Lecture Title PATHOLOGY

Dr. Who | August 1, 2017

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CANDIDIASIS Pathogenesis of Candidiasis
CASE 1: Phenotypic switching- modify structure to be able to escape
A 22-year old pregnant female, who just finished a course of host-defenses
antimicrobial therapy for UTI, complained of intense Large number of adhesins- mediate adherence to host cells
vulvovaginal pruritis with white, thick, curd-like discharge. Her and contribute to virulence
OB-Gyne did a pap smear. o Integrin-like protein- binds to fibrinogen, fibronectin and
laminin
o Protein that binds to epithelial cells
o Agglutinins that bind to endothelial cells or fibronectin
Enzymes, including:
o Aspartyl proteinases- promote tissue invasion by
degrading extracellular matrix proteins
o Catalases- enable resistance to oxidative killing by
phagocytic cells

Clinical Classification of Candidiasis

Figure X. Vaginal Candidiasis. From lecturers presentation.
Disease: Candidiasis or Moniliasis
Originate when the normal commensal flora breach the
skin or mucosal barriers.
Candida species usually live as benign commensals and
seldom produce disease in healthy people
o Most frequent cause of human fungal infection- C.
albicans
Risk/ Predisposing Factors- Any state
Immunosuppression
o Prolonged antibiotic treatment
o Prolonged steroid administration
o Pregnancy
o Underlying diseases (e.g. Diabetes Mellitus)
o Altered immunity
o Polyendocrine disturbance
Morphology:
o Budding yeasts
o Pseudohyphae- formed by elongated budding, show
constrictions along their length, and appear eosinophilic to
gray-brown on Papanicolaou stain
o Fragmented leukocyte nuclei and rouleaux formation of
squamous epithelial cells speared by hyphae may be
seen.
Usual Treatment: Anti-fungals
1. Cutaneous and Mucosal Candidiasis (Superficial Infections)
In an immunocompetent person, hanggang dito lang yung level
ng candidiasis nila, cutaneous and mucosal
Oral thrush
o Creamy white pseudo-membrane or patches covering the
tongue or the buccal mucosa can be scraped
o Easily detached a reddened and inflamed surface
o Masses of fungal organisms
o Common among patients with HIV
of
Figure X. Oral thrush, gross and histology. Note tangled masses of
pseudohyphae in the section of the tongue on the right. From lecturers
presentation.
Diaper Rash
o Observed in areas where moisture and heat combine
o Pruritic, eczematous cutaneous lesion
o Acute and chronic inflammation with microabscesses
o Granulomatous reaction in the chronic state
Candida is notorious for its satellite lesions

Figure X. Diaper Rash. From lecturers presentation.

Figure X. Histology of Vaginal Candidiasis. Note the spearing of
squamous cells by pseudohyphae. From lecturers presentation
Vaginal thrush- associated with intense itching and thick curd-
like discharge

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Intertriginous candidiasis (groin, axillary, interdigital)-
usually found in skin folds

Figure X. Chronic Mucocutaneous Candidiasis. From lecturers

presentation.
Figure X. Intertrigo. From lecturers presentation.
Pathologic Findings
Stomatitis- inflammation of the mouth and lips Pseudohyphae and budding yeasts of Candida (3-7 m)
Onychomycosis- fungal infection of the nail Presence of pseudohyphae is the most important clue in the
Esophagitis- inflammation or irritation of the esophagus diagnosis of Candidiasis
Balanitis- inflammation at the end of the penis You usually request for PAS stain or Silver stain of esophageal
candidiasis/ fungi
2. Invasive/ Systemic Candidiasis Candida can appear as yeast-like forms, pseudohyphae and
Candida can travel through the blood stream and infect the true hyphae
different part of your body, like the brain, the joints, the bone Usually, candidiasis can affect any epithelial surface of the
and even the peritoneal cavity body
Esophagitis- seen among AIDS patients and in those with
hematolymphoid malignancies
Intestinitis
Infant diarrhea
Bronchopulmonary candidiasis
Pyelonephritis
Cystitis
Endocarditis- most common fungal endocarditis, usually
occurring in the setting of prosthetic heart valves
Myocarditis
Endophthalmitis
Meningitis
Arthritis Figure X. Pathologic Findings in Candidiasis. (Left) Note presence of
Osteomyelitis pseudohyphae and budding yeasts. (Right) shows silver staining of
Peritonitis esophageal candidiasis. From lecturers presentation
Macronodular skin lesions
CRYPTOCOCCOSIS

CASE 2:
A 42-year old male HIV patient complains of dysphagia and
substernal chest pain. He also had oral thrush. He was advised
to undergo endoscopy. On endoscopy, multiple adherent dark
brown plaques with mucosal hyperemia and edema were seen
in his distal esophagus.
CASE 3:
A 38-year old SLE patient complains of worsening headache
and altered mental status. She has been a chronic steroid user
for 5 years. She underwent lumbar tap and CSF finding showed
this appearance after adding India ink:

Figure X. Cryptococcosis. From lecturers presentation.

Figure X. Candidiasis. From lecturers presentation.
Diagnosis: Esophageal Candidiasis- seen in severely
immunosuppressed patients
When you request for India ink, one species comes to mind.
See the capsule- there is clearing between the nuclei and the
cytoplasm
India ink kasi is negative stain. It stains the background para
makita niyo yung morphology nung nandun sa stain

3. Chronic Mucocutaneous Candidiasis

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Causative agent: Cryptococcus neoformans
Major lesions caused by Cryptococcus are in the CNS involving
meninges, cortical gray matter and basal nuclei
In healthy individuals- can cause Meningoencephalitis
Can cause opportunistic infections in patients with:
o AIDS
o Leukemia
o Lymphoma
o SLE
o Sarcoidosis
o Transplant recipient
Morphology:
o 5-10 m cryptococcal yeast
o Highly characteristic thick gelatinous capsule
containing a polysaccharide that stains intense red
with periodic acid-Schiff (PAS) and mucicarmine in Figure X. Soap bubble lesion in Cryptococcal Meningitis. From
tissues lecturers presentation.
Staining Methods:
o Mucicarmine stain- Cryptococci in a Virchow-
Robin perivascular space
o Periodic Acid-Schiff (PAS) Stain

Cryptococcosis of the Lungs

Gross: Irregularly shaped, yellow nodule
Histology:
Figure X. Cryptococcosis in Mucicarmine (Left) and PAS Stain (Right). o Foreign-body granulomas
From Lecturers presentation. o Tb-like caseating granuloma- seen in
immunocompetent individuals, since the
macrophages are still capable of phagocytosing the
NOTE: cryptococcal fungi
2 Species of Cryptococcus:
1. C. neoformans- most common cause of
meningoencephalitis, usually found in pigeons or bird
droppings
2. C. gatii- can also cause cryptococcosis, usually found
in immunologically normal individuals, and associated
with certain species of trees which leave debris on soil

Pathogenesis of Cryptococcosis
Spores are usually present in soil and bird (particularly
pigeon) droppings and infects people when it is inhaled

Virulence Factors of C. Neoformans

Thick polysaccharide capsule Figure X. Tissue showing cryptococcosis of the lung. From lecturers
o Glucoronoxylomannin- inhibits phagocytosis by powerpoint
alveolar macrophages, leukocyte migration and
inflammatory cell recruitment In immunosuppressed individuals, a prominent extracellular
Melanin production growth of the fungi is seen
o Laccase- catalyzes formation of a melanin-like Staining Method: Methenamine silver stain- extracellular
pigment yeasts of C. neoformans within an alveoli
Enzymes
o Serine proteinase- cleaves fibronectin
o Basement membrane proteins- aids tissue invasion
Phenotypic switching

Pathologic Findings
Cryptococcal Meningitis
Gross: Microcyst formation
Microscopy: Soap bubble lesion- form gelatinous masses of
cells within Virchow-Robin space or other perivascular spaces,
particularly among immunosuppressed patients
o Budding cells of Cryptococcus have a narrow base
o Fungal yeasts in the vascular space

Figure X. Methenamine silver stain of Cryptococcosis. Note

extracellular yeasts of C. neoformans spread within the alveoli.
From lecturers presentation.

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