ENDEMIK MIKOSIS ( SISTEMIK...

JAMUR-JAMUR PENYEBAB

ENDEMIK MIKOSIS ( SISTEMIK MIKOSIS)

CoccidioidomycosisCoccidioidomycosis

Valley Fever, San Joaquin Fever, Desert Rheumatism

CoccidioidomycosisCoccidioidomycosisCoccidioidomycosisCoccidioidomycosis

• Coccidioidomycosis is also known as • Coccidioidomycosis is also known as valley fever, San Joaquin fever, and desert rheumatismdesert rheumatism

Center for Food Security and Public Health Iowa State University - 2004

OverviewOverviewOverviewOverview

• Organism• Organism• Economic Impact

Epidemiology• Epidemiology• Transmission• Clinical Signs• Diagnosis and Treatmentg• Prevention and Control • Actions to take

• Actions to take

• Coccidioidomycosis results from direct inhalation of the spores of the dimorphic fungus Coccidioides the spores of the dimorphic fungus Coccidioides immitis from the soil or from dust in the air. C. immitis has both a saprophytic and parasitic phase in its life cycle. It grows as a mold in the soil, and when disturbed, the hyphae fragment forms a durable disturbed, the hyphae fragment forms a durable structure called arthroconidia which becomes airborne. When the arthroconidia are inhaled, they transform into thick-walled multinucleate spherules that then separate to produce thousands of

d hi h h d h lp p

endospores, which can then produce a new spherule ands begin the cycle anew. Photo on top hyphae and arthroconidia. Photo on bottom spherules containing endospores. Photo source: http://botit botany wisc edu/toms fungi/jan2002 hthttp://botit.botany.wisc.edu/toms_fungi/jan2002.html

The OrganismThe Organism

Coccidioides immitisCoccidioides immitisCoccidioides immitisCoccidioides immitis

• Dimorphic fungus• Dimorphic fungus−Saprophytic phase−Parasitic phaseParasitic phase

• From soil or dustArthroconidia become −Arthroconidia become airborne, inhaled

−Transform into Transform into spherule and endospore

CoccidioidesCoccidioides immitis

LifecycleLifecycle phases

ImportanceImportance

HistoryHistoryHistoryHistory

• 1892: First reported as disease• 1892: First reported as disease• 1920-1930

Soil recognized as reservoir for agent−Soil recognized as reservoir for agent

• 1987CDC dd idi id i t l −CDC adds coccidioidomycosis to annual survey of HIV-associated diseases

1991 1995• 1991-1995− Incidence increases tenfold in San

Joaquin Valley CACenter for Food Security and Public Health

Iowa State University - 2004

Joaquin Valley, CA

Economic ImpactEconomic ImpactEconomic ImpactEconomic Impact

• Infection is costly• Infection is costly−Time lost from work−Direct medical costsDirect medical costs

• 1990: Kern County, CACost more than $66 million−Cost more than $66 million

• Costly to livestock industryI f ti b id d− Infection can be widespread

−Diagnosis/treatment can be significant

EpidemiologyEpidemiology

Geographic DistributionGeographic DistributionGeographic DistributionGeographic Distribution

• Endemic areas• Endemic areas−Southwestern U.S.

New Mexico, Texas, New Mexico, Texas, California, Arizona

−Northern Mexico−Central America−Argentina

• 10-50% skin test positive

Morbidity/MortalityMorbidity/MortalityMorbidity/MortalityMorbidity/Mortality

• Two forms in humans• Two forms in humans−60% asymptomatic

Only identified with positive skin testOnly identified with positive skin test

−40% mild to severe diseaseCan be fatalImmuno-compromised persons highly susceptible to serious infection

Diffi lt t bidit i • Difficult to assess morbidity in animals

TransmissionTransmission

Animal TransmissionAnimal TransmissionAnimal TransmissionAnimal Transmission

• Direct inhalation of C immitis spores • Direct inhalation of C. immitis spores from soil or dust−Rare animal-to-animal transmissionRare animal to animal transmission

Placental infection reported in horses

− Incidence increases after disturbance

• Dusty conditions−Most bovine infections contracted from Most bovine infections contracted from

dusty feedlot

Human TransmissionHuman TransmissionHuman TransmissionHuman Transmission

• Direct inhalation of C immitis spores• Direct inhalation of C. immitis spores−Present in contaminated soil and dust−Only established mode of transmissionOnly established mode of transmission

• Not person-to-personNot animal to person• Not animal-to-person

• Increased incidence after disturbance

Human TransmissionHuman TransmissionHuman TransmissionHuman Transmission

• Natural disturbances• Natural disturbances−Dust storms−EarthquakesEarthquakes

• Human disturbancesConstruction sites

http://vfce.arl.arizona.edu

−Construction sites−Archaeological digs

http://griefnet.org

C.immitisC.immitis

Animals and Coccidioidomycosis

Clinical SignsClinical SignsClinical SignsClinical Signs

• Disease varies in severity and • Disease varies in severity and species affected

• Incubation period: 1-3 weeks• Incubation period: 1 3 weeks• Asymptomatic to disseminated

Si f i f• Signs of primary form−Fever (104-105°F)

h−Lethargy, inappetence−Dry, harsh cough

M b f d ith k l hCenter for Food Security and Public Health

Iowa State University - 2004

May be confused with kennel cough

Clinical Signs: DogsClinical Signs: DogsClinical Signs: DogsClinical Signs: Dogs

• Signs of disseminate form• Signs of disseminate form−Fever, anorexia, weight loss− Infection of the bonesInfection of the bones

Lameness, limpingJoint swellingg

−Chronic coughing−Abscesses and draining skin lesionsg−Diarrhea

Clinical Signs: Other AnimalsClinical Signs: Other AnimalsClinical Signs: Other AnimalsClinical Signs: Other Animals

• Cats• Cats−Draining skin lesions, abscesses,

subcutaneous granulomatous massesg−Fever, loss of appetite, weight loss−Dyspnea, lameness, neuropathiesysp ea, a e ess, eu opat es

• Horses−Abortion osteomyelitisAbortion, osteomyelitis

• Pigs and ruminantsUsually asymptomatic

−Usually asymptomatic

Post Mortem LesionsPost Mortem LesionsPost Mortem LesionsPost Mortem Lesions

• Gross lesions• Gross lesions−Disseminated or limited to lungs,

mediastinum, thoracic lymph nodes, y p

• Resemble tuberculosis lesions−Discrete variable sized firm grayish Discrete, variable sized, firm, grayish

on cut surface

• Pyogranulomatous lesionsPyogranulomatous lesions−Contain purulent exudates and fungal

spores

DiagnosisDiagnosisDiagnosisDiagnosis

• Clinical• Clinical−C. immitis infection should be suspected

In endemic areasIn endemic areasWith characteristic clinical signs

• Laboratory TestsLaboratory Tests−Fungal spores found in exudates−SerologySerology

Complement-fixing antibody tests

Treatment Treatment Treatment Treatment

• Should be initiated immediately• Should be initiated immediately• For disseminated infections

Long term therapy for at least one year−Long-term therapy for at least one year−Antifungal agents

Likelihood of recovery• Likelihood of recovery−Primary form: Good prognosis

Di i t d f G d d i−Disseminated form: Guarded prognosis

Coccidioidomycosis in Humans

Clinical Signs: Primary FormClinical Signs: Primary FormClinical Signs: Primary FormClinical Signs: Primary Form

• Incubation period: 1-4 weeks• Incubation period: 1 4 weeks• Usually subclinical

Fever chills cough sore throat• Fever, chills, cough, sore throat• Chest pain• Nodular lesions• Nonspecific respiratory symptomsp p y y p• Complications less common−Pneumonia, pleural effusion

Pneumonia, pleural effusion

Clinical Signs: Clinical Signs: Disseminate FormDisseminate Form

• Severe form of diseaseSevere form of disease• Weeks to months to years after

primary infectionp y• Symptoms include

− Low-grade fever, anorexia, weight loss− Muscle aches and stiffness, weakness− Excessive sweating

Widespread focal lesions− Widespread focal lesions

• In HIV-infected personsMucopurulent or bloody sputum

− Mucopurulent or bloody sputum

Post Mortem LesionsPost Mortem LesionsPost Mortem LesionsPost Mortem Lesions

• Skin lesions• Skin lesions−Exanthems, maculopapular lesions

• Pulmonary signs• Pulmonary signs−Bronchitis, pneumonia, pleural effusion

Bone and joint lesions• Bone and joint lesions• Lymphadenopathy• Abdomen−Masses, hepatomegaly, splenomegaly

SamplingSamplingSamplingSampling

• Before collecting or sending any • Before collecting or sending any samples, the proper authorities should be contactedshould be contacted

• Samples should only be sent under • Samples should only be sent under secure conditions and to authorized laboratories to prevent the spread of laboratories to prevent the spread of the disease

• Differentials• Differentials−Tuberculosis

• Clinical• Clinical−Coccidioidomycosis should be

considered considered In endemic areasFollowing a dust/soil disturbancegWith characteristic clinical signs

• C immitis spherules visualized in• C. immitis spherules visualized in−Sputum, pleural fluid, cerebrospinal

fluid or exudates from draining lesionsg

• Complement fixation− IgG anticoccidioidal antibodiesIgG anticoccidioidal antibodies

Titer ≥1:4 = current or recent infectionTiter ≥1:32 = increased risk of extrapulmonary dissemination

• Skin test of epidemiological value

Treatment Treatment Treatment Treatment

• Primary coccidioidomycosis• Primary coccidioidomycosis−Treatment generally unnecessary

• Severe/chronic coccidioidomycosis• Severe/chronic coccidioidomycosis−Antifungal agents effective

Prognosis generally good−Prognosis generally good

• Disseminate coccidioidomycosisM i i i l t −May require invasive or long-term therapyPrognosis poor to guarded

−Prognosis poor to guarded

Public Health SignificancePublic Health SignificancePublic Health SignificancePublic Health Significance

• Reportable disease • Reportable disease −Humans in endemic areas

CaliforniaCaliforniaNew Mexico Arizona

−Notify state department of health

• Serious threat to immunocompromised persons−High mortality rate

Prevention and Control

Recommended ActionsRecommended ActionsRecommended ActionsRecommended Actions

• Notification of Authorities• Notification of Authorities−Federal:

Area Veterinarian in Charge (AVIC) Area Veterinarian in Charge (AVIC) www.aphis.usda.gov/vs/area_offices.htm

−State veterinarian www.aphis.usda.gov/vs/sregs/official.htm

• State or local health department

Quarantine and DisinfectionQuarantine and DisinfectionQuarantine and DisinfectionQuarantine and Disinfection

• Quarantine not necessary• Quarantine not necessary−Coccidioidomycosis not communicable

• Disinfection• Disinfection− Iodine

Chlorine−ChlorineHypochlorite (5.25% is household bleach)

−Phenolics: Tek-Trol®−Phenolics: Tek Trol®−Quaternary ammoniums

Di-Quat 10-S and Roccal®-D Plus

Di Quat 10 S and Roccal® D Plus

VaccinationVaccinationVaccinationVaccination

• No effective immunization available• No effective immunization available−Efforts being made to develop vaccine

• Precautionary measures should be • Precautionary measures should be taken to avoid infection

Reduce exposure to soil and dust−Reduce exposure to soil and dustMan and animalOf particular importance in endemic areasO pa t cu a po ta ce e de c a eas

AcknowledgmentsAcknowledgments

De elopment of this Development of this presentation was funded by a grant from the by a grant from the Centers for Disease Control and Prevention to the Center for Food Security and Public Health at Iowa State UniversityState University.

AcknowledgmentsAuthor: Jean Marie Gladon BS

AcknowledgmentsAuthor:

Co author:

Jean Marie Gladon, BS

James Roth DVM PhDCo-author:

James Roth, DVM, PhD

d C SReviewer: Bindy Comito Sornsin, BA

Lecture 3: Endemic FungiLecture 3: Endemic FungiLecture 3: Endemic FungiLecture 3: Endemic Fungi

• Dimorphic Fungi with mold forms found in o p c u g t o d o s ou dsoil, spores inhaled, yeast forms producing disease in lungs or disseminated. Specific geographical niches All can cause disease geographical niches. All can cause disease in normal hosts but more problematic in patients with altered CMI. Cause disease pin animals as well as humans. Environmental, not person-to-person spreadspread.

• Coccidioides immitis, Histoplasma capsulatum, Blastomyces dermatitidis,

capsulatum, Blastomyces dermatitidis, and Paracoccidioides brasiliensis are most important species.

Coccidioidomycosis ( ll )

Coccidioidomycosis ( ll )(Valley Fever)(Valley Fever)

• Coccidioides immitis: Dimorphic fungus Cocc d o des t s o p c u gusliving as mold (saprophytic) form in soil in semiarid regions of southwestern US, Central America South America In US Central America, South America. In US, greatest incidence in Arizona and Central Valley of California. Cases outside endemic yarea generally related to travel or shipping of contaminated materials from endemic area Arthroconidia spread through air area. Arthroconidia spread through air, with higher incidence of infection after heavier than usual spring rains and during

dust storms. Other animals may be infected. Epidemic after Northridge earthquake

Cocci in SW USCocci in SW USCocci in SW USCocci in SW US

Pathogenesis of C.immitisPathogenesis of C.immitis• Arthroconidia inhaled into lungs,

transform into spherules filled with endospores (the yeast or parasiticform) Spherules rupture release form). Spherules rupture, release endospores more spherules. Histology: Granulomas. Most cases are

i d di bl l b asymptomatic and diagnosable only by skin testing, but roughly 40% develop pulmonary or extrapulmonary pulmonary or extrapulmonary symptoms.

• Pulmonary cocci-Flu-like illness with fever, cough, arthralgias known as valley fever. May have associated erythema nodosum (tender red

erythema nodosum (tender red nodules on lower extremities) as sign of vigorous CMI response. Chest X-ray f d l d f l h l

Disseminated Coccidioidomycosis

Disseminated CoccidioidomycosisCoccidioidomycosisCoccidioidomycosis

• Overall, <1% of patients have disseminated disease with skin, bones, and meninges (with granulomatous basilar meninges (with granulomatous basilar meningitis) key areas of spread. Dissemination may be soon after exposure or late (reactivation) Risk factors include or late (reactivation). Risk factors include altered CMI (e.g. AIDS, organ transplant) and pregnancy (the latter due to altered immune function and trophic effects of estrogen/progesterone for cocci). Patients with dissemination typically have high yp y gcomplement fixation antibody titers and negative skin tests.Striking racial/ethnic differences in rate of

• Striking racial/ethnic differences in rate of dissemination, with Filipinos>African Americans>Native

Cocci spherule with d

Cocci spherule with dendosporesendospores

ArthroconidiaArthroconidiaArthroconidiaArthroconidia

Coccidioides immitis spherules i l i

Coccidioides immitis spherules i l iin lung tissuein lung tissue

Saprophytic form of C i i i

Saprophytic form of C i i iC.immitisC.immitis

ArthroconidiaArthroconidiaArthroconidiaArthroconidia

Cocci osteomyelitisCocci osteomyelitisCocci osteomyelitisCocci osteomyelitis

Disseminated cocci Disseminated cocci Disseminated cocci Disseminated cocci

CoccidioidomycosisCoccidioidomycosisCoccidioidomycosisCoccidioidomycosis

Chronic cutaneous coccidioidomycosis Chronic cutaneous coccidioidomycosis Chronic cutaneous coccidioidomycosis showing granulomatous lesions of the face,

neck and chin (Courtesy of John Rippon, USA

Chronic cutaneous coccidioidomycosis showing granulomatous lesions of the face,

neck and chin (Courtesy of John Rippon, USA

Domingo EzcurraDomingo EzcurraDomingo EzcurraDomingo Ezcurra

Erythema nodosumErythema nodosumErythema nodosumErythema nodosum

Cocci treatment/preventionCocci treatment/prevention

• Low risk patients with mild localized pulmonary disease may not need treatment.

• High risk patients with pulmonary disease or all patients with disease or all patients with disseminated disease (defined clinically or by high CF titer) treated, usually with y g ) , yfluconazole.

• Meningitis treated with intrathecal h t i i ( f ) amphotericin (some cases of cure) or

lifelong high dose fluconazole, often following induction with IV

following induction with IV amphotericin.

• AIDS patients need lifelong therapy

HistoplasmosisHistoplasmosis

HistoplasmosisHistoplasmosisHistoplasmosisHistoplasmosis

• Histoplasma capsulatum: Dimorphic Histoplasma capsulatum: Dimorphic fungus with mold (saprophytic) form found in soil, bird/bat droppings , / pp gworldwide. Most cases in Missouri, Mississippi, Ohio river valleys. As

ith i t id with cocci, cases may occur outside of endemic areas due to travel, shipping Infectious microconidia shipping. Infectious microconidia spread through the air. Other animals may be infected Hazard for

animals may be infected. Hazard for spelunkers (exposure to bat guano).

H.capsulatumH.capsulatum

Histo pathogenesisHisto pathogenesisHisto pathogenesisHisto pathogenesis• Conidia inhaled, develop into yeast cells,

engulfed by alveolar macrophages. engulfed by alveolar macrophages. INTRACELLULAR, resistant to lysosomal killing. Replication by budding in macrophages with dissemination though macrophages, with dissemination though R-E system. In endemic areas up to 90% have positive skin test indicating exposure. Of th 95% t ti t ll d Of these, >95% asymptomatic, controlled by CMI but with later evidence of calcified granulomas especially in lungs/ spleen.g p y g p

• Acute pulmonary histoplasmosis-with large inoculum, acute flu-like illness with fever myalgias cough Hilar and

fever, myalgias, cough. Hilar and mediastinal adenopathy, pulmonary infiltrates/nodules. Usually resolves

Histo: Shakespeare, Scheiffelin Starlings Stool

Histo: Shakespeare, Scheiffelin Starlings Stool Scheiffelin, Starlings, Stool,

and SpreadScheiffelin, Starlings, Stool,

and Spread• In 1890 Eugene g

Scheiffelin introduced 100 European starlings into Central Park, NYC as part of an effort to bring part of an effort to bring all of the birds mentioned by Shakespeare to the US. (I Henry IV I.iii, 218-226)

• Now there are 200M-1B starlings in N. America. h d Their droppings are a

major route of transmission for

histoplasmosis.

Histoplasmosis Geography in Histoplasmosis Geography in USUS

Histo pathogenesisHisto pathogenesisp gp g• Conidia inhaled, develop into yeast cells, engulfed by

alveolar macrophages. INTRACELLULAR, resistant to l l killi R li ti b b ddi i lysosomal killing. Replication by budding in macrophages, with dissemination though R-E system. In endemic areas up to 90% have positive skin test indicating exposure. Of these, >95% asymptomatic, d ca g e posu e O ese, 95% asy p o a c,controlled by CMI but with later evidence of calcified granulomas especially in lungs/ spleen.

• Acute pulmonary histoplasmosis-with large i l t fl lik ill ith f l i inoculum, acute flu-like illness with fever, myalgias, cough. Hilar and mediastinal adenopathy, pulmonary infiltrates/nodules. Usually resolves spontaneously.

• Chronic thoracic histoplasmosis-may have • Chronic thoracic histoplasmosis-may have progressive pulmonary fibrosis, pericarditis, mediastinitis. Dormant disease can reactivate.

Disseminated HistoplasmosisDisseminated HistoplasmosisDisseminated HistoplasmosisDisseminated Histoplasmosis

• In patients with impaired CMI (e g • In patients with impaired CMI (e.g. AIDS, immunosuppressives) severe dissemination with multiorgan dissemination with multiorgan involvement and sepsis syndrome may occur. Yeasts seen in ymacrophages in spleen, liver, bone marrow, blood, skin, etc. Poor granuloma formation.

Diagnosis of HistoplasmosisDiagnosis of

HistoplasmosisHistoplasmosisHistoplasmosis• Stains of tissue showing yeast cells in

macrophages.l f k l bl d• Culture of sputum, urine, skin lesions, blood,

bone marrow. At 25˚C for mold, at 37˚C for yeast. Hyphae have macroconidia and microconidia. Like cocci, LAB HAZARD.

• Skin test with histoplasmin mycelial antigen—used only for epidemiology, not individual y p gy,diagnosis. May lead to false positive antibody tests.

• Antibody assays-CF and ID tests available with • Antibody assays CF and ID tests available with H and Y antigens. Cross reactions with other fungi. Rise in titer helpful.Serum/urine antigen detection (done in

• Serum/urine antigen detection (done in Indiana)-very helpful to diagnose disseminated disease

Mycelial form of H. l

Mycelial form of H. lcapsulatumcapsulatum

• Note larger • Note larger, tuberculate macronidiamacronidia(with bumps) and smaller microconidia.

Histo yeast cells in peripheral bl d

Histo yeast cells in peripheral bl dblood WBCblood WBC

Histo in lymph nodeHisto in lymph nodeHisto in lymph nodeHisto in lymph node

Ocular HistoplasmosisOcular HistoplasmosisOcular HistoplasmosisOcular Histoplasmosis

Pulmonary/Mediastinal Histo

Pulmonary/Mediastinal HistoHistoHisto

Splenic calcifications in HistoSplenic calcifications in HistoSplenic calcifications in HistoSplenic calcifications in Histo

Histoplasmosis of the lower gum showing

Histoplasmosis of the lower gum showingshowing

ulcer around base of the teeth.showing

ulcer around base of the teeth.

Skin lesion in disseminated h

Skin lesion in disseminated hhistohisto

Treatment/prevention of h l

Treatment/prevention of h lhistoplasmosishistoplasmosis

• Asymptomatic or mild pulmonary sy pto at c o d pu o a ydisease in immunocompetent-no specific treatmentM l di• More severe pulmonary disease-itraconazole

• Severe disseminated disease in • Severe disseminated disease in immunocompromised-initial amphotericin followed by itraconazole. Lifelong in AIDS patients.

• Mediastinal, pericardial involvement may require surgery stents etc

may require surgery, stents, etc. Possible role for steroids for fibrosis—use caution!!

BLASTOMYCOSISBLASTOMYCOSIS

BlastomycosisBlastomycosisBlastomycosisBlastomycosis

• Blastomyces dermatitidis: Dimorphic fungus-a o y d a d o p u gumold with thin hyphae and ovoid conidia (infectious form) at 25˚C, thick walled budding yeast with broad attachment to budding yeast with broad attachment to single bud in tissue at 37˚C. Difficult to isolate from nature; reservoir not clear but soil likely with cases somewhat clustering around river banks. No good skin test; frequency of asymptomatic disease unknown frequency of asymptomatic disease unknown. In North America, geography similar to histo, with somewhat more extension into Southern C d Cli i ll t di l

Canada. Clinically apparent disease less frequent than histo. Some cases from other continents.

Blastomycosis GeographyBlastomycosis GeographyBlastomycosis GeographyBlastomycosis Geography

Blasto pathogenesisBlasto pathogenesisBlasto pathogenesisBlasto pathogenesis

• Inhalation of conidia Primary • Inhalation of conidia. Primary pulmonary disease may present with fever, cough, myalgias. May lead to fever, cough, myalgias. May lead to chronic pneumonia. Host response both neutrophils, granulomas.p , g

• Dissemination more common in immunocompromised. Key sites: immunocompromised. Key sites: skin, bone, genitalia, CNS.

Diagnosis of BlastomycosisDiagnosis of BlastomycosisDiagnosis of BlastomycosisDiagnosis of Blastomycosis

• Stains of sputum, pus, urine, tissue-Stains of sputum, pus, urine, tissuecharacteristic yeast forms, rarely hyphal forms.yp

• Culture-Mold at 30˚C, conversion to yeast on rich medium at 37˚C.y

• Skin test-not worthwhile• Serology-Some role for CF, ID, EIA Serology Some role for CF, ID, EIA

antibody detection. Problems with cross reactivity with other fungi.

Blastomyces dermatitidis hyphae form (room temp Blastomyces dermatitidis hyphae form (room temp hyphae form (room temp

culture)hyphae form (room temp

culture)

Blasto Yeast forms with b d b d b dd

Blasto Yeast forms with b d b d b ddbroad-based buddingbroad-based budding

Extensive lung involvement l

Extensive lung involvement lin Blastoin Blasto

Pneumonia in BlastoPneumonia in BlastoPneumonia in BlastoPneumonia in Blasto

Cutaneous BlastomycosisCutaneous BlastomycosisCutaneous BlastomycosisCutaneous Blastomycosis

Bone involvement in BlastoBone involvement in BlastoBone involvement in BlastoBone involvement in Blasto

Blastomycosis /

Blastomycosis /treatment/preventiontreatment/prevention

• Mild or localized disease treated with • Mild or localized disease treated with itraconazole.

• Severe disease treated with • Severe disease treated with amphotericin.

• No specific means of prevention• No specific means of prevention.

PARACOCCIDIOIDO MYCOSIS

Paracoccidioidomycosis Paracoccidioidomycosis (South American Blastomycosis)(South American Blastomycosis)

• Paracoccidioides brasiliensis-Paracoccidioides brasiliensis• Dimorphic fungus with characteristic yeast

form with large multiply budding cells with ˚

g p y gnarrow attachments in tissue and 36˚C rich medium culture. F d i C l d S h A i • Found in Central and South America. Probable soil source but not clear. Men>>Women (?Exposure) Worst • Men>>Women (?Exposure). Worst problem in Brazil—death rate up to 1.5/1000.

1.5/1000.

Paracocci GeographyParacocci GeographyParacocci GeographyParacocci Geography

Diagnosis of d d

Diagnosis of d dParacoccidioidomycosisParacoccidioidomycosis

• Yeast forms in fluids or tissues• Yeast forms in fluids or tissues• Culture with appropriate conversion

to yeast form at 36 C rich mediumto yeast form at 36 C, rich medium• Rising titer of CFT or

immunodiffusion antibody (helpful immunodiffusion antibody (helpful, correlate with severity of disease)Skin testing for epidemiology not • Skin testing for epidemiology, not diagnosis

Multiply budding yeast forms in Paracocci-(”Mariner’s /Pilot wheel )

Mucosal lesion in ParacocciMucosal lesion in ParacocciMucosal lesion in ParacocciMucosal lesion in Paracocci

Skin lesions in ParacocciSkin lesions in ParacocciSkin lesions in ParacocciSkin lesions in Paracocci

Lung disease in ParacocciLung disease in ParacocciLung disease in ParacocciLung disease in Paracocci

Genital Paracocci resembling h l

Genital Paracocci resembling h lsyphilissyphilis

Mucocutaneous paracoccidioidomycosis

Extensive destruction of facial featuresExtensive destruction of facial features

Treatment/prevention of d d

Treatment/prevention of d dParacoccidioidomycosisParacoccidioidomycosis

• Mild-moderate disease treated with • Mild moderate disease treated with itraconazole. Interestingly, trimethoprim-sulfa has activity, but trimethoprim sulfa has activity, but tendency to relapse.

• Severe disease treated with • Severe disease treated with amphotericin.

• No known means of prevention• No known means of prevention.

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