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Flashcards in Grab Bag Deck (367):
1

You see this on cytology. What is it?

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M. canis

Large, rough, thick walled multiseptate macroconidia

2

What is  this?

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M. gypseum

3

What is this?

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T. verrucosum

4

What do you suspect is wrong with this cow?

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This cow probably has ringworm. Likely T. verrucosum

5

What are you most concerned about for this horse?

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Looks like ringworm. Likely T. equinum or M. gypseum

Multiple dry, scaled, raised lesions

Can be chronic or subclinical.

6

What's this?

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Geotrichium candidum

This is an issue for reptiles and amphibians

7

What's this?

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Sporothrix schenckii

8

What are you concerned about for these patients?

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FOLLICULITIS

A, Multiple tufted papules and nodules over lateral thorax. These lesions are often confused with urticaria. B, Multiple areas of discrete “nonreactive” alopecia caused by follicular inflammation. C, Widespread alopecia due to coalescence of pustular lesions. Dog had been treated with corticosteroids instead of antibiotics. D, Multiple small crusted follicular papules over tarsal region. 

9

What do you see here?

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This hair shaft has been invaded by fungal hyphae and is surrounded by large numbers of ectothrix spores (arrow). 

10

This could be.....

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Single circular lesion with alopecia and scaling on rump of dog infected with Trichophyton mentagrophytes. 

11

What are you most concerned about?

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Multifocal annular lesions of peripherally expanding alopecia, erythema, and scaling in dog infected with M. canis. Affected area has been shaved to enhance visualization of lesions.  

12

What might this dog have?

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Multifocal annular lesions of peripherally expanding alopecia, erythema, and scaling in dog infected with Trichophyton mentagrophytes. 

13

You see all three of these dogs on the same day. Before you grab the wine, what is your leading differential for them?

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Symmetrical facial alopecia and hyperpigmentation in dog infected with Trichophyton mentagrophytes. B, Asymmetrical facial alopecia and hyperpigmentation in dog infected with T. mentagrophytes. C, Crusting, alopecia, and hyperpigmentation of nose and ear pinna of dog infected with T. mentagrophytes. 

14

Hmmm.....what test would you order for this little love bug?

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This looks like a kerion secondary to M. canis

Let's order a DTM or dermatophyte PCR

15

What is a leading differential for this dog?

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Parson (Jack) Russell terrier with facial lesions caused by Microsporum persicolor. B, Close-up of facial lesions of Parson (Jack) Russell terrier with M. persicolor. 

16

You're called to an animal shelter to look at these cats. What do you think is happening with them?

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A, Scaling and alopecia of ear pinnae in cat infected with Microsporum canis. B, Scaling and alopecia on dorsal neck of cat infected with M. canis.

17

Hmmm...what is this showing?

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Hyphae within and arthrospores surrounding hair infected with Microsporum gypseum. 

18

What do you think is wrong with this claw?

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M. pachydermatis

19

A differential for this cat...

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Sporothrix schenckii

20

Yikes! What is this?

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Feline sporotrichosis

Numerous yeasts, and cigar bodies (arrow) in a macrophage. 

21

Yucky. What is this?

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Mycetoma on foot of dog. B, Mycetoma due to Torula sp. in a cat. Note multiple black tissue trains associated with draining tracts over hip. 

22

What is this?

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Mycetoma due to Torula sp. in a cat. Glass slide with plucked hair and crust on right and purulent exudate containing black tissue grains on left. 

23

What is this showing you?

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Direct smear from cat with phaeohyphomycosis. Pigmented fungal hyphae within a macrophage. 

24

?

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Zygomycosis

25

What's your top differential?

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Hemorrhagic bullae and ulcerated nodules caused by Pythium insidiosum on foreleg of German shepherd dog. B, Same dog as in A. Lesions have progressed to form a large ulcerated lesion with invasion of organisms into muscles of foreleg 

26

What's this? What stain?

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Canine pythiosis.

Numerous hyphae in pyogranulomatous dermatitis

(GMS stain) 

27

What are you suspecting here?

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Large alopecic mass with necrotic foci caused by Pythium insidiosum on back of boxer. B, Surgical débridement of lesion in A shows invasiveness of organisms. C, Closer view of lesion in B showing presence of yellowish “kunkers” (oomycetic hyphae surrounded by necrotic debris and inflammatory cells). 

28

Thoughts here?

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Blastomycosis

29

What is this?

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Broad-based budding and thick, refractile, double-contoured cell walls are characteristic of Blastomyces dermatitidis organisms (arrows). 

30

What's this?

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Direct smear from dog with coccidiomycosis. Ruptured spherule releasing endospores and surrounded by degenerate neutrophils. 

31

What are you concerned about with this dog?

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Canine cryptococcosis. B, Nasal swelling and discharge caused by Cryptococcus neoformans. C, Closer view of nodule on rear leg of dog infected with C. neoformans. 

32

These poor cats. What do you think they have?

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A, Nodule involving planum nasale of cat with cryptococcosis. B, Large ulcerative granuloma involving nose of cat with cryptococcosis. C, Swelling with multiple draining tracts over bridge of nose of cat with cryptococcosis. 

33

What the heck?

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A, Multiple nodules on face of cat with cryptococcosis. B, Multiple nodules are also present on trunk of cat shown in A. C, Multiple ulcer- ated nodules on head of cat with cryptococcosis. D, Multiple nodules are also present on lips and in oral cavity of cat shown in C

34

This is a direct smear. What are you concerned for? What stain was used?

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Direct smear from cat infected with C. neoformans. India ink staining shows clear halos formed by capsules surrounding organisms. 

35

What is this?

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Macrophage containing numerous intracellular yeasts in a direct smear from cat with histoplasmosis

36

You saw a wacky looking yeast on this dog? What is your concern?

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Candidiasis

37

What did this cat have?

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Ulcers over shoulders of cat with candidiasis. B, Closer view of one of ulcers in A. C, Facial lesions of cat with candidiasis. D, Closer view of periocular and perioral lesions of cat in C. 

38

Name that disease...

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White piedra (Trichosporon asahii) in a dog. B, Closer view showing white-to-gray concretions encircling hair shafts of dog in A. C, Microscopic examination of hairs from dog in A shows nodules encircling hair shafts.

39

This is extremely rare. Yeast-like organisms. Name that weird disease.

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Rhodotorula dermatitis in cat: alopecia, erythema, and crusting on nose and muzzle. B, Rhodotorula dermatitis in a cat: alopecia and erythema of a lateral digit. 

40

Cutaneous mycoses/dermantophyte/ which microsporum species? 

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  • m. canis
  • most common
  • Large, rough thick-walled multiseptate macroconidia

41

Cutaneous mycoses/ dermanophyte/ which microsporum species?

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  • M. gypseum
  • Large, rough thick-walled multiseptate macroconidia

42

cutaneous mycoses/ dermatophyte/ which microsporum species?

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  • M. nanum
  • Large, rough thick-walled multiseptate macroconidia

43

cutaneous mycoses/ dermatophyte/ which trichophyton species? 

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t. mentagrophytes -Differ from Microsporum in their cylindrical, cigar-shaped, thin/thick-walled smooth macroconidia that are produced rarely and in small numbers

44

cutaneous mycoses/ dermanophyte/ which trichophyton species? 

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t. verrucosum - Differ from Microsporum in their cylindrical, cigar-shaped, thin/thick-walled smooth macroconidia that are produced rarely and in small numbers

45

disease? what organisms cause this? 

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canine ringworm

M. canis , M. gypseum , T. erinacei, T. mentagrophytes

Brittle hair, dry and scaly skin, crusts and scabs

T. mentagrophytes cause Kerion (swelling and ulceration)

46

disease? what organism causes this?

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Feline ringworm M. canis

Often asymptomatic

Serve as a primary reservoir - otitis

47

disease? what organism causes this? 

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Bovine Ringworm

T. verrucosum

Scaling and alopecia

48

disease? which organism causes this?

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Porcine Ringworm -M. nanum -circular, roughened lesions, usually no hair loss

49

disease? which organisms cause this? 

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Equine Ringworm T. equinum and M. gypseum -multiple dry, scaly raised up lesions -chronic and subclinical

50

ringworm in chickens is due to what organism? 

M. gallinae -"favous" or "white comb" -white patches on combs of infected males, may spread to feathers

51

likely condition?

 what organism causes this?

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otitis externa Malassezia (shoe-shaped yeasts) -dermatomycoses

52

cutaneous mycoses/ dermatomycoses/ what organism? 

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malassezia -lipophilic yeast - footprint shaped -M. pachydermatities causes otits extern and seborrheic dermatitis

53

DZ? Cause?

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seborrheic dermatitis M. pachydermititis= opportunistic pathogen

54

cutaneous mycoses/ what is this?

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Malasezzia shoe-print shaped yeast 

55

dermatomycoses/ cutaneous mycoses/ what is this?

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Geotrichum candidum - Hyaline septate hyphae fragment into arthroconidia -soil and decaying matter -amphibians and reptiles  

56

Trichosporon 

cutaneous mycoses dermatomycoses

57

SQ mycoses/ what is this?

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Sporothrix schenckii -dimorphic, dematiaceous fungus -flouret arrangement dogs, cats horses

58

direct tissue smear of SQ mycoses

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Sporothrix schenckii -cigar shaped yeasts -lymphocutaneous infections= spreads along lymphatics

59

SQ DZ

What's a differential?

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sporotrichosis -lesions not painful or pruritic "rose handler's dz" in humans -cats sensitive to iodine so tx with itraconazole

60

SQ mycoses---> a DZ of Equidae 

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epizootic lymphangitis -Histoplasma capsulatum var. farciminosum -thermally dimorphic -granulomatous, nodular lesions -pear shaped, double contoured budding yeast

61

SQ mycoses 

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chromoblastomycosis -brown pigmented sclerotic bodies = thick walled muriform cells -firm, ulcerative nodules localized to the feet and legs

62

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Eumycotic mycetoma -rare -fistulous tumor develops foot and/or abdomen

63

SQ mycoses. causative agent of Bovine Nasal Granuloma 

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Curvularia -granulomatous swellings in the nasal cavity- white polyps -dematiaceous fungi -contain up to 4 cells and slightly curved

64

SQ mycoses. also causes bovine nasal granuloma

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Bipolaris -macroconidia thick walled, contain 4 or more cells -dematiaceous fungi

65

systemic mycoses- thermally dimorphic

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Blastomycosis -Blastomyces dermatitidis -LUNGS--> skin, eyes, bone -humans, dogs, cats -thick-walled, broad-based budding yeast cells -can be systemic/disseminatioin and cutaneous

66

systemic mycoses- thermally dimorphic

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Blastomycosis -severe biohazard -ohio, missouri, tennessee, mississippi river

67

systemic mycoses/ thermally dimorphic 

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Balstomycosis -mold form -hyaline hyphae -spherical conidia that look like a balloon on a short stalk

68

systemic mycoses/ thermally dimorphic

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Coccidiomycosis -Coccidiodes immitis -dogs, horses, llamas -LUNGS----> bone, skin -large spherules with thick walls containing round endospores

69

systemic mycoses/ thermally dimorphic

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Coccidiomycosis -southwestern USA -mycelial form dangerous to handle - mold= alternating barrel-shaped arthroconidia

70

systemic mycoses/ thermally dimorphic

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Histoplasmosis -Histoplasma capsulatum -dogs, cats -pulmonary infections, chronic DZ, GIT in dogs -small yeast cells within M@, round yeast cells with basophilic centers and a clear halo

71

systemic mycoses/ thermally dimorphic

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Histoplasmosis -culture considered biohazard -large, rounded, single celled, tuberculate macroconidia and small microconidia - likes nitrogenous soils -tennessee, mississippi, ohio, missouri

72

systemic mycoses/ NOT a dimorphic fungi

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Cryptococcosis -Cryptococcus neoformans -CAPSULATED YEAST -cats -soil with pigeon excreta

73

systemic mycoses/ NOT thermally dimorphic

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Cryptococcosis -remains in yeast form for both environment and host -unencapsulated in the env. -capsulation of yeast in vivo

74

opportunistic fungi- DZ in birds 

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Candidiasis (Thrush, Crop mycosis, Sour crop) -Candida albicans -GIT of birds= crop -white raised pseudomembranes -listlessness and inappetence -tx copper sulfate in water

75

opportunistic fungi

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Candidia albicans -ovoid budding yeast cells with thin walls -pseudohyphae or hyphae may be present -normal inhabitant of nasopharynx, GIT, external genitalia -most frequently infects birds

76

opportunistic fungi- DZs in other animals besides birds

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canidia ablicans -exfoliative dermatitis, otitis externa in dogs -GIT canidiasis in foals and calves -cutaneous and mucocutaneous infections in pigs

77

opportunistic fungi

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Aspergillosis -Aspergillus spp. -respiratory infection -pulmonary infections in birds -mycotic abortion in cattle -guttural pouch mycosis horses -hyaline, septate hyphae that branch dichotomously, -characteristic conidial arrangement

78

opportunistic fungi DZ in resp tract of birds

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Aspergillosis -characteristic white material in abdominal air sacs, lungs or membranes of body cavities

79

Aspergillosis DZ in ruminants

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-mycotic pneumonia- multiple discrete granulomas -bovine mycotic abortion- aborted at 6-9 mos gestation, lesions found in uterus, fetal membranes, fetal skin --- intercaruncular areas thickened, leathery, dark red to tan --- cutaneous lesions on fetus may resemble ringworm

80

aspergillosis in horses

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gutteral pouch mycosis -epistaxis -mycotic plaques=necrotic, inflamed lesions in wall of guttural pouch

81

fungal-like agent

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pneumocystic pneumonia -most common in horses= cough, exercise intolerance -trophozoites= basophilic, dense, oval with a lobed surface and single nucleus -intracystic bodies= aggregates of oval dense, basophilic structures against a thick, foamy background

82

fungal-like agent 

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pythiosis -Pythium insidiosum=associatedwith water -Equine Pythiosis (Bursatti, Swamp cancer, Leeches) -ulcerative lesions of limbs and ventral abdomen -lesions contain "kunkers" or "leeches"

83

fungal-like agent

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equine pythiosis -lack chitin and ergosterol -lesions pruritic -tx radical incision the best

84

canine pythiosis= fungal-like agent 

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-cutaneous, subcutaneous, GIT infections -poor prognosis -surgical excision best

85

fungal-like agent 

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Bovine protothecal mastitis -achlorophyllic algae, Prototheca zopfii, P. wickerhamii -from dirty env, lack of hygiene -fibrotic hard udder, fall in milk production, clots in milk, increase in somatic cell count -floret-like arrangements

86

polyene macrolides 

-broad anti fungal activity -bind to sterol components, disrupt cell membrane= internal acidification=halt enzymatic functions -Amphotericin B, Nystatin, Primaricin

87

Imidazoles 

-wide spectrum antifunal -block the synthesis of ergosterol=internal cell disruption and cell death -miconazole, ketoconazole, itraconazole, fluconazole

88

Flucytosine 

-antifungal -converts to fluorouracil which interferes with RNA and Protein synthesis -used against Cryptococcal meningitis, Candidiasis, Aspergillosis, Chromomycosis, Sporotrichosis

89

Griseofulvin

-systemic antifungal (dermatophytes) -fungistatic -disrupts mitotic spindle= production of multinucleate fungal cells

90

Iodides

-antifungal -NaI for sporotrichosis (not cats!)

91

Topical Antifungal Agents

-to control superficial mycotic infections -Amorolfine- interferes with the synthesis of sterols, against dermatophytosis -Terbinafine- decreases synthesis of ergosterol, against dermatophytes, yeast, used in combination with other drugs to enhance efficacy

92

Antibiotics

-low molecular weight microbial metabolites= kill or inhibit growth -Alexander Fleming with Penicillium -use depends on selective toxicity

93

Inhibition of Cell Wall Synthesis 

penicillins (G+), cephalosporins, bacritracin, vancomycin -prevent cross-linking of peptidoglycan chains -interferes with transpeptidation

94

Injury to Plasma Membrane

Polymyxin B (G-) -bind to membrane phospholipids and resulting in structural disorganization -potentially nephrotoxic and neurotoxic= limited to topical use

95

Inhibition of Protein Synthesis

-Chloramphenicol-to 50s, inhibits formation of peptide bond -Erythromycin-to 50s, prevents movement of ribosome along mRNA -Tetracyclines- interfere with attachment of tRNA to mRNA-ribosome complex -Streptomycin-change shape of 30s, code on mRNA read incorrectly

96

Inhibition of NA Replication and Transcription 

-Quinolones-block DNA gyrase -Rifampin- blocks DNA-directed RNA polymerase, antimycobacterial activity -Novobiocin-block DNA gyrase

97

Inhibition of Synthesis of Essential Metabolites

Trimethoprim/ Sulfanilamide-block PABA incorporation into folic acid (required for NA synthesis)

98

Bacterial mechanisms of antibiotic resistance

-have antibiotic degrading enzyme, antibiotic altering enzyme, antibiotic resistance gene, efflux pump 1. Inherent (natural) resistance 2. Acquired resistance

99

What is the causative agent of black piedra?

Piedraia hortae

100

What is the causative agent of white piedra?

Trichosporon beiglii

101

Where would you find a lesion from white piedra on a horse?

A grossly visible nodule on the long hairs of the mane, tail and distal limbs

102

What is the definition of mycetoma?

a unique infection where the organism is present in tissues as granules or grains

103

Three Cardinal Principles

Leadership, Friendship, Service

104

What is the definition of 'dematiaceous'?

Pigmented hyphae

105

What is the causative agent of basidiobolomycosis?

Ulcerative granulomatous equine skin disease Basidiobolus ranarum

106

Zycomycosis - 2 orders:     Order Mucorales           - 4 genera

Zycomycosis: * Order Mucorales * genera Rhizopus * genera Mucor * genera Absidia * genera Mortierella

107

Zygomycosis:   - 2 Orders       - Order Entomophthorales             - Two genera

Zygomycosis: * Order Entomophthorales * Genera Conidiobolus * Genera Basidiobolus

108

What is a characteristic of Conidiobolomycosis coronatus?

* Ulcerative granulomatous equine disease * * Often affects the nostril in horses, leading to  mucohemorrhagic nasal discharge and dyspnea due to nasal discharge

109

What is the causative agent of Mucormycosis in horses?

Absidia corymbifera

110

What is the causative agent of sporotrichosis and what is the usual transmission?

Sporothrix schenkii Wound contamination Steriods/immunosuppressives CI and can cause relapse 4-6 mo after apparent clinical cure

111

What is the most common form of sporotrichosis in the human?

cutaneolymphatic

112

What is the treatment of choice for sporotrichosis in the horse?

Iodides Treated 30 days past clinical cure

113

What are the side effects of iodidism (intolerance of iodide meds)?

Variable Scaling/alopecia, depression, anorexia, salivation, nervousness, or CV abnormalities Can also cause abortion in mares

114

What is the causative agent of Rhinosporidiosis?

Rhinosporidiosis seeberi Affect nostrils, can present as polyps endemic in India and Sri Lanka; only found in the southern US in north america

115

What is the definition of deep mycosis?

fungal infection of internal organs that may secondarily disseminate by hematogenous spread to the skin Usually from a ubiquitous saprophyte; not contagious

116

What is the causative agent of Blastomycosis and what are the four elements of the "microfocus model" for geographic distribution?

Blastomyces dermatitidis Four elements: 1. Moisture 2. Soil type (sandy, acid) 3. Presence of wildlife 4. Soil disruption

117

What are two other colloquial names for Blastomycosis and where is it found?

Gilchrist disease; Chicago disease Mostly in North America -- well defined endemic distribution -- Mississipi, Missouri, New York, Ohio and St. Lawrence River Valleys and mid-Atlantic states

118

Blastomyces dermatitidis

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1. Systemic mycoses fungus: Large yeast w/ broad-based buds 2. Endemic: East of Mississippi River 3. Natural habitat: beaver dams, river banks 4. KOH mount- destroys everything except for fungal cell walls (very resilient)

119

Coccidiomycosis

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-large spherules with characteristic thick/double wall -endospores similar in size to large yeasts (usually in granulomas)

120

Coccidiomycosis

Caused by Coccidiodes immitis and C. posadasii Dimorphic fungus, mold in soil and spherule in tissue highly contagious arthrospores, inhaled to infect lungs spherules (large) in micro tissue samples Thick doubly refractive wall, filled with endospores erythema nodosum (NE) Amphotericin B or itraconazole

121

San Joaquin Valley Fever is also known as...?

Coccidiomycosis

122

Coccidiomycosis in horses

* Rare * No age or sex, but Arabians may be more at risk * Dx in late fall and early winter * common present: chronic weight loss, persistent cough, musculoskeletal pain, phasic pyrexia and skin lesions * Cutanous lesions in ~20% and may be the initial clinical sign - -- abscesses ,

123

Which systemic mycosis is associated with the following things: 1. San Joaquin River Valley 2. Ohio, Mississippi and Missouri river valleys 3. Pigeon droppings.

1. Coccidiomycosis 2. Blastomycosis 3. Cryptococcus

124

What are the two causative agents of Cryptococcis?

1. Cryptococcus neoformans v. neoformans --- most prevalent in the US and Europe 2. Cryptococcus neoformans v. gatti ---- prevalent in SoCal, Australia, SE Asia, Africa, and S. America ---Can also affect immunocompetent individuals and can be very difficult to treat

125

What is the typical presentation of Cryptococcosis in the horse?

Rare Rhinitis and/or nasal granulomas, and CNS dz (especially meningitis) Multiple cryptococcal granulomas may occur on the lips

126

Cryptococcosis

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* Meningitis (Most Cs) or Encephalitis in AIDS (opportunistic!) * Pulmonary + Skin Dz * Eti * C.Neoformans Epi * Pigeon droppings Cystic encapsulated yeast masses " Soap Bubbles " due to accumulated cryptococcal capsular polysaccharide Dx * Culture on Sabouraud 's * CSF, sputum, & urine * India ink > CAPSULE NON-dimorphic budding yeasts

127

What is a special stain to identify Cryptococcus?

Mayer mucicarmine stains the organisms capsule (which is carminophillic) red

128

Pythium insidosum (oomycete) typically presents with lesions on the _______ of the animal

Ventral aspect. Areas of the body often exposed to water

129

pythium

oomycetes, phyco, swamp cancer, florida horse leeches, seen in gulf coast, habitat is water, moist soil, motile zoospores invade skin, convert to hyphae, granulomatous response, eosinophils are prominent (kunkers/leeches- masses of hyphae, necrotic macrophages, eosinophils), diagnosis- biopsy, histopathology, culture

130

What is the difference between dermatophytosis vs dermatomycosis?

Dermatophytosis - infection of the keratinized tissues (claw, hair, stratum corneum) caused by a species of Microsporum, Trichophyton, or Epidermophyton Dermatomycosis - caused by non-dermatophyte

131

What are the 2 genera oomycete most important pathogens of animals?

1. Pythium 2. Lagenidium

132

The term 'fungus' includes what?

Yeasts (unicellular) and molds (multicellular, filamentous)

133

What does the cell wall of fungi consists of? (4)

Chitin, chitosan, glucan, mannan

134

Vegetative filament of a fungus is called? 

Hyphae

135

What is a mass of hyphae known as?

Mycelium

136

Asexual state of a fungi is called?

Anamorph

137

Sexual state of a fungi is called?

Telemorph

138

Dermatophytes are primarily found in what state? (asexual/sexual)

Anamorph (asexual)

139

What distinguishes oomycytes from fungi?

Oomycetes cell walls are composed primarily of β-1,3-glucan polymers and cellulose with very little chitin (fungal cell walls are mainly chitin and ergosterol)

140

What are the major tissue reactions observed with fungal infections? 

1. Acute suppurative inflammation and microabscess formation 2. Chronic inflammation - PG 3. Necrosis- fungi invade blood vessels---> infarction-->tissue death

141

What is the MOA of nystatin and amphotericin B on fungi?

Bind with ergosterol in fungal cell membranes --> altered cell permeability and eventual cell death

142

Name 6 things azoles inhibit synthesis of?

Ergosterol Triglyceride Phospholipid Chitin Oxidative and perioxidative enzymes

143

What are naftifine and terbinafine?

Allylamines

144

MOA of allylamines?

Inhibit ergosterol biosynthesis and squalene epoxidase Bind to stratum corneum and penetrate into hair follicles

145

MOA of griseofulvin

Binds to keratin and inhibits cell wall synthesis, nucleic acid synthesis, and mitosis Fungistatic

146

Highest and lowest concentrations of grisofulvin are attained in what locations?

Stratum corneum - highest Basal layers - lowest

147

MOA of azoles

Inhibit cytochrome P450 enzyme lanosterol 14-demethylase, thus inhibiting conversion of lanosterol --> ergosterol and causing accumulation of C14 methylated sterols

148

What determines the potency of each azole?

Affinity for binding the cytochrome P450 moiety

149

What 2 properties allow pulse regime for triazoles and allylamines?

Lipophilic and keratinophilic

150

Ketoconazole is widely distributed with highest concentrations in what locations? (4)

Liver, kidney, pituitary, adrenals

151

Where is ketoconazole secreted? (6)

Urine, sweat, sebum, cerumen, saliva, milk

152

Ketoconazole may require how many days to reach steady state and effective therapeutic concentrations in the skin?

10-14 days

153

Ketoconazole impairs ergosterol synthesis in fungal cell walls by inhibiting cytochrome P450 enzyme, what other 2 MOAs?

- Interacts with membrane phospholipids - Inhibits yeast transformations to mycelial forms

154

Contraindications of ketoconazole

Pregnancy or lactation Hepatic dysfunction Thrombocytopenia

155

Reduced absorption of ketoconazole can be seen with what concurrent meds?

H2 blockers, antacids, proton pump inhibitors

156

What are the immunomodulatory and antiinflammatory effects of ketoconazole? (4)

- Suppression of neutrophil chemotaxis and lymphocyte blastogenic responses - Inhibition of 5-lipoxygenase activity - Inhibition of leukotriene production

157

What first choice antifungal should be used for CNS and ocular tissue disease? Keto/itra/fluconazole?

Fluconazole Keto and itra do not penetrate well into CNS or ocular tissues

158

Oral formulation of itraconazole require how many days to reach steady state?

14-21 days

159

Where is Itraconazole metabolized and excreted?

Metabolized by liver Excreted in bile and urine

160

Ketoconazole inhibits 11-hydroxylase. Which means what?

Blocks conversion of deoxycorticosterone to corticosterone ( reduce synthesis of cortisol and testosterone in dogs )

161

In dogs, what antifungal was reported to cause vasculitis and necroulcerative skin lesions when given at 10mg/kg/day?

Itraconazole

162

Fluconazole is primarily eliminated by what?

Renal excretion

163

Which azole suppresses adrenal/sex hormones?

Ketoconazole

164

Which is the most fungal enzyme-specific of the 3 systemic azoles?

Fluconazole Thus side effects are rare

165

What class of antifungal is terbinafine?

Allylamine

166

MOA of terbinafine

Inhibits ergoesterol biosynthesis and squalene epoxidase --> fungal cell wall ergosterol deficiency and IC accumulation of squalene

167

Is terbinafine fungicidal or fungistatic?

Both

168

How is terbinafine metabolized and excreted?

Liver Urine

169

Does terbinafine generally inhibit cytochrome P450 systems?

No More selective than azoles

170

What class of antifungal is flucytosine?

Fluorinated pyrimidine

171

What class of drug is amphotericin B?

Polyene

172

MOA of amphotericin B

Fungistatic that irreversibly binds to ergosterol

173

Amphotericin B can enhance cell-mediated immunity by?

Stimulating lymphocyte, macrophage, and neutrophil function and induce production of TNF

174

Amphotericin B is primarily indicated for treatment of what infections?

Severe systemic mycotic infections

175

What is a common side effect of Amphotericin B?

Nephrotoxicity

176

How does Amphotericin B cause renal toxicity?

Increases IC Ca in vascular smooth muscle cells and stimulates eicosanoid synthesis, resulting in reduced renal blood flow

177

MOA of iodides

(exact mechanism uncertain) May facilitate phagocyte killing of fungal cells

178

Iodides are highly effective in the treatment of what?

Cutaneous and cutaneolymphatic sporotrichosis

179

MOA of lufenuron

Interfere with formation of fungal cell wall and insect exoskelton (not recc for use as sole agent in fungal infection tx)

180

MOA of Caspofungin

Cyclic hexapeptide that inhibits 1,3-β-D-glycan synthase (blocking cell wall synthesis in fungi)

181

What dermatophyte is a natural resident (occ pathogen) of mice and voles?

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Microsporum persicolor

182

What dermatophyte is associated with exposure to rodents or their immediate environment?

Trichophyton mentagrophytes

183

What dermatophyte is geophilic that inhabits rich soil?

Microsporum gypseum

184

Hair shafts containing infectious M canis arthrospores may remain infectious in the environment for how many months?

Up to 18 months

185

What is the infective portion of the dermatophyte call?

Arthrospore - formed by segmentation and fragmentation of fungal hyphae

186

Arthrospore adhere strongly to what in order to germinate?

Keratin

187

Do ectothrix of endothrix produce masses of arthrospores on the surface of hair shafts

Ectothrix

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188

Dermatophytes produce what 3 keratinolytic enzymes?

- keratinase - elastase - collagenase

189

Dermatophytes penetrate hair cuticle and grow within the hair shaft until what point?

Keratogenous zone (Adamson fringe)

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190

Dermatophytes require what type of hairs for survival?

Actively growing hairs (anagen)

191

Which 2 dermatophytes have been shown to produce substances (especially mannans) that diminish cell-mediated immune responses and indirectly inhibit stratum corneum turnover?

Trichophyton rubrum and T mentagrophytes

192

What is the keratinase from M canis?

μ- chymotrypsin-type serine proteinase

193

Which dermatophyte can produce proteolytic enzymes that induce keratinocyte acantholysis? 

Trichophyton spp

194

Presence of what ectoparasites can be important in establishment and spread of dermatophytes in cats?

Fleas and Cheyletiella mites

195

What cat breed has a genetic predisposition to dermatophytes?

Persians

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196

What dogs breeds (2) have a genetic predisposition to dermatophytes? And what type?

- Yorkshire and Manchester terriers - Granulomatous dermatophytosis from T mentagrophytes - Yorkies are susceptible to severe forms of dermatophytosis a/c with M canis and T mentagrophytes

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197

What dermatophytes (2) can mimic autoimmune skin disease such as PE or PF (symmetriacl nasal or facial folliculitis and furunculosis)?

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T mentagrophytes M persicolar

198

What is 'sylvatic ringworm'?

Dermatophytosis acquired from wild mammals - more common in adults

199

What dermatophyte typically produce facial lesions, predominantly scaly or papulopustular and crusty + concurrent depigmentation of the nasal planum and nostrils may occur

M persicolor

200

Dermatophytic pseudomycetoma has been reported only in what cat breed?

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Persians

201

What is a pseudomycetoma?

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One or more SC nodules that are often ulcerated and discharging Nodules most commonly over dorsal trunk or tail base

202

Arthrospores in the environment are infectious for how many months?

12-24 months

203

Example of reverse zoonosis

Humans transmitting T rubrum (athlete's foot) to cats and dogs

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204

Which dermatophytes (4) have positive a Woods lamp test? (yellow-green color)

M distortum, M canis, M audouinii, , T schoenleinii ("distorted cats")

205

What % of M canis fluoresce?

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About 50%

206

Name 2 dermatophytes that do not invade hairs

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M persicolor

Epidermophyton floccosum (humans only)

visualized in scales - true epidermophytes

207

What samples should be taken if M persicolor is suspected?

Surface keratin as fungal hyphae does not invade hairs

208

What gene is for rapid and specific detection of dermatophytes?

Chitin synthase 1 gene (CHS1)

209

Dermatophytosis in healthy dogs and shorthaired cats often undergoes spontaneous remission within what time frame?

3 months

210

Which azole is the least effective in the treatment of dermatophytosis in dogs and cats?

Fluconazole

211

Which Malassezia is non lipid dependant? (does not require lipid suppplementation during culture in vitro)

Malassezia pachydermatis

212

Where is M pachydermatis commonly found on normal cats and dogs?

Skin, ear canals, mucosal surfaces (oral, anal), anal sacs and vagina

213

List the 6 lipid-dependant species.

Malassezia furfur M globosa M sympodialis M obtusa M restricta M slooffiae

214

Name the 3 Malassezia spp that has been isolated from healthy cats

Malassezia sympodialis M globosa M furfur

215

What are the 7 types of strains (sequevars) of M pachydermatis

Ia through Ig

216

What is the predominant sequevar of M pachydermatis?

Type Ia - ubiquitous

217

What is the sequevar of M pachydermatis exclusively recovered from dogs?

Type Id

218

What proteins on yeast cell walls are important for adherence to canine corneocytes?

Trypsin-sensitive proteins or glycoproteins

219

What is present on canine corneocytes that serve as ligands for adhesins expressed by M pachydermatis?

Mannosyl-bearing carbohydrate residues

220

Name the virulence factors expressed by M pachydermatis

Various proteases, lipases, phopholipases, lipoxygenases, phosphatases, glucosidase, galactosidase, leucine arylamidase, urease, zymosan

221

What processes (5) contribute to the pathogenesis, inflammation and pruritus of Malassezia dermatitis?

Proteolysis, lipolysis, alteration of local pH, eicosanoid release, complement activation

222

Dogs with Malassezia dermatitis have elevated serum concentrations of what Ig compared to heathy dogs?

IgA and IgG (but they do not appear to be protective against infection)

223

Histologically, Malassezia dermatitis is often characterized by what?

Prominent exocytosis of lymphocytes (CD3+) Subepithelial accumulation of mast cells (suggest a hypersensitivity reaction)

224

Malassezia growth is optimal at what pH level?

pH 4-8

225

Widespread Malassezia dermatitis in cats has been associated with what concurrent diseases? (3)

- FIV infection - thymoma - pancreatic adenocarcinoma

226

What skin disease in Westies is postulated to be a reaction to severe infections with Malassezia?

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Epidermal dysplasia

227

Numbers of cutaneous M pachydermatis are significantly greater in what body locations of atopic dogs then normal dogs?

Groin, interdigital spaces, ear canals, directly under the tail base 

228

What breed of cat may be predisposed to paronychia associated with M pachydermatis?

Devon rex

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229

Which Malassezia has a more rounded bullous shape and a narrowed-based monopolar budding. And smaller than M pachydermatis?

Malassezia sympodialis

230

What is the majority of intraepithelial and dermal lymphocytes in dogs with Malassezia dermatitis?

CD3+ T cells

231

Will lipid-dependant Malassezia sp grow well on Sabouraud dextrose agar?

No

232

What agar/medium are preferred to isolate Malassezia from cats (mainly lipid dependant)?

Modified Dixon agar and Leeming medium

233

What is chromomycosis?

Subcutaneous and systemic diseases caused by fungi that develop in the host tissue in the form of dark-walled (pigmented, dematiaceous) fungal elements

234

Chromomycosis can be separate into what 2 forms?

Phaemohyphomycosis and chromoblastomycosis

235

What is phaemohyphomycosis?

Organism appears as septate hyphae and yeastlike cells

236

What is chromoblastomycosis?

Fungus present as large rounded, dark-walled cells (sclerotic bodies, chromo bodies, Medlar bodies)

237

Oomycosis include what spp?

Pythium and Lagenidium

238

What is mycetoma?

Unique infection Organism is present in tissues within granules or grains associated with tumefaction and draining sinuses

239

Mycetoma can be eumycotic or actinomycotic. What does that mean?

Actinomycetales order: Actinomyces and Nocardia which are bacteria Eumycotic mycetomas: caused by dematiaceous fungi (black-grained mycetoma) or nonpigmented fungi (white-grained mycetoma)

240

What is sporotrichosis caused by?

Sporothrix schenckii - a ubiquitous dimorphic fungus, saprophyte in soil

241

In the environment, Sporothrix exists in what form?

Mycelial form growing on living and decaying plant material

242

When does Sporothrix convert to its yeast form?

After inoculation into tissues such as puncture wounds by thorns/splinters

243

What is the characteristic of the cutaneolymphatic form of sporotrichosis?

Nodule on the distal aspect of one limb, with subsequent ascending infection via the lymphatics

244

How do cats most often acquire sporotrichosis?

Contaminated claws and teeth from another cat (cat fight), especially intact male cats that roam outdoors

245

What is the most common form of sporotrichosis in humans?

Cutaneolymphatic Most lesions are on extremity or face

246

Is sporotrichosis zoonotic?

Yes, especially from infected cats

247

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Sporothrix schenckii

Pleomorphic yeast, round, oval or cigar-shaped

248

What stains sporothrix?

PAS or Gomori methamine silver (GMS)

249

True/False. S schenckii grows on Sabouraud dextrose agar at 30 C

True

250

What test is useful for diagnosis of sporotrichosis in dogs, especially when cultures are negative

A fluorescent antibody test -Sporothrix antigen-specific direct FA test

251

PCR testing for sporotrichosis is used to detect what in infected tissues of cats?

Chitin synthase 1 gene in extracted DNA

252

What treatment is contraindicated in dogs and cats with sporotrichosis?

Glucocorticoids and other immunosuppressive drugs

253

Local hyperthermia as an adjuvant treatment may be beneficial in what fungal disease?

Sporothrix, because it is temperature sensitive

254

What is the traditional treatment for sporotrichosis?

Oral administration of a supersaturated solution of potassium iodide

255

Signs of iodise toxicity?

Ocular and nasal discharge, dry hair coat with excessive scaling, vomiting, depression and collapse. Cats are more sensitive to toxic side effects of iodides

256

What is the treatment choice of sporotrichosis in cats?

Itraconazole

257

What is the prognosis of cure for sporotrichosis in cats?

Guarded

258

What are some unpigmented fungi that cause white-grain mycetomas?

Acremonium and Pseudoallescheria

259

What is the most commonly reported fungus causing eumycotic mycetoma in the US?

Pseudallescheria boydii

260

What are the 3 cardinal features of eumycotic mycetoma (maduromycosis)?

- tumefaction - draining tracts - grains (granules) in the discharge

261

What is the treatment of choice for eumycotic mycetomas?

Surgical excision, as they are often solitary on the limbs of face Medical treatment is often unsuccessful

262

What are the characteristics of chromomycosis (phaeohyphomycosis and chromoblastomycosis)?

Forming pigmented (diatomaceous) hyphal elements (NOT grains) in tissues, the pigment is MELANIN (virulence factor)

263

What stains melanin?

Masson-Fontana

264

What is the most common cause of disseminated pheohyphomycosis in humans?

Scedosporium prolificans

265

Clinical features of cutaneous pheohyphomycosis in dogs?

Single or multifocal poorly circumscribed nodules that may ulcerate or develop draining tracts (GSDs may be predisposed)

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266

What are Medlar bodies (“copper pennies”)?

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Round to oval pigmented yeast forms in chromomycosis

267

Hyalohyphomycosis are opportunistic infections by pigmented or non pigmented fungi?

Nonpigmented

268

Common sites of inoculation of hylahyphomycosis

Clawbeds, skin, eyes (cornea) and joints

269

True/False Zygomycetes are a class of fungi that are ubiquitous saprophytes of soil and decaying vegetation and known to be a component of normal skin and haircoat flora

True

270

What is this?

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Hyphae are often surrounded by eosinophilic "sleeves" (Splendore-Hoeppli phenomenon)

271

Portal of entry of Zygomycosis may be?

GI, respiratory or cutaneous via wound contamination

272

Zygomycetes fungal elements stain well with what?

GMS, variably with PAS

273

Pythium spp rely on what for their normal life cycle?

Aquatic plants and other organic substances  

274

Name differences between fungi and pythiosis (2)

- pythium produce motile flagellate zoospores - cell walls that contains cellulose and β-glucan with no chitin and littler ergoesterol

275

What fungi can cause skin lesions and fatal GI disease?

Zygomycetes

276

Has there been a GI form of pythiosis reported?

Yes, in California

277

What species of pythiosis is isolated from dogs, cats, humans and horses?

Pythium insidiosum

278

Skin lesions may contain "kunkers". What fungal disease is this?

Pythium spp

279

What are "kunkers"? 

Yellowish gritty coral-like bodies composed of Pythium spp hyphae surrounded by necrotic tissue and inflammatory cells

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280

True/False It is common for dogs to have both cutaneous and GI pythiosis

False

281

What can you see in gastrointestinal pythiosis?

Weight loss, V/D, haematochezia. Severe segmental transmural thickening of the stomach, small intestines, colon +/- rectum

282

Where are hyphal elements most common and most numerous?

Within foci of necrosis

283

What is the treatment of choice for pythiosis?

Wide surgical excision

284

Which antifungal may be more effective for pythiosis?

Caspofungin - potent inhibitor of β-glucan synthase ( Pythium spp do not share cel wall characteristics with true fungi, thus keto etc is disappointing)

285

Majority of species in the genus Lagenidium are parasites infection what?

Algae, fungi, shrubcs, nematodes, crustaceans, insect larvae

286

True/False Systemic disease is commonly present in Lagenidiosis

True PG vasculitis and infection of the great vessels (e.g vena cava), LNs, lung etc

287

What tests can be used to differentiate between Lagenidium and Pythium?

PCR amplification of DNA from cultures isolates of tissue samples

288

Blastomycosis is caused by what fungi?

Blastomyces dermatitidis Dimorphic saprophyte fungus

289

What controls the change of blastomycosis fungus from a mycelial to yeast phase?

The gene bys-1

290

What is characteristic of Blastomyces dermatitidis organisms?

Broad-based budding and thick, refractile, double-contoured cell walls

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291

Growth of blastomyces require what?

Moist, acidic soil rich in organic material

292

What is the ideal location for Blastomyces?

Beaver dams

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293

What is Gilchrist or Chicago disease?

Blastomycosis - disease of N America

294

How is blastomycosis usually acquired? 

Inhalation of spores from mycelial growth in the environment Spores settle in airways and transform into yeast and primary infection in the lungs

295

What are the important virulence factors in blastomycosis that function in adherence of the yeast to host cells and suppress inflammatory responses?

BAD1 and WI-1 antigens

296

Majority (85%) of dogs with blastomycosis have what lesions?

Lung lesions

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297

What % of dogs with blastomycosis develop skin lesions?

20-50%

298

What are the preferred skin sites in dogs with blastomycosis?

Nasal planum, face, clawbeds

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299

4 lesion locations of blastomycosis in dogs

Lungs 85%

Skin 20-50%

Ocular 40%

Bone 30%

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300

What cat breed may be predisposed to blastomycosis?

Siamese

301

What special stains are used for blastomycosis?

PAS, GMS or Gridley fungal stain

302

What is most sensitive for dogs with pulmonary blastomycosis?

BALF (bronchioalveolar fluid)

303

What is the most sensitive for animals with disseminated blastomycosis disease?

Urine (detection of Blastomyces dermatitidis antigens)

304

What is the drug of choice for blastomycosis in dogs?

Itraconazole

305

Dogs with what fungal disease appear to have a tenfold increased risk compared with humans and can serve as sentinels in humans?

Blastomycosis

306

What is Valley Fever/San Joaquin Valley fever?

Coccidiomycosis

307

What is the ecologic niche of coccidiomycosis?

Sandy alkaline soils, high temp, low rainfall, low elevation

308

What areas has coccidioides been isolated from?

Rodent burrows in desert-like areas

309

Name the 2 coccidioides

Coccidioides immitis and Coccidioides posadasii

310

Which coccidioides is found in the San Joaquin Valley of California?

Coccidioides immitis

311

What is the major route of infection of coccidiomycosis?

Inhalation Arthroconidia enter bronchioles and alveoli

312

What are spherules in coccidiomycosis?

Large, wound, thick-walled spherial cells filled with endospores in the lungs

313

Other than skin disease, what other clinical signs are usually seen with coccidiomycosis?

Coughing, dyspnea, persistent/fluctuating fever, anorexia, weight loss, lameness, ocular disease

314

What is the most common systemic mycosis in cats?

Cryptococcosis

315

Cryptococcosis causes disease in what species?

Cats, people, dogs, ferrets, horses, goats, sheep, cattle, dolphins, birds, koalas and other marsupials

316

What are the 2 most common Cryptococcus species?

C neoformans and C gattii

317

Based on molecules studies, what are the 3 subtypes of cryptococcus?

C neoformans var neoformans (serotype D), C neoformans var gattii (serotypes B and C) and C neoformans var grubii (serotype A)

318

Which cryoptococcus sp infect immunocompetent hosts?

C gattii

319

Which cryoptococcus sp infect immunosuppressed hosts?

C neoformans

320

Where is C neoformans found?

Droppings, filth and debris of pigeon roosts

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321

What promotes the growth of cryptococcal organisms?

Nitrogen-rich alkaline environment (pigeon guano)

322

What is implicated as the environmental niche for C gattii?

Eucalyptus trees Koala bears may serve as sentinel host

323

Name some virulence factors of Cryptococcosis

Polysaccharide capsule, melanin, mannitol, lactase, phenol oxidase and other enzymes

324

How is melanin a virulence factor of cryptococcus?

Melanin protects the fungal cells from toxic hydroxyl radicals and oxidative stress

325

What makes up the polysaccharide capsule in cryptooccus?And the genes?

Gluconoxylomannan; 2 capsular genes - CAD59 and CAP64

326

What is the primary route of crypotococcal infection?

Inhalation - occ localized lesions from penetrating wound in cats

327

What is the most common manifestation of cryptococcosis in people?

Cryptococcal meningitis

328

True/False Cryptococcal skin lesions are generally a marker of disseminated disease

True

329

What stains cryptococcus for cytologic diagnosis?

India ink stain Diff-Quick, Gram stain, new methylene blue

330

What stains the cryptococcus capsule? And what color?

Mayer mucicarmine stains capsule (carminophilic) red

331

What is a highly specific and sensitive test for cryptococcosis?

Latex agglutination test detecting crypto capsular antigens in serum or CSF

332

What is the drug of choice for tx of less severely affected crypto animals?

Azoles - itraconazole

333

Histoplasma capsulatum prefers what environment/conditions?

Warm, moist, humid conditions, nitrogen-rich organic matter (bird and bat excrement, decaying wood)

334

What are the 2 varieties of Histoplasmosis?

Histoplasma capsulatum var capsulatum Histoplasma capsulatum var duboisii

335

What is the route of exposure to Histoplasmosis?

Inhalation of infective microconidia

336

How is histoplasmosis disseminated?

From the lungs, microconidia convert to yeast phase, which are engulfed by phagolysosomes within macrophages and may be disseminated via lymphatic and blood vessels to organs

337

What is the most common clinical manifestation of histoplasmosis?

Large-bowel diarrhoea with tenesmus, mucus and hematochezia

338

Rectal scrapings are a good source of tissue to evaluate for the presence of what organism?

Histoplasma

339

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Histoplasma - small round yeast bodies with basophilic center and lighter halo

340

Name 2 Candida spp that are isolated from ears, nose, oral cavity and anus of normal dogs

Candida albicans and C parapsilosis

341

What are the virulence factors of Candida?

Acid proteinases and keratinases that degrade stratum corneum and phospholipases that facilitate penetration of tissues

342

What are the predilection sites for Candidiasis?

Mucous membranes, MCJ, areas of moisture 

343

Candida spp show narrow/broad based and multilateral budding

Narrow-based

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344

What is Piedra?

Asymptomatic fungal infection of the extrafollicular portion of the hair shaft caused by Piedraia hortae and Trichosporon beigelii

345

Match: Black or white piedra Piedraia hortae and Trichosporon beigelii

Piedraia hortae - black Trichosporon beigelii - white

346

Match: Black/white piedra Temperate climite / tropics

Black piedra - tropics White piedra - temperate climate of S American, Europe, Asia, Japan, SE USA

347

What is rhinosporidiosis?

Chronic granulomatous disease caused by Rhinosporidium seeberi

348

What is a sporangia in rhinosporidiosis?

Large spherical bodies that developed in tissues from small round spores

349

What is the predisposing factor in rhinosporidiosis?

Trauma

350

How is rhinosporidiosis infection acquired?

Mucosal contact with stagnant water or dust

351

What clinical signs are found in dogs with rhinosporidiosis?

Wheezing, sneezing, unilateral seropurulent nasal discharge, epistaxis

352

What fungi? Single or multiple nasal polyps varying in size, covered with numerous pinpoint white foci

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Rhinosporidiosis

353

Rhodotorula dermatitis has been reported in what species?

1 cat with FeLV and FIV

354

What is the most common species encountered in nasal aspergillosis?

Aspergillus fumigatus

355

What breed is predisposed to disseminated aspergillosis?

GSDs

356

Where is Alternaria spp found?

Ubiquitous saprophytic fungi in soil and organic debris. Common flora of canine and feline intergument

357

True/False Trichosporum spp cause cutaneous disease only

False Cutaneous and systemic disease

358

Trichosporon beigelii causes what?

White piedra in people, monkeys and horses

359

How is trichosporonosis diagnosed?

Histopath confirmation of fungal organism in tissue and a host response to the organism

360

Where is Prototheca spp found?

Soil, raw and treated sewage, swimming pools etc

361

Where is the portal of entry in disseminated protothecosis?

Colon

362

Match Prototheca wickerhamii Prototheca zopfii Cutaneous and disseminated infection

Prototheca wickerhamii - cutaneous in dogs and cats Prototheca zopfii - disseminated infection in dogs

363

What is the most common clinical sign of protothecosis?

Bloody diarrhoea, intermittent

364

Which dog breed appears to be predisposed to protothecosis?

Collies

365

67% of protothecosis have what involvement?

Ocular Leukokoria from vitreous clouding

366

What is the characteristic morphological form of Prototheca?

Morula - Internal septation of spherules into multiple endospores( wheel-like daisy like appearance)

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367

What skin locations are affected by prototheca?

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Pressure points, MCJs (esp nostrils), scrotum and footpads 

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