounded by one or two rows of cells
(sterigmata) from which chain of asexual conidia are
produced.
Sexual spores are ascospores.
Conidiophore at the end has a terminal vesicles, which
support a single row of phialides on the upper two thirds of
the vesicle.
Conidia are forming long chains .
The septate hyphae show dichotomous branching (45 angle).
And rarely the characteristic sporing heads of Aspergillus are
present.

Aspergillus fumigatus

Aspergillosis
The ability of Aspergillus to establish
disease in human is directly related to
the immunocompromised host.
Leukemia
Chronic infection TB
In patients with AIDS, aspergillosis is
usually restricted to the lungs with a
variety of distinct manifestations.

Aspergillus

Aspergillosis
Is a spectrum of diseases of humans and animals caused by
members of the genus Aspergillus.
These include:
(1) Mycotoxicosis
Due to ingestion of contaminated foods, Fungi ordinarily do not
produce toxins that affect humans. However, Aspergillus flavus is a
notably exception. The aflatoxin produced by this fungus is a
known carcinogenic hepatotoxin
Aspergillosis most frequently affect the lungs,, the disease is
usually caused by A. Fumigatus
Inhalation of Aspergillus spores(conidia) may lead to:
1- Allergic aspergillosis: Allergic bronchopulmonary aspergillosis
(ABPA):
Aspergillus causes inflammation in the lungs and allergy symptoms
such as coughing and wheezing,due to the growth of the fungus in
the airways to produce plugs of fungal mycelium which may block
off segments of lung tissue, and when coughed out is diagnostic.
2- Allergic Aspergillus sinusitis:
Aspergillus causes inflammation in the sinuses and symptoms of a
sinus infection (drainage, stuffiness, headache).

Aspergillosis

2- Fungus ball or Pulmonary Aspergilloma


Colonization in preformed cavities, and debilitated tissue.
Which is characteristically seen in the old cavities of TB patients.
This is easily recognized by x-ray, because the lesion is a compact ball of mycelium
eventually surrounded by dense fibrous wall , (actually a colony of mold growing in the cavity) is
shaped like a half-moon (semi-lunar growth).
The patients may cough up the fungus elements because the organism frequently invades
the bronchus, but usually does not spread to other parts of the body.
Chains of conidia can sometimes be seen in the sputum.
3- Chronic pulmonary aspergillosis:
A long-term (3 months or more) condition in which Aspergillus can cause cavities in the lungs.
One or more fungal balls (aspergillomas) may also be present in the lungs.
4- Invasive aspergillosis,
A serious infection that usually affects people who have weakened immune systems, such as
people who have had an organ transplant or a stem cell transplant.
Invasive aspergillosis most commonly affects the lungs, but it can also spread to other parts
of the body causing systemic and fatal disseminated disease.
The type of disease and severity depends upon the physiologic state of the host and the
species of Aspergillus involved. They may cause endocarditis, otomycosis and cutaneous lesions.
5- Paranasal granuloma
A. flavus & A. fumigatus may colonize and invade the Paranasal sinuses and the infection may
spread through the bone to the orbit of the eye and the brain.
This condition is seen most often in worm dry climates and is common in parts of Sudan
6- Cutaneous (skin) aspergillosis:
Aspergillus enters the body through a break in the skin (for example, after surgery or a burn
wound) and causes infection, usually in people who have weakened immune systems. Cutaneous
aspergillosis can also occur if invasive aspergillosis spreads to the skin from somewhere else in
the body, such as the lungs.

Aspergillus
Laboratory Diagnosis
Direct Microscopy
The fungus appear as non-pigmented septate hypha that usually
show evidence of dichotomous branching (45 angle), and rarely the
characteristic sporing heads of Aspergillus are present.
Wet mounts in either 10% KOH & Parker ink or Calcofluor and/or
Gram stained smears.
Culture
A. fumigatus grow readily at 25-37 C on SDA without cycloheximide,
colonies appear after incubation for 2-6 days.(colonial appearance)
Aspergilli are identified on the basis of colony morphology.
Malt Extract Agar or Czapek Dox Agar at 37C and 25C, and
microscopic examination (foot cells and vesicle are characteristic
of the genus; colony morphology, size, color on both media at
two temperatures; and the microscopic arrangement of conidia;
presence of sexual fruiting body).

Aspergillus
Laboratory Diagnosis
Skin test
A. fumigatus antigen are useful for the
diagnosis of allergic aspergillosis.
Serological Tests
for the detection of antibodies to Aspergillus
species have proven to be of value in the
diagnosis of allergic, aspergilloma, and
invasive aspergillosis. However, they should
never be used alone, and must be correlated
with other clinical and diagnostic data(ELISA).
PCR from BAL and blood samples is being
standardized and validated in reference
laboratories for the early detection of IA.

Treatment
Allergic forms are treated with
corticosteroids
Aspergilloma is treated by
surgical excision or sometimes
with antifungal agents
Invasive aspergillosis, the drug of
choice is intravenous
amphotericin B.

What causes actinomycosis?


Actinomycosis is caused by a family of bacteria
known as actinomyces bacteria. In most cases, the
bacteria live harmlessly on the lining of the mouth,
throat, digestive system and the vagina (in women).
The bacteria only pose a problem if the tissue lining
becomes damaged by injury or disease, allowing the
bacteria to penetrate deeper into the body. This is
potentially serious because the actinomyces
bacteria are anaerobic bacteria, which means they
thrive in parts of the body where there are low
levels of oxygen, such as deep inside human tissue.
However, one advantage of the fact that
actinomyces bacteria are anaerobic is that they
cannot survive outside the human body. This means
that actinomycosis is not a contagious condition.

Actinomyces
Gram-positive bacilli bacteria with branching filaments,
that some times developed into mycelia.
Actinomyces are true bacteria due to the lack of
mitochondria and a nuclear membrane, reproduction
by cell fission and susceptibility to penicillin but not to
antifungal chemotherapeutic agents.
Actinomyces are morphologically similar to Nocardia
except that they Actinomyces are not acid-fast.
Facultative anaerobes, but often fail to grow
aerobically on primary culture, they grow best under
anaerobic or micro-aerophilic conditions with the
addition of 5-10% carbon dioxide.
Mostly soil saprophytes, and occasionally cause
chronic granulomatous infections in animals and man

Actinomyces

Actinomyces

Almost all species are commensal of


the mouth and have a narrow
temperature range of growth around
35- 37 C.
Actinomyces actually means "ray fungus"
in Greek

They are responsible for the disease


known as actinomycosis which in man
is usually caused by Actinomyces
israelli.
Other species, A.bovis, A.viscosus,
A.odontolyticus

Pathogenesis
Actinomycosis is a very chronic
disease characterized by
multiple abscesses and
granuloma, tissue destruction,
extensive fibrosis and the
formation of sinuses.
Within diseased tissues the
actinomycetes from large
masses of mycelia embedded in
an amorphous protein-

Pathogenesis
The mycelial masses may be large
enough to be visible to the naked
eye and, as they are often light
yellow in color, they are called
sulphur granules.
In older lesions the sulphur
granules may be dark brown and
very hard due to the deposition of
calcium phosphate in the matrix.

Pathogenesis

Actinomyces infection from a maseter


abscess opened to the skin

Pathogenesis
In man, about two third of cases of actinomycosis
occur in the:
1- Cervicofacial region and the jaw is often involved.
The disease is endogenous in origin:
Dental is a predisposing factor. An affected human
often has recently had dental work, poor oral
hygiene, periodontal disease, radiation therapy, or
trauma (broken jaw) causing local tissue damage to
the oral mucosa, all of which predispose the person
to developing actinomycosis. Males are affected
more frequently than female and in some regions the
disease is more common in rural agricultural workers
than in town dwellers, probably due to lower
standers of dental care in the former.

Actinomycosis
The Cervicofacial type
Fever
Hard tender lumps with or without
open sinuses mostly in and around
the mandibular region
Sulfur granules in the abscess. (sulfur
granules can be seen in nocardia
infections but those are acid fast)
Wt. loss
Rarely with cervical
lymphadenopathy.

The Cervicofacial type

Pathogenesis
Thoracic actinomycosis
Commences in the lung, probably as a result of aspiration of
Actinomyces of the mouth.
Sinuses often appear in the chest walls and ribs and spine
may be eroded.

Abdominal actinomycosis
Commences in the appendix or, less frequently, in colonic
diverticula.

Pelvic actinomycosis
Occasionally occurs in women fitted with plastic intra-uterine
contra septic devices.
Punch actinomycosis is a rare infection of the hand acquired
by injury of the knuckles.
The lymphatics are not usually involved in actinomycosis but
hematogenous spread to the liver, brain and other eternal
organs occasionally occurs.

Laboratory Diagnosis
Pus from suspected cases is
shaken with sterile water in a tube.
Sulphur granules settle to the
bottom and may be removed with a
Pasteur pipette.
Granules crushed between two
glass slides are used to prepare
Gram- stained films, which relieve
the Gram-positive mycelia

Laboratory Diagnosis
Sulphur granules and mycelia in tissue
sections are identifiable by use of
fluorescein-conjugated specific
antisera. Granules for culture are
washed thoroughly in saline in a tube or
Petri dish, crushed in a drop of saline
with a glass rod, and used to inoculate
brain-heart infusion agar, blood agar
and either glucose broth, enriched
thioglycolate broth or commercially
available Actinomyces broth.

Laboratory Diagnosis
Cultures are incubated, both
aerobically and anaerobically,
with addition to 5% carbon
dioxide for up to 10 days.
After incubation for several
days, A.israielii form so called
spider-colonies which resemble
molar teeth and its identity may
be confirmed by means of
biochemical tests or staining

Molar tooth colony

Treatment
Actinomyces are sensitive to
many antibiotics.
Large doses are required for
prolong period
Surgical interference.
Penicillin is frequently used
Erythromycin also been used
successfully

Mycetoma

Mycetoma

Mycetoma
Is a chronic slowly progressed , painless
granulomatous infection of the skin,
subcutaneous tissues, fascia and bone.
Which most often affect the foot or hand.
Infection is characterized by swelling, purplish
discoloration, tumorlike, and multiple sinus
tract that that drain pus that contain
compacted colonies (grain), whose color
depends on the organism responsible
(madurella grains are black).
Infection gradually progress deeper, and may
lead to amputation .

Mycetoma
It may be caused by one of the two types of mycetoma.
1- Actinomycetoma
(Actinomycetes-bacterial mycetoma)
Caused by species of the aerobic actinomyces,
including:
A- Streptomyces (S. somaliensis)
Produce yellow, small, hard grain resemble sand grain
B- Actinomadura (A. madurae)
Produce big. White soft grain that resemble A. nidulans
C.pelletieri
Produce small soft red grain
D-Nocardia (N. brasilensis)
Produce small, hard creamy grains

Mycetoma
2- Eumycetoma (moulds-fungi mycetoma).
Caused by different groups of fungi have
septate hyphae, include
A- Madurella mycetoma
Common in Sudan, produce big, hard,
black grain.
Madurella grisea black grain.
B- Acremonium
C- Curvularia
D- Aspergillus nidulans

Mycetoma
The disease is most prevalent in the subtropical
regions of Africa, Asia & central America.
Hot and dry for 9 months.
Acacia tree , big thorns, where organism can
grow
Infection follows traumatic inoculation of the
organism into the subcutaneous tissue from soil
or vegetable sources, (thorns).
Male agricultural workers.(minor skin injuries).
Mycetoma is more common in men than women,
particularly those aged 20 to 50.
It generally presents as a single lesion on an
exposed site and may persist for years.
Two thirds arise on the foot.

Mycetoma
Mycetoma is a chronic, suppurative infection of the
subcutaneous tissue and contiguous bone , results from
the traumatic implantation of the aetiologic agent.
Clinical manifestations:
The clinical features are fairly uniform, regardless of the
organism involved.
The feet are the most common site for infection. Other
sites include the lower legs, hands, head, neck, chest,
shoulder and arms.
Most cases start out as a small hard painless nodule which
over time begins to soften on the surface and ulcerate to
discharge a viscous, purulent fluid containing grains.
The infection slowly spreads to adjacent tissue, including
bone, often causing considerable deformity. Sinuses
continue to discharge serosanguinous fluid containing the
granules which vary in size, color and degree of hardness,
depending on the aetiologic species.

These grains are the hallmark of mycetoma.

Mycetoma
Laboratory diagnosis:

1. Clinical Material: Tissue biopsy or excised sinus,


serosanguinous fluid containing the granules which vary
in size, color and degree of hardness, depending on the
aetiologic species., and blood for serology.
2. Direct Microscopy: Serosanguinous fluid containing
the granules should be examined using either 10% KOH
and Parker ink or calcofluor white mounts, and tissue
sections should be stained using H&E, PAS digest, and
Grocott's methenamine silver (GMS).
H&E stained tissue section showing blacked grained
eumycotic mycetoma caused by Madurella mycetomatis.
Interpretation: The presence of white to yellow or black
pigmented grains, from a patient with supporting
clinical symptoms should be considered significant.
Biopsy and evidence of tissue invasion is of particular
importance. Remember direct microscopy or
histopathology does not offer a specific identification of

Laboratory diagnosis
3. Culture: Clinical specimens should
be inoculated onto primary isolation
media, like Sabouraud's dextrose agar.
4. Serology: Immunodiffusion tests
are used. There are currently no
commercially available serological
procedures for the diagnosis of
mycetoma.
5. Identification: Characteristic clinical,
microscopic and culture features

Mycetoma
Treatment
The combination of antifungal for eumycetoma,
along with antibiotics and antimicrobials for
actinomycetoma and surgery, are the gold
standard for the management of mycetoma
patients.
The most popular treatment regimes nowadays for Eumycetoma
are Ketoconazole / Itraconazole for extended periods of time with a
mean duration of 912 months.
These drugs have many serious side effects.
The side effects are more noticeable with Ketoconazole, and these
include hepatotoxicity.
In actinomycetoma, combined medical and surgical treatments are
beneficial.
The current most acceptable treatment options for actinomycetoma
are the combination of amikacin sulfate and cotrimoxazole until
cure.

Mycetoma
Treatment
Surgery for mycetoma
Surgery is indicated in mycetoma for
localized lesions, resistance to medical
treatment or for better response to medical
treatment in patients with massive disease.
The surgical options range from wide local
and debulking excisions to amputations.
Amputation is indicated in advanced
mycetoma not responding to medical
treatment with severe secondary bacterial
infection, and it can be a life-saving
procedure.

Patient with massive actinomycetoma


of the upper limb, before medical
treatment (A)
and after medical treatment (B).
B
A

Eumycetoma lesion
Macroscopic
eumycetoma
lesion
appearance
after
1-year
treatment
with
Itraconazole.
Note the
lesion is well
localized and
encapsulated
with thick
capsule.
Numerous
grain
colonies were