Fungi

• histoplasmosis
• blastomycosis
• coccidiodomycosis
• paracoccidioidomycosis

Histoplasmosis

• Historian exploring cave
• scene: Disease is spread by bats, especially in caves
• map: endemic to midwestern/central U.S. along MS/Ohio river valley
• coughing: Transmission through respiratory tract

• butterfly: Dimorphic: mold in cold, heat in yeast
• macrophage cage: Histology of macrophage with intracellular oval bodies. KOH stain
• puddle: Macrophage with histoplasma inside, smaller than both RBC/macrophages
• red stone drip: Serum rapid antigen test
• yellow stone drip: Urine rapid antigen test

• wall in the back: lung fibrosis and calcification
• book with TB cacti: Histoplasma may mimic tuberculosis in presentation
• Hilar calcifications: on Xray
• coughing: pneumonia
• pale stones on right with red dots: Erythema nodosum

• cane: Disseminated disease occurs in immunocompromised states
• bull with spots: Hepatosplenomegaly (prevalent with macrophages)

• pinecones: Local or mild infections are treated with "-conazoles"
• amphibians frog under cane: Systemic or disseminated infections are treated with amphotericin

Blastomycosis

• Blast of cannons
• Valley scene and map: Geographic distribution: Great Lakes + Ohio River Valley (more on east coast)
• soldier inhaling smoke: Transmission: Inhalation of aerosolized spores

Great lakes

• Dimorphic butterfly: Yeast in heat, mold in cold
• fused cannon balls: Broad based budding, same size as red blood cell
• yellow river: Detection via urine antigen test

• lung with cannon balls: Chest X-ray has patchy alveolar infiltrates/haziness
• cannon balls in lung: Lesions or cavities in lungs

Systemic:

• statue with craters in chest and rod exposed in leg: Systemic disease affects the SKIN and BONES
• Bone involvement: osteomyelitis
• cane: Immunocompromised

• pine cones on side with nonimmunocompromised solder: Itraconazole for local infections
• frogs around statue: Amphotericin for disseminated infections

Coccidioidomycosis

• Presidio: coccidio
• San juaquin: aka san juaquin fever
• map and scene: Distribution: Southwestern United States
• dust: Route of transmission: inhalation of spores in dust
• cracks in ground: Earthquakes are a risk factor for infection

• butterfly: Cocci is dimorphic. Mold in cold but spherule in body
• red spores in tumbleweeds: Cocci forms spherules filled with endospores inside lungs
• smaller red hat next to tumbleweed: Cocci spherules are larger than red blood cells

• solder sweating, coughing, on ground: Clinical manifestation may look like an acute pneumonia: cough, fever and arthralgias
• lung wall holes, bricks caved in/out: Radiographic images may show either nothing or cavities and/or nodules.
• pillar resembling shins: Cocci is associated with erythema nodosum (only with healthy people, robust immune response)
• cracked skin/leg: Skins and lungs are common sites of infection
• May disseminate to the bone in immunocompromised patients
• guy holding head: Meningitis may be seen in immunocompromised if cocci disseminates to the meninges. Headache/stiff neck
• cane: Immunocompromised

• pinecones: Local lung infection treatment: conazoles
• amphibian frog: Systemic infection treatment: Amphotericin B

Paracoccidioidomycosis basiliensis

• paracocci: pirates
• map: Geographical distribution: South America

• butterfly: Dimorphism
• captain's wheel: Yeast form looks like a "Captain's Wheel". Yeast in body (heat)
• red center of wheel compared to wheel: Bigger than a red blood cell

• coughing: Transmission: respiratory droplets
• white beads: Cervical lymphadenopathy, moves downward
• circular medallion: Progresses to lungs, causing granulomas in lungs
• poor dentation: Mucocutaneous lesions, ragged borders with small hemorrhage

• pinecone: Itraconazole for mild infections
• frogs: Amphotericin for serious infections

Cutaneous Mycoses

• malassezia furfur
• dermatophytes
• sporothrix

Malassezia furfur

• malassezia italian restaurant
• versi di colore sauce: causes Pityriasis Versicolor
• woman wearing fur coat: furfur

• "Spaghetti and meatball" appearance on KOH prep of skin scrapings

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• heat lamps to keep food warm: Flourishes with heat, humidity and sweating

• sauce on chef back and chest: Pityriasis versicolor: hypo- and hyper-pigmented skin patches, located on back and chest (in sun)

• broken bottle of olive oil: Lipid degradation produces acid that damages melanocytes
• corns on top layer of cake: Confined to the stratum corneum, the most superficial layer

• baby with spaghetti: Association of Malassezia fungemia in neonates (in NICU) receiving lipid infusions or TPN through catheters, cause sepsis/thrombocytopenia

• stain glass window with blue sun: Treatment with topical selenium sulfide, also known as Selsun Blue, proding corneum shedding

Dermatophytes

• T, E, M boys: Trichophyton, Epidermophyton and Microsporum

• tin man: Dermatophytes cause tinea, rarely invade
• naked: Dermatophytes infect the skin
• tin man scratching: Pruritic lesions
• aka ring worm because looks like rings of rusts
• rust on head: Tinea capitis is on the head/scalp
• Tinea corporis is on the body
• Tinea cruris is in the groin, also known as "jock itch"
• Tinea pedis is on the foot, also known as "athlete's foot"
• Also nails

• athletic headband: athletes, swimmers walking barefoot, wrestlers at risk
• dog: Animals can be a source of transmission

• sprinkling salt: Diagnosed with KOH prep of skin scrapings
• lamps in woods in trees: "Wood's lamp can be used to diagnose Microsporum "

• pine cones: Treat tinea with topical -azoles

• wizard of oz: Dermatophytes can also cause onychomycosis (nail infections)
• Turban: Terbinafine treats onychomycosis
• can of grease: Griseofulvin treats severe onychomycosis, likes to deposit in keratin tissues. GI SE

Sporothrix schenckii

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• butterfly: Dimorphic
• smoking gardner: Sporothrix look like cigar shaped yeast under a microscope
• branching rose stems: Hyphae are thin and branched, at 25 C

• rose buds: causes "rose gardener's disease".

• green area: Fungus commonly found on tree bark, bushes and other plants
• Spores introduced into body by cuts and wounds

• vines ascending. Vines travel up arm lymph: Infection spreads in an ascending pattern along the path of draining lymphatics. Looks like red bumps on skin

• pinecones: Itraconazole is the drug of choice to treat lymphocutaneous sporotrichosis
• KI pesticides: Saturated solution of potassium iodide may also be used to treat lymphocutaneous sporotrichosis

Opportunistic

• candida
• aspergillus
• cryptococcus
• mucor
• PCP

Candida Albicans

is an opportunistic dimorphic fungus that grows as budding yeast cells, pseudohyphae, true hyphae, or spores. Pseudohyphae are distinguished from true hyphae by the lack of cytoplasmic connection between cells and relative frailty..

For most dimorphic fungi, the mnemonic "mold = cold, yeast = heat" applies. C. albicans is unusual because the mold form grows at 37°C while the yeast form (pseudohyphae and budding yeasts) predominates at 20°C.

Butterfly morphs

Germ tube test

A diagnostic test where a sample of fungal spores are suspended in serum and examined by microscopy for germ tubes, which is an outgrowth produced by spores from fungi during germination. A positive germ tube test is strongly indicative of C. albicans..

Germ tube= true hyphae Snow cones at 37, ice balls at 20

Normal mold = hyphae = cold yeast = budding = hot

Candida mold = hyphae = hot yeast = budding = cold

Normal habitat

Found in the mucous membranes of respiratory, GI, and female genital tracts, with tendencies to overgrow in warm, moist areas..

Part of the normal flora may contaminate sputum cultures

Overgrowth

Can lead to:

• Oral thrush of the mouth that appears as a white exudate on mucous membranes.

• Vaginitis that presents with itching, copious secretion, and “cottage cheese” appearing clumps.

• Cutaneous candidiasis can present as a beefy red rash with satellite pustular lesions in moist intertriginous areas (where two skin areas touch) such as under the breasts, axilla of the arm, or anogenital region. This can also manifest as a diaper rash in infants.

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  • Red diper. Heat and humidity.
  • Immunocompromised or steroid usage
  • KOH: used for scraping prep
  • Adult scraping the snow..

Oral candidiasis risk

Use steroids: Little boy with blue steroid inhaler Use steroids without rinsing the equipment..

Vaginitis risks

• Candies: diabetes

• Drugs: Antibiotics

• Birth control pills all risks for candida

  Teacher getting hit:

Vaginitis typically presents with a normal vaginal pH less than 4.5 versus bacterial vaginosis or trichomonal vaginitis, where vaginal pH may be higher than 4.5..

Open until 4pH

Oral thrush presents as white plaques that can be removed or scraped away. Contrast this with hairy leukoplakia, a manifestation of EBV also present in AIDS patients, which presents as white plaques on the side of the tongue that cannot be scraped off..

In immunocompromised individuals, persistent infection can spread and lead to esophagitis and disseminated candidiasis, which may lead to infective endocarditis..

Pink slides with white snow. Pseudomembrane formation

Endocarditis

3 mountains with hearts: tricuspid valve Commonly seen in IV drug users (in heroine) First valve drug goes to

Candida esophagitis presents as retrosternal pain upon swallowing is considered an AIDS-defining illness. Oral thrush is not considered AIDS-defining. Starts seeing at CD4<100

Max 100 lbs..

T-cell deficient patients are more likely to get superficial Candida infections, whereas neutropenic patients are more likely to have disseminated candidiasis (hematogenous).

Catalase positive cat. CGD: disseminated..

Treatment

Treatment include:

• Nystatin mouthwash and oral fluconazole for thrush and esophagitis

• Topical azoles or oral fluconazole for vaginitis

• Oral fluconazole or any IV echinocandins for disseminated candidiasis. Pinecones for conazoles Play Nyce for oral Frogs, amphibians for immunocompromised Cap on elderly: capsofungin for immunocompromised..

  

Aspergillus fumigatus

• asparagus farm with plane spraying fumes: aspergillus fumigatus

• cat: Catalase positive
• peanut plant with acute angle with septations: Aspergillus hyphae form acute angles and have septations
• ASpergillus: A for acute. S for septation
• peanut plant yellow flower with stalks: Transmission: inhalation of conidiophores, which are "fruiting bodies"

• peanut plant, wheat field: Aflatoxins, toxins produced by Aspergillus flavus, are associated with peanuts and grain crops
• cow with liver spot in front of crab : Aflatoxins may cause hepatocellular carcinoma
• corn, soybean

• hepatocellular carcinoma from aflatoxin
• ABPA, allergic bronchopulmonary aspergillosis
• aspergilloma
• disseminated aspergillosis

• plane with letters. Farmer running/migrating, sweating, inhaler in hand: ABPA (allergic bronchopulmonary aspergillosis) is a type I HSR that causes wheezing, fever and migratory pulmonary infiltrates. Also association with CF patients
• IgE on inhaler: ABPA is associated with asthma and may show increased IgE levels in the serum

• farmer on left. Cactus: fungus balls. Aspergillomas form in cavities, such as in TB/klebsiella cavities. People with cavities in lungs already are at risk
• peanuts underground: Aspergillomas are gravity-dependent, fungus at bottom of cavity on chest xray

• Farmer with cane: Angioinvasive aspergillosis: Immunocompromised. Pts with neutropenia from leukemia/lymphoma
• sprinklers look like vasculatures: Disseminated aspergillosis is angioinvasive. Invades blood vessels and disseminates throughout whole body
• farmer coughing/fever/hemoptysis: symptoms
• scarecrow with spots at kidney, heart, head black spot with ring: Renal failure
• Endocarditis
• Ring-enhancing brain lesion (seizures, focal neuro deficits, with symptoms)
• black nose: Paranasal sinus necrosis, necrosis around nose, also seen in mucor

• pinecones and vortex: Use voriconazole for aspergillus infections, also surgery removal
• frogs: Use amphotericin for serious infections

Cryptococcus neoformans

• Egyptian crypt for cryptococcus
• coffins: Yeast are round and heavily encapsulated
• repeating pattern on coffin: Cryptococcus capsule has a repeating polysaccharide capsular antigen. Main virulence factor for antiphagocytes
• NH3 spray bottle: Urease positive

• pigeons with droppings. Archaeologists coughing: Cryptococcus is inhaled from soil and/or pigeon droppings. Settles in lungs
• cane: Immunocompromised (HIV)

• archaeologists coughing: Pulmonary Crypto causes cough and dyspnea
• Neck brace: Can cause cryptococcosis, a fungal meningitis. Most common cause of fungal meningitis
• sweating: fever

• soap bubbles on lung: Diagnose with a microscopic exam of bronchopulmonary washing
• red and silver stripes: Diagnosis of pulmonary Crypto can be aided by mucicarmine or methenamine silver stain
• vase with bubbling tar: India Ink test can diagnose Crypto meningitis with lumbar puncture/CSF. Background dark, transparent organism
• latex gloves next to repeating patterns: Latex agglutination test detects polysaccharide capsular antigens and causes their agglutination

• soap bubbles on head: Causes "soap bubble" lesions in gray matter

• frogs, pinecone, with flute: flucytosine/amphoterecin B joint treatment with maintenaince fluconazole

Mucormycosis

• Mu Car Rides: Mucor and Rhizopus

• cane: Immunocompromised. Leukemia/neutropenia
• candy: Diabetic and neutropenic patients are at risk of developing Mucor infections
• bread: Rhizopus is a bread mold
• mechanic coughing, fumes: Transmission is through inhalation, proliferate in blood vessel walls where high glucose/ketones are
• Ketone autoparts: Patients in DKA with a high ketone load are at risk of developing Mucor infections

• tire arm at 90 angles without sepate: Hyphae have wide-angle branching and are non-septate

• red jumper cables: Mucor proliferates in blood vessels
• oil pan with holes: Penetrates cribiform plate and enters the brain, leading to rhinocerebral and frontal cortex abscesses
• mechanic with oil on face: Necrotic tissue may present as black eschar on the face. Poor prognosis

• car is a frog: Treat with surgery and amphotericin

Pneumocystis pneumonia

• ping pong: 2 P's, PCP
• Aid for aids: PCP, caused by Pneumocystis jiroveci, is an AIDS-defining illness
• 20 to 0: Increased risk of infection when CD4 count < 200
• respiratory transmission

• cane and coughing: Causes symptoms in immunocompromised people
• no cane, no symptoms: Asymptomatic in healthy individuals
• Causes cough, dyspnea and fever. Not productive like bacteria

• glass tables with cracks: "Ground glass" appearance on chest X-ray
• BAL bottle: Diagnose infection with bronchoalveolar lavage (BAL) sample, easier than lung biopsy
• silver disks at center of table: Use methenamine silver stain on tissue sample to help with diagnosis
• ovoid ping pong: Yeast are ovoid shaped on silver stain

• Back hand: Bactrim, or TMP-SMX, can be used as prophylaxis and treatment
• jar of pin pong balls that look like eggs: Sulfonamides (part of Bactrim) are used for prophylaxis/treatment
• pentagon paddles: Pentamidine is an alternative drug used for prophylaxis and treatment