主要致病性真菌課件

主要致病性真菌淺部真菌感染（致病性真菌感染和條件致病性真菌感染）深部真菌感染（致病性真菌感染和條件致病性真菌感染）1主要致病性真菌淺部真菌感染（致病性真菌感染和1淺部感染真菌表面感染真菌皮膚癬真菌皮下組織真菌感染2淺部感染真菌表面感染真菌233表面感染真菌位置：寄居于人體皮膚和毛干的最表層。因不接觸組織細(xì)胞，很少引起宿主細(xì)胞反應(yīng)統(tǒng)稱(chēng)：角層癬菌代表：秕糠馬拉癬菌(Malassezia

furfur)癥狀：由于此菌能產(chǎn)生對(duì)黑色素細(xì)胞有抑制作用的二羧酸，使花斑癬局部色素減退，如汗?jié)n斑點(diǎn)，俗稱(chēng)汗斑。誘發(fā)因素為高溫多汗4表面感染真菌位置：寄居于人體皮膚和毛干的最表層。因不接觸組織Malassezia

furfurTineaversicoloronskinsurface(sweatstain)ThelesionsaresmallhypopigmentedorhyperpigmentedmaculesMostcommonsite:back,underarm,upperarm,chest,neckMostcommoninadolescentandyoungadultmalesAssociatedwithincreasedsweating5MalasseziafurfurTineaversicoPityriasisversicolorshowinghyperpigmentedlesionsina

CaucasianandhyphopigmentedlesionsinanAustralianAborigine6PityriasisversicolorshowingCultureofMalasseziafurfuronDixon'sagar(containsglycerolmono-oleate)7CultureofMalasseziafurfuroPiedraiahortae(何德毛結(jié)節(jié)菌)ItusuallyaffectedthescalphairThenodulesaredarkerincolor,harder,andmorefirmlyattachedtothehairsBlackPiedra8Piedraiahortae(何德毛結(jié)節(jié)菌)ItusuPiedraiahortaeformsahardsuperficialpigmentednodulearoundthehairshaft(在毛干上形成硬的黑色結(jié)節(jié)，如沙粒狀)9PiedraiahortaeformsahardsFungalotitisexternaFungalinfectionoftheexternalauditorycanalCausedbyseveralspeciesofAspergillus(mostoftenA.niger),butCandidaalbicansisalsocapableofinfectingthissiteThemajorsymptomsareitchingandfeelingoffullnessinear10FungalotitisexternaFungalin1111皮膚癬真菌引起皮膚淺部感染皮膚癬是人類(lèi)最多見(jiàn)的真菌病統(tǒng)稱(chēng)：皮膚癬菌，大約40多個(gè)種，分屬于3個(gè)屬嗜角質(zhì)蛋白，37℃不能生長(zhǎng)，侵犯部位：角化的表皮，毛發(fā)，指（趾）甲病理變化：由真菌增殖及代謝產(chǎn)物刺激宿主引起12皮膚癬真菌引起皮膚淺部感染12致病性

指（趾）甲皮膚毛發(fā)毛癬菌屬+++表皮癬菌屬++-小孢子癬菌屬-+

+一種皮膚癬菌可在不同部位引起病變相同部位的病變也可由不同的皮膚癬菌引起13致病性指（趾1414TineapediscausedbyT.rubrum.Sub-clinicalinfection(left)

showingmildmacerationunderthelittletoeandmoresevere

infection(right)showing

extensivemacerationofalltoewebspacesTineaistransmittedviathefeetbydesquamatedskinscalesinsubstrateslikecarpetandmatting.15TineapediscausedbyT.rubru手足癬－治療原則水皰型－溫和搽劑和霜?jiǎng)┙腔^(guò)度型－先角質(zhì)剝脫劑，再用抗真菌霜?jiǎng)┙n糜爛型－粉劑收干，抗繼發(fā)感染，再溫和抗真菌16手足癬－治療原則水皰型－溫和搽劑和霜?jiǎng)?6TineaUnguiumusuallycausedbyTrichophytonsp17TineaUnguiumusuallycausedby甲癬－治療原則局部治療－甲涂劑系統(tǒng)治療－伊曲康唑，特比萘芬等聯(lián)合治療－配合拔甲或削甲治療18甲癬－治療原則局部治療－甲涂劑18TineaCorporis:

causedbyM.canis,followingcontactwithinfectiouskittens

19TineaCorporis:

causedbyM.c

TineaCruris(Jockitch):

Infectionofthegroin,mainlyseeninmen20TineaCruris(Jockitch):

InfTineaCapitis(scalpringworm)Tineafavosa發(fā)內(nèi)孢子21TineaCapitis(scalpringworm)TineaCapitis(scalpringworm)Tineaalba發(fā)外孢子22TineaCapitis(scalpringworm)TineaCapitis(scalpringworm)膿癬23TineaCapitis(scalpringworm)頭癬－治療原則剪發(fā)洗發(fā)搽藥服藥消毒24頭癬－治療原則剪發(fā)24Candidiasisofskin,mucous

membranesandnails

PredisposingfactorsInfancy,pregnancy,oldageDisordersofimmunefunction,e.g.,leukemia,corticosteroidtherapyChemotherapy,e.g.,immunosuppressive,antibioticEndocrinedisease,e.g.,diabetesmellitusCarcinoma25Candidiasisofskin,mucousme念珠菌性間擦疹好發(fā)部位：腋窩、乳房下、腹股溝、會(huì)陰，多見(jiàn)于嬰兒及肥胖者。26念珠菌性間擦疹好發(fā)部位：腋窩、乳房下、26Cutaneouscandidiasis:includingInterdigitalcandidiasis,diapercandidiasis,paronychiaandonychomycosisVulvovaginalcandidiasisandbalanitisInterdigitalcandidiasisCandidiaonychomycosisandparonychia

27Cutaneouscandidiasis:includOropharyngealcandidiasis:

includingthrush,glossitis,stomatitisandangularcheilitisOralthrush28Oropharyngealcandidiasis:in皮下組織真菌感染主要有孢子絲菌和著色真菌申克孢子絲菌，屬腐生性真菌，常因外傷接觸帶菌的花草等引起感染。此菌可引起孢子絲菌下疳。此菌也可引起深部感染。是一種二相性真菌。著色真菌感染發(fā)生在暴露部位，稱(chēng)著色真菌病。我國(guó)主要有卡氏枝孢霉和裴氏著色芽生菌。29皮下組織真菌感染主要有孢子絲菌和著色真菌29Sporotrichosis此菌可經(jīng)微小損傷侵入皮膚，然后沿淋巴管分布，引起亞急性或慢性肉芽腫，使淋巴管形成鏈狀硬結(jié)，稱(chēng)為孢子絲菌下疳。30Sporotrichosis此菌可經(jīng)微小損傷侵入皮膚，然后沿ChromomycosisInfectionsoccurinexposedareas,skinlesionsbecomedark,socalledchromomycosisRepresentivespecies:Cladosporiumcarrianii,Fonsecaeapedrosoi,etc.Are

saprophyticfungi,usuallyentersthebodybytrauma31Chromomycosis31經(jīng)外傷侵入丘疹結(jié)節(jié)結(jié)節(jié)融合成疣狀或菜花狀斑痕形成影響淋巴回流肢體象皮腫32經(jīng)外傷侵入32ChromomycosisChronicverrucouschromoblastomycosisofthehandduetoCladophialophoracarrionii

33ChromomycosisChronicverrucousMycetoma足分枝菌病是由多種放線菌或真菌引起的一種慢性化膿性肉芽腫性疾病，主要感染足部，以腫脹、竇道和顆粒為特征。

causedbyfungiarecalledeumycetoma(40%)Actinomycetomaiscausedbyactinomycetes(60%)Itischaracterizedbytheformationofabscess,whichcontainlargeaggregatesoffungaloractinomycetefilamentsknownasgrains34Mycetoma足分枝菌病是由多種放線菌或真菌引起的一種慢EumycetomaDarkgrainsMadurellamycetomatisLeptosphaeriasenegalensisExophialajeanselmeiPalegrainsFusariumsp.Acremoniumsp.ScedosporiumapiospermumActinomycetomaWhite-yellowgrainsActinomaduramaduraeNocardiabrasiliensisYellow-browngrainsStreptomycessomaliensisRed-pinkgrainsActinomycetomapellettieri35EumycetomaActinomycetoma35深部真菌感染引起深部感染的真菌包括兩大類(lèi)：致病性真菌與條件致病性真菌致病性真菌主要有組織胞漿菌、球孢子菌、副球孢子菌和芽生菌，這些真菌均屬二相性。多見(jiàn)于美洲，我國(guó)極少見(jiàn)。它們侵襲深部組織和內(nèi)臟以及全身，引起慢性肉芽腫樣炎癥、潰瘍和壞死。條件致病性真菌包括有：念珠菌、隱球菌、曲霉菌與毛霉菌、肺孢子菌等。36深部真菌感染引起深部感染的真菌包括兩大類(lèi)：致病性真菌與條件致CharacteristicsofsystemicdimorphicmycosesAreuncommon,oftenoccursinendemicareas

Mostinfectionsareasymptomaticorself-limitinginimmune-compromisedhosts,infectionsareoftenfatalThepatternofinfectionaresimilarRouteofacquisitionisinhalationPulmonaryinfectionDisseminatedinfection(Blood,Bonemarrow,BrainandCSF,Joint)37CharacteristicsofsystemicdiCoccidioidomycosisCoccidiodesimmitisisconsideredtobethemostvirulentoffungalpathogens.Restrictedtohot,semi-aridareasofSWUSAandMexico.Growsinthesoil,butinhalationofasinglesporecaninitiateinfection.Ininfectedtissues,C.immitisappearsasamixtureofendosporesandspherules.ConidiaSpherules38CoccidioidomycosisCoccidiodesCoccidioidomycosis:Encounter:Myceliumfoundindry,dustysoil.ContactbyinhalationofarthroconidiaSpread:Mostcommonlyanasymptomaticselflimitedpulmonarydisease,butmayspreadviathebloodtoskin,softtissues,bones,jointsandmeninges.ImmuneResponse:T-cellmediated(Th-1)EvasionofDefenses:Resistanttokillingbyphagocytes --proteinrich,hydrophobicouterwall --alkalinehaloassociatedwithureaseE. Damage:secretedproteinasesbreakdowncollagen,elastinhemoglobin,IgG&IgA39Coccidioidomycosis:Encounter:1.Ethnicity:Filipinos,AfricanAmericans,NativeAmericansathigherrisk2. Age:Extremesmoresusceptible3. Sex:Malesmoresusceptible4. Pregnancy:3rdtrimester5. ImmunosuppressionF.Diagnosis1. Exam:Suppurativeorgranulomatousinflammation2. Histopathology:spherulesorendosporesseeninsputum,exudatesortissue3. Culture:—danger,highlyinfectious!4. Serology:Complementfixationassay(incerebrospinalfluid),particleagglutinationassay

G.TreatmentAmphotericinBfollowedbyanazoleE.RiskFactorsCoccidioidomycosis:401.Ethnicity:Filipinos,AfriHistoplasmosis

(alsocalledcavedisease)CausedbythedimorphicfungusHistoplasmacapsulatumTuberculatedmacroconidia,grownat25CIntracellularyeastat37CHistoplasmosisischaracterizedbyintracellulargrowthofthepathogeninmacrophagesandagranulomatousreactionintissue.Thesegranulomatousfocimayreactivateandcausedisseminationoffungitoothertissues.41Histoplasmosis(alsocalledcaHistoplasmosisA.Encounter.H.capsulatumgrowsinsoil,especiallysoilcontaminatedbyguano.Inhalationofconidiafromtheenvironmentissourceofinfection.Thisismorelikelyinendemicareas.InU.S.theseincludetheAtlanticOceantoN.Dakota(500,000cases/yearinU.S.),exceptNewEngland&Florida.MostcasesoccurinOhioValleyandMississippiValley)42HistoplasmosisA.Encounter.H.

MoreHistoplasmosis90%ofcasesareasymptomatic,butinrarecasesflulikerespiratorysymptomsoccurDisseminatedhistoplasmosisoccursin1:200casesandisdiagnosedfrequentlyinpatientswithAIDSlivinginthecentralU.S.Inthesecases,theorganismspreadsviabloodfromthelungtoinvolvebonemarrow,adrenalglands,heartvalvesandCNS4. Spreadcanalsobeassociatedwithunderlyinglungdisease(e.g.,emphysema).B.SpreadC.ImmuneResponseCell-mediatedresponsesareofprimaryimportanceActivatedmacrophagecankillyeastcellsD.EvasionofDefensesSurvivalinmacrophages—elevatespHofphagosomesYeastcellsabsorbiron(siderophore)andcalciumfromhostAlterationofcellsurface43MoreHistoplasmosis90%ofcasHistoplasmosisDirecthistologyandcultureofbloodorbonemarrowSerologicaltestingforantibodyandhistoplamaantigeninbloodandurine.E.DiagnosisD.DamageLung--bronchialobstructionandinflammatorysequelaeDisseminatedhistoplasmosis-fulminantdiseasethatmayresultintoxicshockCNS-fatalifuntreated.44HistoplasmosisDirecthistologEvenMoreHistoplasmosisF.TreatmentAmphotericinstillmainstayoftherapyvs.disseminatedandseverepulmonaryhistoplasmosis.Ketoconasoleoritraconasoleiseffectiveastherapyforself-limiteddisease(usedinAIDS).OcularHistoplasmosisAsmallfractionofindividualsformscartissueintheretinamanyyearsaftertheoriginalhistoplasmosisinfection.Liveorganismscannotberecoveredfromthesespecimens.Thescarringcanobscurethemaculaandleadtolossofcentralvision.Thefirstsignsaresmall“histospots”.Advanceddiseaseistreatedwithlaserphotocoagulationtolimittheproliferationofbloodvessels.45EvenMoreHistoplasmosisF.TreBlastomycosisGranulomatousmycoticinfectionthatpredominantlyinvolveslungsandskin;butcanspreadtootherorgans.Mostprevalentinmales40-60yearsofageandchildren.BlastomycesdermatitidisDimorphicorganismoriginatesinthesoilandinfectionensuesbyinhalationofspores.Convertstoyeastinanimalhostsorat37o

invitro.46BlastomycosisGranulomatousBlastomycosisEncounter:Mostcasesareinsouthern,central,andsoutheasternUSA.Infectionisbyinhalationofspores.Spread:Thepulmonaryinfectioniseitherself-limitedorprogressive.Disseminationoftenoccurstotheskinandtothebone-80%ofpatientshavelargeskinlesions;alargenumberalsohavegranulomatouspulmonarylesions.RiskFactors:Occupationalcontactwithsoil;owningadog.Livinginendemicarea.EvasionofDefenses:EscapesphagocytosisbyneutrophilsandmonocytesbysheddingitssurfaceantigenafterinfectionDamage:Consequenceoftheimmuneresponsetotheorganism—skinlesions,respiratoryinfiltrates.Diagnosis:basedonclinicalfindingsandmicroscopicdetectionoforganismsintissuespecimens47BlastomycosisEncounter:MostcAmphotericinBisthedrugofchoiceforrapidlyprogressiveblastomycosisItraconazoleorKetoconazoleforlessseverecasesImmuneresponse1.Alveolarmacrophageprovideafirstlineofdefense.2. T-cellstimulatedPMNskillBlastomycescellsbyoxidativemechanisms.ConidiaaremoresensitivetokillingbyPMNsbecauseyeastaretoobig.TH-1responseisofprimaryimportanceBlastomycosisTreatment48AmphotericinBisthedrugofOpportunisticfungalinfectionsOpportunisticmycosesarefungalinfectionsthatdonotnormallycausediseaseinhealthypeople,butdocausediseaseinpeoplewithweakenedimmunedefenses(immunocompromisedpeople).Weakenedimmunefunctionmayoccurduetoinheritedimmunodeficiencydiseases,drugsthatsuppresstheimmunesystem(cancerchemotherapy,corticosteroids,drugstopreventorgantransplantrejection),radiationtherapy,infections(e.g.,HIV),cancer,diabetes,advancedageandmalnutrition.Themostcommoninfectionsare:CandidiasisCryptococcosisAspergillosisPneumocystiscariniipneumonia(PCP)Penicillosismarneffei49Opportunisticfungalinfection白假絲酵母菌(Candida

albicans)

形態(tài)：圓形或卵圓形單細(xì)胞真菌，革蘭陽(yáng)性繁殖：出芽繁殖，形成假菌絲，在組織易形成芽生孢子培養(yǎng)：普通瓊脂、血瓊脂與沙保培養(yǎng)基需氧。室溫或37℃甚至42℃生長(zhǎng)良好菌落灰白色或奶油色，表面光滑，帶有濃厚的酵母氣味。有大量向下生長(zhǎng)的營(yíng)養(yǎng)假菌絲，呈類(lèi)酵母型。在玉米粉培養(yǎng)基上可長(zhǎng)出厚膜孢子屬于假絲酵母菌屬，俗稱(chēng)白念，為酵母型真菌，是條件致病菌可引起皮膚、黏膜和內(nèi)臟的急性或慢性炎癥，即念珠菌病，是最常見(jiàn)的深部感染真菌病，口腔念珠菌病是艾滋病患者最先出現(xiàn)的繼發(fā)性感染。生物學(xué)特性50白假絲酵母菌(Candidaalbicans)形態(tài)：圓形假菌絲和厚膜孢子51假菌絲和厚膜孢子51SystemicinvolvementUrinarytractinfectionPulmonarycandidiasisEndocarditisMeningitisCandidaemia(septicaemia)Infancy,oldage,pregnancy,prolongantibiotic,HIV/AIDS,diabetes52SystemicinvolvementUrinarytr微生物檢查：1、直接鏡檢：同時(shí)見(jiàn)出芽的念珠菌與假菌絲2、分離培養(yǎng)與鑒定：假菌絲，芽生孢子芽管形成試驗(yàn)/厚膜孢子形成試驗(yàn)3、白色念珠菌細(xì)胞壁甘露聚糖抗原/ELISA

特異性高但敏感性低4、動(dòng)物試驗(yàn)：小鼠53微生物檢查：1、直接鏡檢：同時(shí)見(jiàn)出芽的念珠菌與假Cryptococcusneoformans屬于隱球菌屬，為酵母型真菌傳染源是鴿子，人因吸入鴿糞污染的空氣而感染主要引起肺和腦的急性、亞急性或慢性感染。生物學(xué)特性圓形，有肥厚莢膜（一般厚度是直徑的兩倍）染色：一般染色法不易著色，墨汁負(fù)染，胞內(nèi)有較大的反光顆粒。出芽繁殖，不形成假菌絲（酵母型菌落）培養(yǎng)特性：沙?；蜓傊囵B(yǎng)基，25℃～37℃生化特性：分解尿素莢膜多糖抗原：A～D和AD5個(gè)血清型，我國(guó)約70%屬A型54Cryptococcusneoformans屬于隱球菌屬，5555致病性外源性感染，肺是主要入侵途徑，也屬于人體正常菌群，引起條件性感染原發(fā)感染通常在肺部，多數(shù)癥狀不明顯，自愈；有的引起支氣管肺炎；嚴(yán)重者呈暴發(fā)性感染并迅速死亡部分患者經(jīng)血行傳播至中樞神經(jīng)及其它組織，引起肉芽腫性炎癥，主要導(dǎo)致慢性腦膜炎致病物質(zhì)：莢膜56致病性外源性感染，肺是主要入侵途徑，也屬于人體正常菌群，引起微生物學(xué)檢查負(fù)染色鏡檢抗原檢查：檢查患者血清和腦脊液中新隱莢膜抗原分離鑒定尿素酶或酚氧化酶動(dòng)物試驗(yàn)：小鼠57微生物學(xué)檢查負(fù)染色鏡檢57曲霉Aspergillus

煙曲霉支氣管哮喘或肺部感染

毛霉Mucor

腐生菌腦、肺、胃腸道卡氏肺孢菌Pneumocystiscarinii

免疫缺陷病人肺炎58曲霉Aspergillus58AspergillusAspergillusisafilamentous,cosmopolitanandubiquitousfungusfoundinnature.Itiscommonlyisolatedfromsoil,plantdebris,andindoorairenvironment.ItisthesecondmostcommonlyrecoveredfungusinopportunisticmycosesfollowingCandida.59AspergillusAspergillusisafimorphologyItisafilamentousfungiHyphaeareseptateandhyaline.ConsistingofaVesicleThemorphologyandcoloroftheconidiophorevaryfromonespeciestoanother.60morphologyItisafilamentous6161AspergillusflavusAspergillusnigerAspergillusfumigatus62AspergillusflavusAspergillus足細(xì)胞→分生孢子梗→頂囊→桿狀小?！疇罘稚咦樱ǚ稚咦宇^）63足細(xì)胞→分生孢子?！斈摇鷹U狀小梗→串狀分生孢子（分生孢子頭Species

ThegenusAspergillusincludesover185species.Around20specieshavesofarbeenreportedascausativeagentsofopportunisticinfectionsinman.Amongthese,Aspergillusfumigatusisthemostcommonlyisolatedspecies,followedbyAspergillusflavusandAspergillusniger.

64Species

ThegenusAspergillusPathogenicityandClinicalSignificance局限性肺曲霉病基礎(chǔ)疾病致肺空洞存在曲霉在此生長(zhǎng)，不侵犯組織不播散曲霉肺炎（免疫功能低下）過(guò)敏性支氣管肺曲霉?。ㄟ^(guò)敏體質(zhì)）65PathogenicityandClinicalSigPathogenicityandClinicalSignificance全身性曲霉病多發(fā)生在某些重癥疾病晚期原發(fā)病灶主要在肺常由敗血癥引起全身性感染生前很難得到確診

66PathogenicityandClinicalSigPathogenicityandClinicalSignificance黃曲霉毒素與惡性腫瘤，尤其是肝癌的發(fā)生密切相關(guān)67PathogenicityandClinicalSigLaboratorydiagnosisThespecimenlikesputumbiopsy,bronchalveolarlavageortransbronchialbiopsydependinginthesiteinvolved.Directexaminationofseptatehyphaeby10%KOHpreparation.血清學(xué)診斷或血清學(xué)試驗(yàn)檢出曲霉細(xì)胞壁半乳糖甘露乳糖抗原.68LaboratorydiagnosisThespecimCulture:InSDAwithantibioticsat25and37c有隔菌絲和分生孢子頭.69Culture:InSDAwithantibiotPneumocystiscariniiPneumonia

70PneumocystiscariniiPneumoniaPCP:HistoricalFeatures1909-FirstrecognizedinlungsofGuineapigsbyChagas.SimilartoTrypanosomacruzi,yetdifferent.TheseobservationswereconfirmedbyCarinisoonafter.1912-Delanoesnameditafteritsdiscovererandtoreflectitstendencytoinfectthelungs.71PCP:HistoricalFeatures1909-PCP:HistoricalFeaturesNotinitiallybelievedtoaffecthumans.1951-VanekdescribedaninterstitialpneumoniawithPneumocystiscariniiorganismsinahuman.1955-Firstreportedinimmunodeficiency.1957-Firstassociatedwithchemotherapy.1982-AIDSandPneumocystiscariniiassociation.72PCP:HistoricalFeaturesNotinPCP:Classification

FungusorProtozoan?Sharesbothfungalandprotozoannucleicacidsandstructuralfeaturesofeach.Doesnotgrowinfungalcultures,andantifungaltherapyisineffective.Foundtorespondtoanti-parasitictherapy.Initially,thoughttobeaProtozoan.Nowbelievedtobeafungus,probablyrelatedtoSaccharomyces.73PCP:Classification

Fungusor卡氏肺孢菌Pneumocystiscarinii

生物學(xué)性狀單細(xì)胞型，兼具原蟲(chóng)及酵母菌的特點(diǎn)，其發(fā)育過(guò)程如下：孢子→小滋養(yǎng)體→大滋養(yǎng)體（二分裂、出芽或接合生殖）→囊前期→孢子囊→囊內(nèi)減數(shù)分裂形成孢子→成熟孢子囊內(nèi)含8個(gè)孢子致病性艾滋病患者最常見(jiàn)的并發(fā)癥和主要的致死原因微生物學(xué)檢查采集痰液，染色鏡檢，若發(fā)現(xiàn)滋養(yǎng)體或孢子囊可確診防治本菌對(duì)多種抗真菌藥物不敏感，用藥首選復(fù)方新諾明74卡氏肺孢菌Pneumocystiscarinii生物X-rayofPneumocystisjiroveciipneumoniaThereisincreasedopacification(whiteness)inthelowerlungsonbothsides,characteristicofPneumocystis

pneumonia

75X-rayofPneumocystisjiroveciPCP:TransmissionAirborneviahuman-to-humantransmissionorenvironmental.Possibly,exposedalmostuniversallyaschildrenandthenhavereactivationlaterasimmunitydecreases.76PCP:TransmissionAirborneviaPCP:TransmissionSiteofInfection:Primarilyinthelungswithinthealveoli.AttachestoanddamagestypeIpneumocytes.Resultsininterstitialinflammationwithlymphocytesandmacrophages.77PCP:TransmissionSiteofInfePCP:ExtrapulmonaryInfectionOncerare,morecommonwithAIDS.Extrapulmonarysitesofinfection:Reticuloendothelialsystem(liver,spleen,bonemarrow)Sinuses,middleear,eye,anddermisaroundhead.78PCP:ExtrapulmonaryInfectionPatientsatRiskAIDSatCD4<200.Congenitalandacquireddefectsincellularimmunity.Organtransplantationrecipients.Chemotherapy.Corticosteroids.Malnutrition.Prematurebirth.79PatientsatRiskAIDSatCD4<ConclusionsMostfungalinfectionsaffectoursurfacenotourcontentsAfewdimorphicfungicancausesystemicinfectionsinotherwisehealthypeople.EndemicareasContactbyinhalationCandidaspeciesinhabitourgutsandusuallystaythere,but,giventheright(wrong)conditionscandisseminatetoinfectalmostanyorgan.ImportantnosocomialinfectionInimmunecompromisedpeople,anyfunguscanbeadeadlypathogen80ConclusionsMostfungalinfecti主要致病性真菌淺部真菌感染（致病性真菌感染和條件致病性真菌感染）深部真菌感染（致病性真菌感染和條件致病性真菌感染）81主要致病性真菌淺部真菌感染（致病性真菌感染和1淺部感染真菌表面感染真菌皮膚癬真菌皮下組織真菌感染82淺部感染真菌表面感染真菌2833表面感染真菌位置：寄居于人體皮膚和毛干的最表層。因不接觸組織細(xì)胞，很少引起宿主細(xì)胞反應(yīng)統(tǒng)稱(chēng)：角層癬菌代表：秕糠馬拉癬菌(Malassezia

furfur)癥狀：由于此菌能產(chǎn)生對(duì)黑色素細(xì)胞有抑制作用的二羧酸，使花斑癬局部色素減退，如汗?jié)n斑點(diǎn)，俗稱(chēng)汗斑。誘發(fā)因素為高溫多汗84表面感染真菌位置：寄居于人體皮膚和毛干的最表層。因不接觸組織Malassezia

furfurTineaversicoloronskinsurface(sweatstain)ThelesionsaresmallhypopigmentedorhyperpigmentedmaculesMostcommonsite:back,underarm,upperarm,chest,neckMostcommoninadolescentandyoungadultmalesAssociatedwithincreasedsweating85MalasseziafurfurTineaversicoPityriasisversicolorshowinghyperpigmentedlesionsina

CaucasianandhyphopigmentedlesionsinanAustralianAborigine86PityriasisversicolorshowingCultureofMalasseziafurfuronDixon'sagar(containsglycerolmono-oleate)87CultureofMalasseziafurfuroPiedraiahortae(何德毛結(jié)節(jié)菌)ItusuallyaffectedthescalphairThenodulesaredarkerincolor,harder,andmorefirmlyattachedtothehairsBlackPiedra88Piedraiahortae(何德毛結(jié)節(jié)菌)ItusuPiedraiahortaeformsahardsuperficialpigmentednodulearoundthehairshaft(在毛干上形成硬的黑色結(jié)節(jié)，如沙粒狀)89PiedraiahortaeformsahardsFungalotitisexternaFungalinfectionoftheexternalauditorycanalCausedbyseveralspeciesofAspergillus(mostoftenA.niger),butCandidaalbicansisalsocapableofinfectingthissiteThemajorsymptomsareitchingandfeelingoffullnessinear90FungalotitisexternaFungalin9111皮膚癬真菌引起皮膚淺部感染皮膚癬是人類(lèi)最多見(jiàn)的真菌病統(tǒng)稱(chēng)：皮膚癬菌，大約40多個(gè)種，分屬于3個(gè)屬嗜角質(zhì)蛋白，37℃不能生長(zhǎng)，侵犯部位：角化的表皮，毛發(fā)，指（趾）甲病理變化：由真菌增殖及代謝產(chǎn)物刺激宿主引起92皮膚癬真菌引起皮膚淺部感染12致病性

指（趾）甲皮膚毛發(fā)毛癬菌屬+++表皮癬菌屬++-小孢子癬菌屬-+

+一種皮膚癬菌可在不同部位引起病變相同部位的病變也可由不同的皮膚癬菌引起93致病性指（趾9414TineapediscausedbyT.rubrum.Sub-clinicalinfection(left)

showingmildmacerationunderthelittletoeandmoresevere

infection(right)showing

extensivemacerationofalltoewebspacesTineaistransmittedviathefeetbydesquamatedskinscalesinsubstrateslikecarpetandmatting.95TineapediscausedbyT.rubru手足癬－治療原則水皰型－溫和搽劑和霜?jiǎng)┙腔^(guò)度型－先角質(zhì)剝脫劑，再用抗真菌霜?jiǎng)┙n糜爛型－粉劑收干，抗繼發(fā)感染，再溫和抗真菌96手足癬－治療原則水皰型－溫和搽劑和霜?jiǎng)?6TineaUnguiumusuallycausedbyTrichophytonsp97TineaUnguiumusuallycausedby甲癬－治療原則局部治療－甲涂劑系統(tǒng)治療－伊曲康唑，特比萘芬等聯(lián)合治療－配合拔甲或削甲治療98甲癬－治療原則局部治療－甲涂劑18TineaCorporis:

causedbyM.canis,followingcontactwithinfectiouskittens

99TineaCorporis:

causedbyM.c

TineaCruris(Jockitch):

Infectionofthegroin,mainlyseeninmen100TineaCruris(Jockitch):

InfTineaCapitis(scalpringworm)Tineafavosa發(fā)內(nèi)孢子101TineaCapitis(scalpringworm)TineaCapitis(scalpringworm)Tineaalba發(fā)外孢子102TineaCapitis(scalpringworm)TineaCapitis(scalpringworm)膿癬103TineaCapitis(scalpringworm)頭癬－治療原則剪發(fā)洗發(fā)搽藥服藥消毒104頭癬－治療原則剪發(fā)24Candidiasisofskin,mucous

membranesandnails

PredisposingfactorsInfancy,pregnancy,oldageDisordersofimmunefunction,e.g.,leukemia,corticosteroidtherapyChemotherapy,e.g.,immunosuppressive,antibioticEndocrinedisease,e.g.,diabetesmellitusCarcinoma105Candidiasisofskin,mucousme念珠菌性間擦疹好發(fā)部位：腋窩、乳房下、腹股溝、會(huì)陰，多見(jiàn)于嬰兒及肥胖者。106念珠菌性間擦疹好發(fā)部位：腋窩、乳房下、26Cutaneouscandidiasis:includingInterdigitalcandidiasis,diapercandidiasis,paronychiaandonychomycosisVulvovaginalcandidiasisandbalanitisInterdigitalcandidiasisCandidiaonychomycosisandparonychia

107Cutaneouscandidiasis:includOropharyngealcandidiasis:

includingthrush,glossitis,stomatitisandangularcheilitisOralthrush108Oropharyngealcandidiasis:in皮下組織真菌感染主要有孢子絲菌和著色真菌申克孢子絲菌，屬腐生性真菌，常因外傷接觸帶菌的花草等引起感染。此菌可引起孢子絲菌下疳。此菌也可引起深部感染。是一種二相性真菌。著色真菌感染發(fā)生在暴露部位，稱(chēng)著色真菌病。我國(guó)主要有卡氏枝孢霉和裴氏著色芽生菌。109皮下組織真菌感染主要有孢子絲菌和著色真菌29Sporotrichosis此菌可經(jīng)微小損傷侵入皮膚，然后沿淋巴管分布，引起亞急性或慢性肉芽腫，使淋巴管形成鏈狀硬結(jié)，稱(chēng)為孢子絲菌下疳。110Sporotrichosis此菌可經(jīng)微小損傷侵入皮膚，然后沿ChromomycosisInfectionsoccurinexposedareas,skinlesionsbecomedark,socalledchromomycosisRepresentivespecies:Cladosporiumcarrianii,Fonsecaeapedrosoi,etc.Are

saprophyticfungi,usuallyentersthebodybytrauma111Chromomycosis31經(jīng)外傷侵入丘疹結(jié)節(jié)結(jié)節(jié)融合成疣狀或菜花狀斑痕形成影響淋巴回流肢體象皮腫112經(jīng)外傷侵入32ChromomycosisChronicverrucouschromoblastomycosisofthehandduetoCladophialophoracarrionii

113ChromomycosisChronicverrucousMycetoma足分枝菌病是由多種放線菌或真菌引起的一種慢性化膿性肉芽腫性疾病，主要感染足部，以腫脹、竇道和顆粒為特征。

causedbyfungiarecalledeumycetoma(40%)Actinomycetomaiscausedbyactinomycetes(60%)Itischaracterizedbytheformationofabscess,whichcontainlargeaggregatesoffungaloractinomycetefilamentsknownasgrains114Mycetoma足分枝菌病是由多種放線菌或真菌引起的一種慢EumycetomaDarkgrainsMadurellamycetomatisLeptosphaeriasenegalensisExophialajeanselmeiPalegrainsFusariumsp.Acremoniumsp.ScedosporiumapiospermumActinomycetomaWhite-yellowgrainsActinomaduramaduraeNocardiabrasiliensisYellow-browngrainsStreptomycessomaliensisRed-pinkgrainsActinomycetomapellettieri115EumycetomaActinomycetoma35深部真菌感染引起深部感染的真菌包括兩大類(lèi)：致病性真菌與條件致病性真菌致病性真菌主要有組織胞漿菌、球孢子菌、副球孢子菌和芽生菌，這些真菌均屬二相性。多見(jiàn)于美洲，我國(guó)極少見(jiàn)。它們侵襲深部組織和內(nèi)臟以及全身，引起慢性肉芽腫樣炎癥、潰瘍和壞死。條件致病性真菌包括有：念珠菌、隱球菌、曲霉菌與毛霉菌、肺孢子菌等。116深部真菌感染引起深部感染的真菌包括兩大類(lèi)：致病性真菌與條件致CharacteristicsofsystemicdimorphicmycosesAreuncommon,oftenoccursinendemicareas

Mostinfectionsareasymptomaticorself-limitinginimmune-compromisedhosts,infectionsareoftenfatalThepatternofinfectionaresimilarRouteofacquisitionisinhalationPulmonaryinfectionDisseminatedinfection(Blood,Bonemarrow,BrainandCSF,Joint)117CharacteristicsofsystemicdiCoccidioidomycosisCoccidiodesimmitisisconsideredtobethemostvirulentoffungalpathogens.Restrictedtohot,semi-aridareasofSWUSAandMexico.Growsinthesoil,butinhalationofasinglesporecaninitiateinfection.Ininfectedtissues,C.immitisappearsasamixtureofendosporesandspherules.ConidiaSpherules118CoccidioidomycosisCoccidiodesCoccidioidomycosis:Encounter:Myceliumfoundindry,dustysoil.ContactbyinhalationofarthroconidiaSpread:Mostcommonlyanasymptomaticselflimitedpulmonarydisease,butmayspreadviathebloodtoskin,softtissues,bones,jointsandmeninges.ImmuneResponse:T-cellmediated(Th-1)EvasionofDefenses:Resistanttokillingbyphagocytes --proteinrich,hydrophobicouterwall --alkalinehaloassociatedwithureaseE. Damage:secretedproteinasesbreakdowncollagen,elastinhemoglobin,IgG&IgA119Coccidioidomycosis:Encounter:1.Ethnicity:Filipinos,AfricanAmericans,NativeAmericansathigherrisk2. Age:Extremesmoresusceptible3. Sex:Malesmoresusceptible4. Pregnancy:3rdtrimester5. ImmunosuppressionF.Diagnosis1. Exam:Suppurativeorgranulomatousinflammation2. Histopathology:spherulesorendosporesseeninsputum,exudatesortissue3. Culture:—danger,highlyinfectious!4. Serology:Complementfixationassay(incerebrospinalfluid),particleagglutinationassay

G.TreatmentAmphotericinBfollowedbyanazoleE.RiskFactorsCoccidioidomycosis:1201.Ethnicity:Filipinos,AfriHistoplasmosis

(alsocalledcavedisease)CausedbythedimorphicfungusHistoplasmacapsulatumTuberculatedmacroconidia,grownat25CIntracellularyeastat37CHistoplasmosisischaracterizedbyintracellulargrowthofthepathogeninmacrophagesandagranulomatousreactionintissue.Thesegranulomatousfocimayreactivateandcausedisseminationoffungitoothertissues.121Histoplasmosis(alsocalledcaHistoplasmosisA.Encounter.H.capsulatumgrowsinsoil,especiallysoilcontaminatedbyguano.Inhalationofconidiafromtheenvironmentissourceofinfection.Thisismorelikelyinendemicareas.InU.S.theseincludetheAtlanticOceantoN.Dakota(500,000cases/yearinU.S.),exceptNewEngland&Florida.MostcasesoccurinOhioValleyandMississippiValley)122HistoplasmosisA.Encounter.H.

MoreHistoplasmosis90%ofcasesareasymptomatic,butinrarecasesflulikerespiratorysymptomsoccurDisseminatedhistoplasmosisoccursin1:200casesandisdiagnosedfrequentlyinpatientswithAIDSlivinginthecentralU.S.Inthesecases,theorganismspreadsviabloodfromthelungtoinvolvebonemarrow,adrenalglands,heartvalvesandCNS4. Spreadcanalsobeassociatedwithunderlyinglungdisease(e.g.,emphysema).B.SpreadC.ImmuneRespo