1. Candidiasis Hani Masaadeh, MD, Ph.D

2. u I. FUNGI (Mycology) u Diverse group of heterotrophs. u Many are ecologically important saprophytes (consume dead and decaying matter) u Others are parasites. u Most are multicellular, but yeasts are unicellular. u Most are aerobes or facultative anaerobes. u Cell walls are made up of chitin (polysaccharide). u Over 100,000 fungal species identified. Only about 100 are human or animal pathogens. u Most human fungal infections are nosocomial and/or occur in immunocompromised individuals (opportunistic infections).

3. u I. FUNGI (Mycology) u Diverse group of heterotrophs. u Many are ecologically important saprophytes (consume dead and decaying matter) u Others are parasites. u Most are multicellular, but yeasts are unicellular. u Most are aerobes or facultative anaerobes. u Cell walls are made up of chitin (polysaccharide). u Over 100,000 fungal species identified. Only about 100 are human or animal pathogens. u Most human fungal infections are nosocomial and/or occur in immunocompromised individuals (opportunistic infections).

4. CHARACTERISTICS OF FUNGI 1. Yeasts u Unicellular fungi, nonfilamentous, typically oval or spherical cells. Reproduce by mitosis: u Fission yeasts: Divide evenly to produce two new cells (Schizosaccharomyces). u Budding yeasts: Divide unevenly by budding (Saccharomyces). Budding yeasts can form pseudohypha, a short chain of undetached cells. Candida albicans invade tissues through pseudohyphae. u Yeasts are facultative anaerobes, which allows them to grow in a variety of environments. u When oxygen is available, they carry out aerobic respiration. u When oxygen is not available, they ferment carbohydrates to produce ethanol and carbon dioxide.

5. Characteristics of Fungal Hyphae: Septate versus Coenocytic

6. IMPORTANT DIVISIONS OF FUNGI 1. Deuteromycota u Not known to produce sexual spores. u Reproduce asexually. u Catch-all category for unclassified fungi: u Pneumocystis carinii: Causes pneumonia in AIDS patients. Leading cause of death in AIDS patients. Candida albicans: Causes yeast infections of vagina in women. Opportunistic infections of mucous membranes in AIDS patients.

7. NUTRITIONAL ADAPTATIONS OF FUNGI Fungi absorb their food, rather than ingesting it. u Fungi grow better at a pH of 5, which is too acidic for most bacteria. u Almost all molds are aerobic. Most yeasts are facultative anaerobes. u Fungi are more resistant to high osmotic pressure than bacteria. u Fungi can grow on substances with very low moisture. u Fungi require less nitrogen than bacteria to grow. u Fungi can break down complex carbohydrates (wood, paper), that most bacteria cannot.

8. FUNGAL DISEASES (Continued) Opportunistic mycoses: Caused by organisms that are generally harmless unless individual has weakened defenses: u AIDS and cancer patients u Individuals treated with broad spectrum antibiotics u Very old or very young individuals (newborns). u Examples: u Aspergillosis: Inhalation of Aspergillus spores. u Yeast Infections or Candidiasis: Caused mainly by Candida albicans. Part of normal mouth, esophagus, and vaginal flora.

9. A primary or secondary mycotic infection caused by members of the genus Candida. The clinical manifestations may be acute, subacute or chronic to episodic. Involvement may be localized to the mouth, throat, skin, scalp, vagina, fingers, nails, bronchi, lungs, or the gastrointestinal tract, or become systemic as in septicaemia, endocarditis and meningitis. Distribution: World-wide. Aetiological Agents: Candida albicans, C. glabrata, C. tropicalis, C. krusei. C. parapsilosis, C. guilliermondii and C. pseudotropicalis. All are ubiquitous and occur naturally on humans. Candidiasis

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20. Trichomoniasis

21. Introduction A sexually transmitted disease (STD), also known as sexually transmitted infection (STI) or venereal disease (VD), is an illness that has a significant probability of transmission between humans or animals by means of sexual contact, including vaginal intercourse, oral sex, and anal sex.

22. General properties Trichomonas vaginalis the only spps. Trichomonas vaginalis the only spps. Trophozoite only. Trophozoite only. Oval 7-15 microns, large nucleus, cytostoma. Oval 7-15 microns, large nucleus, cytostoma. 5 flagella, undulating membrane. 5 flagella, undulating membrane. Axostyle. Axostyle. Anaerobic growth. Anaerobic growth. Survives up to 24 hours. Survives up to 24 hours.

23. Genus Trichomonas Its includes a group of flagellated protozoa It infect humans and animal Human Trichomonads: 3 species of trichomonads found in human. Two are normally harmless.

24. Pentatrichomonas hominis T. tenax T. vaginalis which is a serious sexually transmitted pathogen.

25. Trichomonas vaginalis: It is the etiological agent of trichomoniasis. Trichomoniasis is a common sexually transmitted disease with a worldwide distribution. transmittable, sexually and through contact with toilet seats and towel. T. vaginalis despite it name, infect both men and women. In females the organism inhabits the vagina and urethra In males it is found in the urethra, prostate or, seminal vesicles.

26. The life cycle consist only of a trophozoite stage which is transmitted by direct contact during sexual intercourse both sexes equally susceptible

27. T. Vaginalis trophozoite Fg=flagella Bb=basal body Nu=nucleus Ax=axostyle um=undulating membrane Cy=cytostomal groove Cs=costa

29. Trichomoniasis Epidemiology. Epidemiology. Sexual intercourse, how frequent, world wide. Sexual intercourse, how frequent, world wide. Male to female ratio, age. Male to female ratio, age. Neoborns and eostrogen level. Neoborns and eostrogen level.

30. Pathogenesis and immunity Direct contact causes all the problems. Direct contact causes all the problems. Not invasive, no toxins. Not invasive, no toxins. Glycoprotein 200k could be responsible. Glycoprotein 200k could be responsible. Vaginal environment plays the major role. Vaginal environment plays the major role. Immune response is of little significance. Immune response is of little significance.

31. Clinical Aspects Persistant vaginitis, 50% asympotmatic. Persistant vaginitis, 50% asympotmatic. Discharge 75%. Discharge 75%. Vulvar itching and burning 50%. Vulvar itching and burning 50%. Dyspareunia 50%. Dyspareunia 50%. Dysurea 50%. Dysurea 50%. Bad odor 10%. Bad odor 10%. Strawberry cervix. Strawberry cervix.

32. Clinical Aspects Males: Males: Urethritis and Prostatitis. Urethritis and Prostatitis. Asymptomatic. Asymptomatic. Dysurea. Dysurea. Non purulent discharge. Non purulent discharge. Non gonococcal urethritis. Non gonococcal urethritis.

33. Diagnosis Clinical picture. Clinical picture. Microscopic morphology (wet mount) Microscopic morphology (wet mount) Male vs female. Male vs female. Antigen detection. Antigen detection. Look for other venereal diseases. Look for other venereal diseases.

34. Treatment Metronidazole. Metronidazole. Treat sexual partners. Treat sexual partners. Disulfaran-like effect. Disulfaran-like effect. Teratogenicity. Teratogenicity. Carcinogenic?? Carcinogenic??

35. Sign and symptoms: T. vaginalis causes different manifestation in men and women. Women are more likely to exhibit symptoms which tend to persist longer Incubation period is 4-28 days. In female ranges from asymptomatic, to mild or moderate irritation, to extreme vaginitis 10 - 50%: asymptomatic The commonest symptoms: vaginal discharge, vulval itching, dysuria, or offensive odor, rare abdominal discomfort Vaginal discharge: up to 70% - varying in consistency from thin and scanty to profuse and thick; the classical discharge of frothy yellow occurs in 10-30% of women Extreme cases associated with vulvitis and vaginitis 2%: strawberry cervix appearance to the naked eye.

36. Focus on pathogen: T. vaginalis females get a disintegration of vaginal epithelial lining. Natural flora (bacteria ) keep the pH of the vagina at 4-4.5 and ordinarily this discourages infections. T. vaginalis can survive at a low pH. Once established it causes a shift toward alkalinity (pH 5-6) which further encourages its growth. There is a tendency to explain stillbirths, spontaneous abortions, morbidity to women who have vaginitis.

37. Physical Examination Pelvic examination: –Inspection of external genitalia. Speculum examination: –insertion and visualization of vagina and cervix, obtaining swabs and slide specimens.

38. Vaginitis - Trichomoniasis –Profuse, frothy discharge, yellow-greenish in color foul odor, vulvar pruritus –Patchy vaginal erythema and (strawberry cervix)

39. Diagnosis: 1-Specimens: –vaginal discharge –urine sediment –prostatic secretion 1.Vaginal pH 2. Whiff test 3.Wet mount 4. Pap smear 5. Culture 6. Direct immunoflouresence assay 7. Polymerase chain reaction 8. Evaluation for other STDs

40. Potassium hydroxide amine test (Whiff test) : Whiff test: 10 % KOH Upon application of 10% potassium hydroxide (KOH) to a vaginal swab sample, a fishy odor is released, which can suggest trichomoniasis or bacterial vaginitis.

41. Ectoparasitic infections Ectoparasites: parasitic organisms that live on the outer skin surfaces 2 common STIs caused by ectoparasites: 1) pubic lice 2) scabies

42. Pubic lice (a.k.a. crabs) Caused by: biting louse called Phthirius pubis Prevalence: more prevalent among young (15-25 yr.old) single people, often associated w/presence of other STIs. Transmission: during sexual contact when two people bring their pubic areas together –Lice can live away from the body for as long as 1 day--can drop off onto underclothes, bedsheets, etc, and eggs deposited by female louse can survive for several days Therefore, it is possible to get pubic lice by sleeping in someone’s bed or wearing someone’s clothes Female pubic louse

43. Pubic lice (cont.) Symptoms: –Itching (that’s not relieved by scratching) –Can also leave bluish-grayish marks on the thighs and pubic area from bites –Self-diagnosis is possible by locating a louse on a pubic hair Treatment: –medicinal lotion (1% permethrin or pyrethrin) applied to all affected areas + all areas w/body hair (genitals, armpits, scalp, even eyebrows); –wash all clothes and bedding that were exposed

44. Scabies (cont.) Symptoms: –Small vesicles or pimple-like bumps, red rash –Intense itching –Favorite sites of infestation: webs and sides of fingers, wrists, abdomen, genitals, buttocks, and female breasts Treatment: –medicinal lotion (prescription & nonprescription available) applied at bedtime, then washed off after 8 hrs –wash all clothes and bedding that were exposed