SUBCUTANEOUS MYCOSES

SUBCUTANEOUS MYCOSES
• The fungi that cause subcutaneous mycoses
normally reside in soil or on vegetation.
• They penetrate the skin to the subcutaneous tissue
by traumatic inoculation with contaminated
material.
• The lesion then becomes granulomatous and
expands slowly from the area of implantation.
• This may extend into the lymphatics and they are
usually confined to the subcutaneous tissues.
However, they may become systemic and produce
life-threatening diseases in rare cases.
 1/ Sporothrix schenckii (sporotricosis)
• Sporothricosis is usually a chronic infection of
subcutaneous tissue, which tends to suppurate,
ulcerate and drain.
• It is a dimorphic fungus and is associated with a
variety of plants.
• The infection is also known as “rose grower’s
disease”.
CLINICAL FEATURES:
Most times, it follows a history of thorn prick on
the thumb of a gardener.
 1) SUBCUTANEOUS FORMS:
• A pustule usually develops at the point of
inoculation, which will ulcerate.
• It may remain localized or will infect the lymphatic
system and from there, the disease will progress up
to the arm with ulceration, abscess formation,
break down of the abscess, discharge of pus and
healing. The progression will usually stop at the
axilla.
• A fixed (plaque) form which does not spread locally
and can spontaneously resolve.
 2) EXTRA CUTANEOUS FORM:
• Osteoarticular infections involve the extremities,
e.g. elbow, hand, foot, not the hip, shoulder &spine.

• Most present with primary involvement of a single

joint which is swollen and painful.

• Other joints may become involved without therapy.

• Repeated joint aspiration and culture or synovial

biopsy may be necessary to make a diagnosis.
 A) Pulmonary Sporothricosis:
• one third of patients affected are alcoholic, one third
have pre-existing illness (such as diabetes, sarcoidosis)
and the last one third are healthy.
• They may be asymptomatic but productive cough,
fever and weight loss are common.
• The inflammatory markers are raised.
• Chest x-Ray may reveal cavitations with or without
hilar lymphadenopathy and effusions.
 B) Patients with HIV:
• Those with low CD4 counts are at greater risk of
widespread ulcerative skin lesions and systemic
dissemination.
• The presentation may be with arthritis and
resemble seronegative arthropathies.
• Visceral involvement may occur, such as
meningitis, lung abscess, liver and spleen, bone
marrow, sinus invasion etc.
 Laboratory specimens:
• Pus, Biopsy material and Sputum
Laboratory diagnosis:
• The yeast form of this fungus in tissue or culture,
can be round (6-8um) or fusiform, but if cigar-
shaped yeast is observed in tissue, it is usually
diagnostic of Sporothricosis.
• At 37oC Sporothrix schenckii grows as white pasty
yeast with small round to oval forms (3-10um).
• At 25oC, this colony is white- cream and very
membranous but as it ages (2-3weeks), it becomes
black and leathery.
Sporothrix schenckii
Sporothrix schenckii
 MICROSCOPY
• A branching mycelium that is about 2-3 um in
diameter with a very delicate septate is seen.

• The pyriform conidia, about 2-4 um in

diameter, form typical arrangements in radial
groups at the end of a conidiophores called
daisies.
 CULTURE
• The specimens are streaked on Sabouraud Dextrose
Agar (SDA) containing antibiotics, incubated at 25-30C.
• The identification is confirmed by the growth at 35C
and conversion to the yeast form.
• NB: biopsy is the best.

SEROLOGY:
• The agglutination test
• latex agglutination test
 2) Chromoblastomycosis:
• This is a chronic, localized infection of the
subcutaneous tissues that is caused by several
species of the dematiaceous (black pigmented -
melanized) fungi which produces verrucous lesions.
• The infection results from
traumatic inoculation by
fungal agents that reside in
soil and vegetation.
 PATHOGENESIS
• The fungi are introduced into the skin by trauma,

mostly of the exposed legs or feet.

• Over months to years, the primary

lesion becomes verrucous and wart-like with

extension along the draining lymphatics.

• Cauliflower-like nodules and crusting abscesses

eventually will cover the area.

• A secondary infection can lead to elephantiasis.

Spread to other parts of the body is rare but

satellite lesions can occur due to either local

lymphatic spread or to auto-inoculation.

CLINICAL FEATURES:
• The lesions can appear along time post
inoculation.
• The primary lesion is usually a small pink
papule that may itch and is followed (possibly
many months later) by violaceous nodules, or
firm tumours.
• These tend to enlarge and form
groups with ulcerations and dark
haemopurulent material on the
surface.
• Some people may develop annular, popular lesions
with active edges and healing in the centre which
can become scarred, or form keloid.
• Fibrosis and oedema of the affected limb may
occur in severe cases.
 DIAGNOSIS:
• The specimens used in diagnosis are pus or tissue.
• All forms of disease produce characteristic sclerotic
bodies which may be identified on biopsy along
with pyogranuloma and micro abscesses.
• Microscopy of exudates may reveal hyphal strands.
• Culture is necessary to confirm identity and may
take 6 weeks.
• There are no serological
tests to aid diagnosis.
 3) Eumycetoma (Madura foot )
• Mycetoma is a chronic subcutaneous infection .
• They appear like tumors and they will invade
contiguous tissues such as bone.
• They usually affect the hands and feet with serous
discharges containing small grains of organism colonies.
• The causative organism is:
1. Leptosphaeria senegalensis & Leptosphaeria
tompkinsiiare common causes in West Africa.
2. Madurella grisea is common in South America.
3. Pseudallescheria boydii is the causative organism in
USA.
Eumycetoma (Madura foot )
 Pathogenesis
• The soil fungi penetrate tissues of the foot or
hand after local trauma and the infection spreads
along tissue planes, destroying connective tissues
and bone.

• Inflammation and scarring formed, lead to

enlargement and disfiguring of the infected area.
 Clinical features
• It is seen mostly in men between 20-40 years of
age who are farmers .
• The feet are most commonly affected, then the
hands, legs, arm head thigh and the back.
• It starts with a small painless nodule, which
quickly increases in size and ruptures forming a
sinus.
• The cycle of swelling, discharge and scarring leads
to a swollen mass of deformed tissue with
multiple discharging fistulae.
• Lymphatic spread to regional lymph nodes
may occur, leading to the invasion of cortex of
bones.

• There will be osteolytic lesions on X-ray with

pathological fractures (rare).

• Once there is fever, it depicts

secondary bacterial infection.

 Laboratory diagnosis:
• The granules may be black, white, yellow, red or
pink, depending on the causative organism, e.g.
white to yellow grains are seen with [Link] .

• Tissue grain stain can detect the fine branching

hyphae and chlamydospores.

• They can be cultured for more-exact diagnosis-

biopsy specimens are best to avoid contamination.
Laboratory diagnosis:
 4) Mucormycosis ( Zygomycosis)
• This is a clinical syndrome caused by a group of
fungal species that belong to the order Mucorales
(Zygomycetes).
• MYCOLOGY: They are spore forming and they
grow rapidly in mould forms in both tissues and
the environment. The common species include
Rhizopus, Rhizomucor, Absidia, and Mucor.
Microscopy allows a degree of speciation (e.g.
appearance of the columellae and rhizoids if
present).
Diagram of major differentiating morphologic features of three of the most
common Mucorales isolated from patients.
Note the presence and location of rhizoids, the columella, and the shape of the
sporangia. The infectious spores reside within the sporangia.
 PATHOGENESIS
• Infection is acquired via the respiratory tract, or in primary
Cutaneous infection, via the inoculation of spores into skin
abrasions.
• Spore germination follows in hosts whose immune
response is deficient (hyperglycaemia, acidosis, HIV/AIDS
patients )
• Macrophages and neutrophils are important in preventing
growth, and normal human serum is fungistatic.
• Hyphae invade tissues, penetrate blood vessel walls &grow
along the vessel contributing to thrombosis &necrosis.
 CLINICAL FEATURES
1) Rhinocerebral disease:

• This is a disease of the immunosuppressed patient

• The infection leads to septic necrosis and infarction

of the tissues of the nasopharynx and orbit.

• The patient develops facial pain or headache with

fever and may have orbital cellulitis and
conjunctival swelling.
• There may be cranial nerve defects with a black
crusty material that is apparent in the nasopharynx.

• The invasion of vessels may lead to retinal artery

thrombosis and visual impairment.

• Other complications are ptosis, pupil dilatation,

cerebral abscess, cavernous sinus and internal carotid
artery thrombosis.

• X- ray of the sinuses may show mucosal thickening

and fluid & bone destruction may be obvious on CT.
Clinical features of rhinocerebral
disease:
2) PULMONARY DISEASE
• This is usually secondary to neutropenia and seen
in Bone marrow transplant (BMT) or leukemia
patients receiving chemotherapy.
• The symptoms are initially mild, with fever,
shortness of breath and cough.
• On progression, there is haemoptysis and erosion
of a blood vessel, leading to pulmonary
hemorrhage.
• CXR (chest radiograph)may show infiltration,
consolidation and cavities.

• Infection may start in one lung segment but

often disseminates in the late stages (e.g.
multiple lung area, spleen and kidney).
3) Cutaneous disease

• The outbreak of this infection has been

associated with colonized bandages.

• The appearance is of cellulitis but if

unrecognized, the organism may penetrate
deeper into the skin with a resultant
necrosis, following vascular invasion.
• Dissemination may follow and it may take the

appearance of a chronic ulcer.

• Some cases have occurred with minor trauma

(e.g. gardeners), major trauma, burns and

insect bites. Skin lesions may also develop

following dissemination from a distant site.

CUTANEOUS DISEASE
4) GASTROINTESTINAL DISEASE

• This is seen in those suffering from

malnutrition although cases have occurred in
renal transplant recipients.

• Any part of the tract may be infected and it is

rapidly fatal. Symptoms include abdominal
pain, fever, nausea and vomiting.
5) CENTRAL NERVOUS SYSTEM DISEASE
• This is rare and is usually due to direct invasion
from infected sinuses.
• Cases have occurred in leukaemia and open head
trauma.
• Presentation is with decreasing levels of
consciousness and multiple focal neurological
deficits.
• Other organs may be affected resulting to
endocarditis, osteomyelitis, renal infection and
allergic sinusitis
 DIAGNOSIS
• Clinical suspicion should be raised by the presence
of vascular invasion and tissue necrosis which may
manifest as black eschars and discharges.

• Lesions may be apparent only on the nasal mucosa

and palate.

• The diagnosis rest on identifying the organism on

biopsy.
• Swabs are insufficient.

• Non septate branching fungal hyphae can be seen

on routine haematoxylin and eosin (H&E) stains and
it will help to distinguish it from Aspergillus.

• There is usually an associated neutrophilic infiltrate

and tissue necrosis may follow blood vessel invasion
with an inflammatory vasculitis.

• Organisms rarely appear in blood cultures.