DERMATOPHYTOSISDERMATOPHYTOSIS( Ti Ri )( Ti Ri )(=Tinea = Ringworm)(=Tinea = Ringworm)

Infection of the skin, hair or nails Infection of the skin, hair or nails caused by a group of keratinophilic caused by a group of keratinophilic caused by a group of keratinophilic caused by a group of keratinophilic fungi, called dermatophytesfungi, called dermatophytes

¨̈ MicrosporumMicrosporum Hair, skinHair, skinMicrosporumMicrosporum Hair, skinHair, skin¨̈ EpidermophytonEpidermophyton Skin, nailSkin, nail

T i h h tT i h h t H i ski ilH i ski il¨̈ TrichophytonTrichophyton Hair, skin, nailHair, skin, nail

DERMATOPHYTESDERMATOPHYTESDERMATOPHYTESDERMATOPHYTES

Digest keratin by their Digest keratin by their keratinaseskeratinaseskeratinaseskeratinasesResistant to cycloheximideResistant to cycloheximideClassified into three groups Classified into three groups depending on their usual habitatdepending on their usual habitatdepending on their usual habitatdepending on their usual habitat

All three dermatophytes contain p yvirulence factors that allow them to invade the skin, hair, and nails

KKeratinases

Elastase

Proteinases

DERMATOPHYTESDERMATOPHYTESDERMATOPHYTESDERMATOPHYTES

ANTROPOPHILICANTROPOPHILICTrichophyton rubrumTrichophyton rubrumTrichophyton rubrum...Trichophyton rubrum...GEOPHILICGEOPHILICM M Microsporum gypseum...Microsporum gypseum...ZOOPHILICZOOPHILICMicrosporum canisMicrosporum canis: cats and dogs: cats and dogsMicrosporum nanumMicrosporum nanum: swine : swine Microsporum nanumMicrosporum nanum: swine : swine Trichophyton verrucosum:Trichophyton verrucosum: horse and horse and swine…swine…

Zoophilic dermatophytes

Microscopic characteristics of dermatophyte genera

Microsporum Epidermophyton Trichophyton

DERMATOPHYTOSISDERMATOPHYTOSISP h i d I iP h i d I iPathogenesis and ImmunityPathogenesis and Immunity

d d Contact and traumaContact and traumaMoistureMoistureMoistureMoistureCrowded living conditionsCrowded living conditionsCellular immunodeficiency Cellular immunodeficiency

(chronic inf.)(chronic inf.)( )( )ReRe--infection is possible (but, infection is possible (but, larger inoculum is needed the larger inoculum is needed the larger inoculum is needed, the larger inoculum is needed, the course is shorter )course is shorter )

DERMATOPHYTOSISDERMATOPHYTOSISl l l fl l l fClinical ClassificationClinical Classification

Infection is named according to Infection is named according to the anatomic location involved:the anatomic location involved:

a. Tinea barbaea. Tinea barbae e. Tinea pedis e. Tinea pedis (Athlete’s foot)(Athlete’s foot)(Athlete s foot)(Athlete s foot)

b. Tinea corporis f. Tinea manuumb. Tinea corporis f. Tinea manuumc Tinea capitis c Tinea capitis Tinea un uium Tinea un uiumc. Tinea capitis c. Tinea capitis g. Tinea unguiumg. Tinea unguiumd. Tinea cruris d. Tinea cruris

(Jock itch)(Jock itch)

DERMATOPHYTOSISDERMATOPHYTOSISCli i l if iCli i l if iClinical manifestationsClinical manifestations

Skin:Skin: Circular, dry, Circular, dry, erythematous scaly itchy lesions erythematous scaly itchy lesions erythematous, scaly, itchy lesions erythematous, scaly, itchy lesions Hair:Hair: Typical lesions,”kerion”, Typical lesions,”kerion”,

i “ l i ”i “ l i ”scarring, “alopecia”scarring, “alopecia”Nail:Nail: Thickened, deformed, Thickened, deformed, , f m ,, f m ,friable, discolored nails, subungual friable, discolored nails, subungual debris accumulation debris accumulation debris accumulation debris accumulation FavusFavus (Tinea favosa)(Tinea favosa)

DERMATOPHYTOSISDERMATOPHYTOSIST i iT i iTransmissionTransmission

Close human contactClose human contactSharing clothes, combs, brushes, Sharing clothes, combs, brushes, towels, bedsheets... (Indirect)towels, bedsheets... (Indirect), ... ( ), ... ( )AnimalAnimal--toto--human contact human contact (Zoophilic)(Zoophilic)(Zoophilic)(Zoophilic)

DERMATOPHYTOSISDERMATOPHYTOSISDi iDi iDiagnosisDiagnosis

l l l lI. ClinicalI. ClinicalAppearanceAppearanceAppearanceAppearanceWood lamp (UV, Wood lamp (UV, 365 365 nm) nm) II. Lab II. Lab A Direct microscopic examinationA Direct microscopic examinationA. Direct microscopic examinationA. Direct microscopic examination((1010--2525% KOH)% KOH)Ectothrix/endothrix/favic hairEctothrix/endothrix/favic hair

DERMATOPHYTOSISDERMATOPHYTOSISDi iDi iDiagnosisDiagnosis

B CultureB CultureB. CultureB. CultureMycobiotic agar Mycobiotic agar

b d d b d d Sabouraud dextrose agar Sabouraud dextrose agar

DERMATOPHYTESDERMATOPHYTESId tifi tiId tifi tiIdentificationIdentification

A. Colony characteristicsA. Colony characteristicsB Microscopic morphologyB Microscopic morphologyB. Microscopic morphologyB. Microscopic morphology

MacroconidiumMacroconidium MicroconidiumMicroconidiumMicrosporumMicrosporum fusiformfusiform (+)(+)MicrosporumMicrosporum--------fusiformfusiform------------------------------(+)(+)EpidermophytonEpidermophyton clavateclavate----------------------------------((--))TrichophytonTrichophyton---- --(few)cylindrical/ (few)cylindrical/ ------ ----(+) (+) TrichophytonTrichophyton (few)cylindrical/ (few)cylindrical/ (+) (+)

clavate/fusiform single, clavate/fusiform single, in clustersin clusters

DERMATOPHYTESDERMATOPHYTESId ifi iId ifi iIdentificationIdentificationC Ph i l i l t tC Ph i l i l t tC. Physiological testsC. Physiological tests

In vitro hair perforation testIn vitro hair perforation testSpecial amino acid and vitamin Special amino acid and vitamin requirementsrequirementsU h d l iU h d l iUrea hydrolysisUrea hydrolysisGrowth on CMA Growth on CMA 11% glucose medium% glucose mediumGrowth on polished rice grainsGrowth on polished rice grainsTemperature tolerance Temperature tolerance

DERMATOPHYTOSISDERMATOPHYTOSISTreatmentTreatment

Topical Topical Miconazole clotrimazole Miconazole clotrimazole Miconazole, clotrimazole, Miconazole, clotrimazole, econazole, terbinafine...econazole, terbinafine...llOralOral

GriseofulvinGriseofulvinffKetaconazoleKetaconazoleItraconazoleItraconazoleItraconazoleItraconazoleTerbinafineTerbinafine

Routine Laboratory Turn Around TimesRoutine Laboratory Turn Around TimesManagement of Cutaneous fungal infections. Management of Cutaneous fungal infections. David Ellis, Mycology Unit, Women’s and Children’s Hospital, Adelaide.David Ellis, Mycology Unit, Women’s and Children’s Hospital, Adelaide.www.mycology.adelaide.edu.auwww.mycology.adelaide.edu.auwww.mycology.adelaide.edu.auwww.mycology.adelaide.edu.au

TotalIdentificationCultureDirect MicroOrganism

2-3 days3 hrs48 hrs24 hrsC. albicans

5-8 days72-96 hrs48 hrs24 hrsOther Yeasts

14-42 days1-28 days14-28 days24 hrsDermatophytes

5-42 days1-28 days5-28 days24 hrsOther Molds

REPORT OF LABORATORY INVESTIGATION “Medical Mycology”

Patient’s name: Lab no : Date: Sender:Patient s name: Lab no.: Date: Sender: Source: Scalp scales/ scalp hair/ skin scales/ toenail/ fingernail/ toewebs/ groin/ …

Ι- Direct Examination: □ KOH 10% preparation □ Blue de methylene staining □ Scotch tape method *Positive Result: Fungus elements present in skin, Nail and scalp: □ Typical dermatophyte hyphae breaking up into arthroconidia (Dermatophytosis) □ Branching filaments (Dermatophytosis)g ( p y )□ Septate, branched hyphae and budding cells (Malassezia furfur or other Malassezia spp.) □ Budding cells in different size & shapes (Malassezia furfur or other Malassezia spp.) □ Pseudohyphae and budding cells (Candidiasis) □ Long filaments, small coccoid forms and rod-like organism (Corynebacterium minutissmum) □ Only Budding cells (Candida spp., Saccharomyces spp., or other true yeasts) Fungus elements present in scalp hair: □ spores outside the hair shaft (Ectothrix) □spores inside the hair shaft (Endothrix) □ mycelium and arthrospores inside the hair shaft (Favus) *Negative Result: □ Fungal elements not present.

II- Culture: □ Fungus not Isolated. □ Specimen/ Culture Unsatisfactory.□ Organism(s) Isolated/ Identified: . . . . . . . . Comment: Medical Mycologist (PhD)

طريقه گزارش نتيجه آزمايش قارچ شناسی طريقه گزارش نتيجه آزمايش قارچ شناسی

DirectDirect MicroscopyMicroscopy-- (KOH (KOH 1010% preparation)% preparation) : : p p )p p )

Typical Typical dermatophytedermatophytehyphaehyphae breaking up into breaking up into

arthroconidiaarthroconidiaarthroconidiaarthroconidia((DermatophytosisDermatophytosis).).

Direct MicroscopyDirect Microscopy-- (KOH (KOH 1010% preparation)% preparation) : :

TypicalTypical dermatophytedermatophyteTypical Typical dermatophytedermatophytehyphaehyphae is present. is present.

طريقه گزارش نتيجه آزمايش قارچ شناسی طريقه گزارش نتيجه آزمايش قارچ شناسی

Di t MiDi t Mi (KOH(KOHDirect MicroscopyDirect Microscopy-- (KOH (KOH 1010% preparation)% preparation) : : Branching Branching hyphaehyphae is is

present (compatible withpresent (compatible withpresent (compatible with present (compatible with DermatophyticDermatophytic

mycelium).mycelium).

Direct MicroscopyDirect Microscopy-- (KOH (KOH 1010% ti )% ti )1010% preparation)% preparation) : :

Typical Typical dermatophytedermatophytehyphaehyphae is present. is present.

Di t MiDi t MiDirect MicroscopyDirect Microscopy--(KOH (KOH 1010% %

preparation)preparation) : Branching : Branching hyphaehyphae is presentis presenthyphaehyphae is present is present (compatible with (compatible with DermatophyteDermatophyte).).

Direct MicroscopyDirect Microscopy--(KOH (KOH 1010% %

preparation)preparation) : Typical: Typicalpreparation)preparation) : Typical : Typical dermatophytedermatophyte hyphaehyphae is is

present. present.