(2) clinical cases i solutions 2008

8/2/2019 (2) Clinical Cases I Solutions 2008

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Clinical cases inMYCOLOGY


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Case 1


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A 4 year old girl in day care was brought to the doctor because ofseveral lesions on her arm. They were reddish and round, slightlyraised and scaling. There were a few pinpoint pustules around theedge of the lesions. The girl had no other lesions except the oneson the arm and had no other symptoms.

Microscopy revealed a filamentous structure cells with existenceof multicelluler conidia.


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1-What is the causative agent of ringworm?A)StreptococcusB) TrichophytonC) Tinea corporisD) Enterobius vermicularis

2-What class of agents are Trichophyton, Microsporum, andEpidermophyton?

A) BacteriaB) Viruses

C) WormsD) Fungi


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3-To do a microscopic exam for fungi one should do which of thefollowing first?A) Gram stainB) Treat the skin scraping with 10% KOHC) Grow it on blood agar firstD) Grow it on Sabourauds agar first

4-How would a case of ringworm be diagnosed?A) Microscopic examination looking for tiny wormsB) Microscopic examination looking for hyphaeC) Growth of a swab on blood agar looking for hemolytic coloniesD) Look for serum antibodies to the fungus
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5-How is ringworm acquired?A) Other peopleB) AnimalsC) The environment; i.e., soilD) All of the above

6-Fungi have cell walls that contain N-acetylglucosamine, so why doesntpenicillin work on fungi?A) fungi are eukaryotes and penicillin only works on prokaryotesB) fungi have a cell membrane that contains sterols like ergosterolC) fungi have a true nucleusD) fungi contain mitochondria
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7-Which if the following is used to treat ringworm?A) PenicillinB) MetronidazoleC) GriseofulvinD) Acyclovir

8-What is the mechanism of action of griseofulvin?A) it interacts with sterols in the cell membraneB) it is deaminated to flourouracil and incorporated into RNAC) it inhibits sterol biosynthesisD) it inhibits microtubular function and acts as a mitotic poison
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9-Can ringworm progress to a more serious systemic disease?A) Yes, it can have serious sequelae, most often it infects the lungsbeing transported there hematogenouslyB) Only in immunocompromised patientsC) No, it is a superficial skin disease only

10-Do you know of a fungal disease that starts with a skin lesion andspreads, usually along the lymphatic glands that drain the primary siteof inoculation?A) SporotrichosisB) Tinea capitisC) Histoplasmosis

D) Rocky Mountain Spotted Fever
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In summary, the child had a case of ringworm or tinea corporis. It waseasily cured with a topical anti- fungal agent. Had it not been, she wouldhave been treated with griseofulvin. She likely acquired it from anotherchild in her day care center.

Other names for fungal skin diseases are tinea capitis (scalp), tinea cruris(groin, also called jock itch), tinea pedis (feet, also called athletes foot).

A scraping of skin from the edge of the lesion on the childs arm wastaken, treated with KOH, and examined under the microscopeFilamentous structures were seen. No flouresence with a Woods lampwas seen

SOLUTION CASE 1
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Case 2
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A 7 year old male developed a crusted area on the lefttemporal scalp with associated hair loss. He hadrecently visited his Grandparents' farm and was incontact with several of the barnyard cats.

Microscopy revealed a filamentous structure cells withexistence of multicelluler conidia
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1. What possible diagnoses that springimmediately to mind?

2. How to confirm that diagnosis?

3. How should be treated?4. Is it a contagious infection? How?

5. What you think the clinical form type of thepicture above? why
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SOLUTION 21-Tinea capitis caused by Microsporum canisAffecting children between 4 and 14 years of age (pre-puberty age).

2-Direct microscopic examination of clinical materials will confirm only the

diagnosis of a fungal infections.Culture grew Microsporum canis (colonies are flat, spreading, white to cream-coloured,with a dense cottony surface which may show some radial grooves. Colonies usually have a

bright golden yellow to brownish yellow reverse pigment)Macroconidia are typically spindle-shaped with 5-15 cells, verrucose, thick-walled and oftenhave a terminal knob. A few pyriform to clavate microconidia are also present

3-The patient responded to a 8 week course of oral griseofulvin.

4-Yes, Microsporum canisis a zoophilic dermatophyte of world-wide distribution whiis a frequent cause of ringworm in humans, especially children. Invades hair, skin anrarely nails. Cats and dogs are the main sources of infection. Invaded hairs show an

ectothrix infection and fluoresce a bright greenish-yellow under Wood's ultra-violet liSpread is usually due to direct contact with human or animal, indirect spreadthrough contaminated fomites. Overcrowding, poor hygiene and protein malnutritiofavor the occurrence of this disease.
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Case 3


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A 30 year old woman presents with scaling reddish browpatches on the anterior chest and upper back. She statethe lesions were more noticeable at the end of thesummer in that these areas failed to tan.

Scrapings of the lesions revealed clumps of small sporeand pseudohyphae in a spaghetti and meatballs pattern .


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1. What possible diagnoses that spring immediatelyto mind?


3. How should be treated?4. Is it a contagious infection? why?

5. What usually the patches are described in thistype of infection?


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Pityriasis versicolor is affecting young people around the pubertal time probablyrelated with hormonal changes and increase in sebum secretion in summer season.

Direct examination of Skin scrapings from patients with superficial lesions mayreveal : yeast and hyphal form which commonly associated with pityriasisversicolor. This appearence called spaghetti and meatballs. The color of the

Malassezia furfur, the causative agents, colonies is creamy yellow to brown (5 daysat 30-37C)

Therapeutic options include the use of topical agents and oral medication. Topical agents include, shampoos and lotions. topical agents may include

terbinafine. Lotions are left on for about 10 minutes and then washed off. Thistreatment is repeated daily for 7 days and then once a month for 6 months.

No, Malassezia furfur, the causative agents is normal commensally flora present onnormal human skin and they usually colonize tissues that are not living.

Solution 3


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Case 4


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A 60 yr. old male presents with an over 20 year historyof chronic erythema and scaling of the soles of bothfeet. Several nails are dystrophic and brittle.

KOH exam is positive for hyphae Culture of nails and skin grows appear smooth, thin wall

and cylindrical shape macroconidia.


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1. What possible diagnoses that spring immediatelyto mind? Why?


3. How should be treated?4. Is it a contagious infection? why?

5. What other fungi can cause nail infection?


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Tinea pedis (papulosquamous pattern) caused byTrichophyton rubrum

Culture of nails and skin grows Trichophyton rubrum. Treatment with oral terbinafine for three months clears

both skin and nails. Grisofulvin is not effective for thetreatment of nail infection. Yes, Contact with bath or pool floors is the most

recognized risk factor and the rate of infection increasesin relation with the number of people using the facilities.

E. flucosumand Candidaspecies.

Solution 4
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Case 5


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Howard, a 10 year-old boy, is referred to the dermatologyoutpatients because of skin on his arm which haspresent for 3-4 months.

He has never been previously been seriously ill, is on no

medications and there is no family history of eczema orany other skin disorder.

On examination he is seen to be a fit and active child, andthe lesions are scaly with raised margins.


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1. What is the diagnosis?2. What other questions might Howard or his parents be asked?3. Where else on the body might you look for tinea infections?4. How may a diagnosis of tinea be confirmed?

5. What options are there for the treatment of tineainfections?6. What are the sources and routes of transmission of this

organism?7. What other non-bacterial (fungal) infections or infestations

of the skin may present with a rash or itching?


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Solution 5

1. These lesions are typical of tinea which is most commonly seen during childho

They are caused by filamentous fungi which invade the stratum cornium. Thregenere are involved: Trichophyton, Epidermophyton and microsporum.

2. Howard should be asked for whether his brother, sisters or playmates havesimilar marks on the skin and whether is a cat or dog at home, as some fungi acquired from animals or on a farm.

3. Tinea infections may be found all over the body and are traditionally calassifieaccording to the anatomically locations., tinea pedis (feet), tinea cruris (groin)

4. Microscopic and macroscopic (culture -3 weeks) examintion of clinical materiamay confirm the diagnosis of the different dermatophytes according their pictuand specific features of every one. Ultraviolet light (Woods light) may fluorescgreen in the case of scalp infection caused by microsporum.

5. Topical treatment include griseofulvin and terbinafine. Skin infection may requ2-4 weeks whereas nail and hair infection may require for 3-9 months of thera

6. Direct and indirect contact of human and animals

7. Superficial candidiasis of skin , nail or feet and pityriasis versicolor.


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Case 6


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A patients with AIDS presented with dysphagia.Examination of t he oropharynx showed areas of reddenedmucosa. On oesophagoscopy, thick white plaques wereseen, which were swabbed and a gram stain preparation

was large violet color spherical cells appearance.


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1- What is your diagnosis? How is these confirmedmicrobiologically?

2-What are some of the factors that predispose toopportunistic fungal infections?

3- What is the treatment?4- What other infections can cause by this organism?5- Is it a contagious infections? why?6- What microscopic examination test named and

indicated in the picture above?

S l ti 6


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1. The swab of the oesophageal plaques shows the presence of yeast, with atypical oval morphology, presence of budding forms and hyphae.

The patients has oral and oesophageal candidiasis. Dysphagia is a commonsymptom of oesophageal candidiasis

2. Neutropenia (especially >7 days), malignancies, postsurgical intensive carepatients, prolonged intravenous catheterization. broad-spectrum or multipleantibiotic therapy use, diabetes mellitis. severe burns, intravenous drugabuse and all AIDS patients.

3. In infants, Nystatin suspension, in older children and adults Clotrimazoletroches or miconazole oral gel.

4. Cutaneous candidiasis, Vulvovaginal candidiasis and balanitis in addition todisseminate to other organs causing SYSTEMIC candidiasis.

5. No/Yes, but it depends on the immune status of human body.

6. Germ tube of C. albicans

Solution 6


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Case 7


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a crew of five workers began partial demolition of an abandonedcity hall building in Belfry, Kentucky. One truck driver whohauled the debris to the dump, four workers who helped thedriver haul and dump the debris, and two people who had washedthe building assisted them. At the time of demolition, a colonyof bats had been observed in the vicinity of the building, and anapproximately 2-foot deep pile of debris covered with bat guanohad accumulated in the building. During the demolition, none ofthe workers wore personal protective equipment (i.e.,respirators, eye protection, gloves, or protective clothing).Within 3 weeks, six of these workers required treatment foracute respiratory illnesses, and three had been hospitalized.Their symptoms included chills, fever, cough, and headache.

Several had substernal discomfort, and several had painful skinlesions. A common source of infection was suspected, probablyan environmental source.


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1-Which of the following diseases have an environmental source andare most likely to be responsible for these mens illnesses?A) asbestosisB) pneumococcal pneumonia or staphylococcal pneumoniaC) Legionnaires disease or tuberculosisD) Cryptococcosis or coccidiodomycosis

E) Histoplasmosis or Blastomycosis

2-Why would you favor a diagnosis of histoplasmosis rather thanblastomycosis?A) Blastomycosis usualy presents as an encephalitisB) Blastomycosis is not endemic in the United States

C) Blastomycosis is not endemic in KentuckyD) Blastomycosis is always asymptomaticE) None of the above


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3-Why would you favor a diagnosis of histoplasmosis rather thancoccidioidomycocis?A) Coccidioidomycocis usually presents as an encephalitisB) Coccidioidomycocis is not endemic in the United StatesC) Coccidioidomycocis is not endemic in KentuckyD) Coccidioidomycocis is always asymptomaticE) None of the above

4-What do histoplasmosis, coccidioidomycocis, and blastomycosis have incommon?A) They are all caused by moldsB) They are all acquired by inhalationC) They all cause a preponderance of inapparent infections

D) They are all caused by dimorphic fungiE) All of the above


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5-All of the following infections are acquired by the inhalation of conidia

EXCEPT:A) BlastomycosisB) HistoplasmosisC) CryptococcosisD) Oral candidiasisE) None of the above

6-How could an acute infection of histoplasmosis be proven?A) Skin test for reactivity to histoplasminB) Growth of the organism from sputumC) Acid fast bacterium seen in the sputumD) Giemsa stain of lung biopsyE) Complement fixation titer of 1:32 or higher


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Case 8


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Two healthy construction laborers were seen by dermatologistafter developing painless bilateral ulcerative lesions along thelymphatics of the forearm.

On examination they were afebrile. There was regionallymphadenopathy, and the lesions extended up the lymphaticsas tender erythematous subcutaneous nodules, some of which

were fluctuant.Histories taken from the patients revealed that these lesions

began to appear 2-3 weeks after they had demolished anattic as part of an urban renewal project. Both stated theygot splinters from carrying wood they had salvaged from the

rafters.The microscopic examination revealed a hyphal filaments mat of

cells appeared as roseette shape.


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1- What is your diagnosis? How is these confirmedmicrobiologically?

2- What is the treatment?

3- What other infections can cause by thisorganism?4- Is it a contagious infections? why?5-At what temperature the microscopic picture

above can appeared? Why?

S l ti 8


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1- Sporotrichosiscaused bySporothrix schenkii. Direct examination of clinicalmaterials microscopically and macroscopically may reveal thedimorphicstructure of this organism. At 37C: as Round/cigar-shaped yeast cells and at25C: as Septate hyphae, rosette-like clusters of conidia at the tips of theconidiophores.

2- Potassium iodide, itraconazole and terbinafine are the favored treatment in thecase of cutaneous infection.

3- Primary pulmonary sporotrichosis in the case of chronic alcoholics andSystemic dissemination involving bones, joints and meninges.

4- No, generally these organisms are a heterogenous group of organisms withlow pathogenic potential that are commonly isolated from soil or decayingvegetation.

5- At 25C: as Septate hyphae, rosette-like clusters of conidia at the tips of theconidiophores.

Solution 8


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Case 9


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A 61-year-old man suffering from acute myeloidleukaemia presented with chest pain and dyspnoea.Computer tomography revealed diffuse bilateralinfiltrates which were considered to be suspicious

for an invasive pulmonary aspergillosis of the leftupper lobe.A biopsy was taken which showed the presence offungal elements and the culture shown below wasisolated.

Direct Microscopy: methenamine silver stain


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Direct Microscopy: methenamine silver stain.

Culture

Microscopy

What is your identification?


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Direct Microscopy: methenamine silver stainsection showing branching septate hyphaetypical for Aspergillus

Culture: Colonies of A. flavusare granular, flat,often with radial grooves, yellow at first butquicklybecoming bright to dark yellow-green with age.

Microscopy: Conidial head of A. flavus.Note: conidial heads with both uniseriate and

biseriate, arrangement of phialides may bepresent


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Aspergillus flavus has a world-wide distributionand normally occurs as a saprophyte in soil andon many kinds of decaying organic matter.

A. flavus is the second most common species

(next to A. fumigatus) to be isolated from humaninfections, and it is often associated withinvasive aspergillosis seen in immunosuppressedpatients and in paranasal sinus infection


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Case 10


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A 10 year old caucasian boy presented to theDermatology Clinic with a kerion lesion of the scalpwhich had taken about 8 weeks to develop.

Direct microscopy showed the presence of fungalelements and the culture shown below was isolated

Clinical appearance


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pp

Direct Microscopy of hair

Culture Microscopy

What is your identification?


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Clinical appearance: Kerion is perhaps anuncommon clinical presentation for thisanthrophophilic dermatophyte but it wasobviously a fungal infection from the directmicroscopy

Direct Microscopy of hair: showing endothrixhair infection

Culture: were slow growing, flat to folded,suede-like and a deep apricot orange in colour

Microscopy: showing reflex branching hyphae,no conidia were seen


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Comment Trichophyton soudanense is an anthropophilic

dermatophyte which is a frequent cause of tineacapitis in Africa. Invaded hairs show anendothrixinfection but do not fluoresce under Wood'sulta-violet light. Although distribution is mainlyin Africa, increasing numbers of cases are nowbeing seen in countries like Australia, USA andEurope due to immigration.


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(2) clinical cases i solutions 2008

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