Difference between revisions of "Fungi"

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'''Fungi''' are [[microorganisms]] that are occasionally seen by pathologists.
[[Image:Pulmonary aspergillosis.jpg|thumb|right|280px|Fungi (aspergillus). [[H&E stain]].]]
'''Fungi''' (singular '''fungus''') are [[microorganisms]] that are occasionally seen by pathologists.


=Overview=
=Overview=
Line 15: Line 16:
*[[Mucor]].
*[[Mucor]].
*[[Aspergillus]].
*[[Aspergillus]].
===Sign out===
*The gold standard for determining the microorganisms is culture.
*As anatomical pathologists are approximately 80% accurate (when measured against culture), it is important to state something like ''correlation with culture is recommended''.<ref name=pmid19228642>{{Cite journal  | last1 = Sangoi | first1 = AR. | last2 = Rogers | first2 = WM. | last3 = Longacre | first3 = TA. | last4 = Montoya | first4 = JG. | last5 = Baron | first5 = EJ. | last6 = Banaei | first6 = N. | title = Challenges and pitfalls of morphologic identification of fungal infections in histologic and cytologic specimens: a ten-year retrospective review at a single institution. | journal = Am J Clin Pathol | volume = 131 | issue = 3 | pages = 364-75 | month = Mar | year = 2009 | doi = 10.1309/AJCP99OOOZSNISCZ | PMID = 19228642 }}</ref>


==Summary table==
==Summary table==
{| class="wikitable"
{| class="wikitable sortable"
|-
|-
! Name (disease)
! Name (disease)
Line 29: Line 34:
! Image
! Image
|-
|-
| Aspergillus (aspergillosis)
| Aspergillus ([[aspergillosis]])
| Fungi
| Fungi
| ?
| ?
Line 37: Line 42:
| ? Immunosuppression
| ? Immunosuppression
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
| [http://commons.wikimedia.org/w/index.php?title=File:Pulmonary_aspergillosis.jpg Aspergillus (WC)], [http://commons.wikimedia.org/wiki/File:Pulmonary_aspergillosis_cytology.jpg Aspergillus cytology (WC)]
| [[Image:Pulmonary_aspergillosis.jpg|thumb|center|150px| Aspergillus. (WC)]]
|-
|-
| Zygomycota (zygomycosis);<br>''more specific''<br>Mucorales (mucormycosis)
| Zygomycota ([[zygomycosis]]);<br>''more specific''<br>Mucorales (mucormycosis)
| Fungi
| Fungi
| ?
| ?
Line 47: Line 52:
| Diabetes, immunodeficient
| Diabetes, immunodeficient
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
| [http://granuloma.homestead.com/ZygoHE_02.jpg Mucormycosis (homestead.com)], [http://commons.wikimedia.org/wiki/File:Zygomycosis.jpg Zygomycosis (WC)]
| [[Image:Zygomycosis.jpg |thumb|center|150px| Zygomycosis. (WC)]]
|-
|-
| Coccidioides, usually C. immitis<br>(coccidioidomycosis)
| Coccidioides, usually C. immitis<br>(coccidioidomycosis)
Line 57: Line 62:
| Immunodeficient
| Immunodeficient
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
| [http://pathmicro.med.sc.edu/mycology/cocc3.jpg Coccidioidomycosis (med.sc.edu)] [http://commons.wikimedia.org/wiki/File:Coccidioides_immitis_on_Sabouraud%27s_medium.jpg C. immitis (WC)] [http://www.webpathology.com/image.asp?case=374&n=3 (webpathology.com)]
| [http://pathmicro.med.sc.edu/mycology/cocc3.jpg Coccidioidomycosis (med.sc.edu)] [[Image:Coccidioides_immitis_on_Sabouraud%27s_medium.jpg |thumb|center|150px|C. immitis (WC)]]  
|-
|-
| Histoplasma (histoplasmosis)
| Histoplasma ([[histoplasmosis]])
| Fungi
| Fungi
| 2-5 micrometers
| 2-5 micrometers
Line 67: Line 72:
| Source: soil with bird droppings
| Source: soil with bird droppings
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
| [http://commons.wikimedia.org/wiki/File:Histoplasma_pas-d.jpg Histoplasmosis (WC)]
| [[Image:Histoplasma_pas-d.jpg|thumb|center|150px| Histoplasmosis. (WC)]]
|-
|-
| Blastomyces (Blastomycosis)
| Blastomyces ([[blastomycosis]])
| Fungi
| Fungi
| 5-15 micrometres
| 5-15 micrometres
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| Habitat: Northeast America, Africa
| Habitat: Northeast America, Africa
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref><ref>[http://pathmicro.med.sc.edu/mycology/mycology-6.htm http://pathmicro.med.sc.edu/mycology/mycology-6.htm]</ref>
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref><ref>[http://pathmicro.med.sc.edu/mycology/mycology-6.htm http://pathmicro.med.sc.edu/mycology/mycology-6.htm]</ref>
| [http://pathmicro.med.sc.edu/mycology/blast1.jpg Blastomyces]
| [[Image:Blastomycosis_cropped.JPG | thumb|center|150px|Blastomyces. (WC)]]
|-
|-
| Paracoccidioides (Paracoccidioidomycosis)
| Paracoccidioides ([[paracoccidioidomycosis]])
| Fungi
| Fungi
| 6-60 micrometres
| 6-60 micrometres
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| Clinical???
| Clinical???
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
| [http://commons.wikimedia.org/wiki/File:Paracoccidioides_brasiliensis_01.jpg P. brasiliensis (WC)].
| [[Image:Paracoccidioides_brasiliensis_01.jpg |thumb|center|150px|P. brasiliensis (WC)]]
|-
|-
| Pneumocystis jirovecii (Pneumocystis carinii pneumonia; abbrev. PCP)
| Pneumocystis jirovecii ([[pneumocystis carinii pneumonia]]; abbrev. PCP)
| Fungi (previously thought to be a protozoan)
| Fungi (previously thought to be a protozoan)
| 7-8 micrometres
| 7-8 micrometres
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| [[HIV]]/AIDS associated
| [[HIV]]/AIDS associated
| <ref name=Ref_APBR684>{{Ref APBR|684}}</ref>
| <ref name=Ref_APBR684>{{Ref APBR|684}}</ref>
| [http://commons.wikimedia.org/wiki/File:Pneumocystosis_carinii_of_lung_in_AIDS_959_lores.jpg PCP (WC)]
| [[Image:Pneumocystosis_carinii_of_lung_in_AIDS_959_lores.jpg|thumb|center|150px| PCP. (WC)]]
|-
|-
| Cryptococcosis
| Cryptococcus ([[cryptococcosis]])
| Fungi  
| Fungi  
| 5-15 micrometres
| 5-15 micrometres
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| HIV/AIDS associated, most common CNS fungus
| HIV/AIDS associated, most common CNS fungus
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
| <ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
| [http://commons.wikimedia.org/wiki/File:Cryptococcosis_of_lung_in_patient_with_AIDS_Methenamine_silver_stain_963_lores.jpg Crytococcosis - methenamine silver (WC)], [http://commons.wikimedia.org/wiki/File:Cryptococcosis_of_lung_in_patient_with_AIDS._Mucicarmine_stain_962_lores.jpg Crytococcosis - mucicarmine (WC)].
| [[Image:Cryptococcosis_of_lung_in_patient_with_AIDS._Mucicarmine_stain_962_lores.jpg |thumb|center|150px| Crytococcosis - mucicarmine (WC)]]
|}
|}
Notes:
Notes:
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=Specific fungi=
=Specific fungi=
==Histoplasmosis==
==Histoplasmosis==
*''Histoplasma capulatum'' - primative fungus, typical location: lung.
===General===
** Often in yeast form in tissue 2-5 micrometres.<ref name=Ref_WMSP103>{{Ref WMSP|103}}</ref>  
*Organism: ''Histoplasma''.
** Nice bright red on PAS-D - [http://en.wikipedia.org/wiki/File:Histoplasma_pas-d.jpg histoplasmosis (wikipedia.org)].
*Specific organism: ''Histoplasma capulatum''.
*** Have a "central dot"<ref>URL: [http://moon.ouhsc.edu/kfung/jty1/opaq/PathQuiz/A6I001-PQ01-M.htm http://moon.ouhsc.edu/kfung/jty1/opaq/PathQuiz/A6I001-PQ01-M.htm]. Accessed on: 19 October 2010</ref> - [http://moon.ouhsc.edu/kfung/jty1/opaq/PathQuiz/PQ-Images/A6I001-3.gif histoplasma (ouhsc.edu)].
*Typical location: [[lung]].
*Common in immunosuppressed individuals, e.g. [[HIV]]/AIDS population.
**Extrapulmonary ''or'' disseminated histoplasmosis is considered to be ''AIDS-defining''.<ref name=pmid19052530>{{cite journal |author=Schneider E, Whitmore S, Glynn KM, Dominguez K, Mitsch A, McKenna MT |title=Revised surveillance case definitions for HIV infection among adults, adolescents, and children aged <18 months and for HIV infection and AIDS among children aged 18 months to <13 years--United States, 2008 |journal=MMWR Recomm Rep |volume=57 |issue=RR-10 |pages=1–12 |year=2008 |month=December |pmid=19052530 |doi= |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5710a1.htm}}</ref>
 
===Microscopic===
Features:
* Often in yeast form - in tissue, spherical, 2-5 micrometres.<ref name=Ref_WMSP103>{{Ref WMSP|103}}</ref>  
* Intracellular<ref name=pmid19547878>{{Cite journal  | last1 = Gorocica | first1 = P. | last2 = Taylor | first2 = ML. | last3 = Alvarado-Vásquez | first3 = N. | last4 = Pérez-Torres | first4 = A. | last5 = Lascurain | first5 = R. | last6 = Zenteno | first6 = E. | title = The interaction between Histoplasma capsulatum cell wall carbohydrates and host components: relevance in the immunomodulatory role of histoplasmosis. | journal = Mem Inst Oswaldo Cruz | volume = 104 | issue = 3 | pages = 492-6 | month = May | year = 2009 | doi =  | PMID = 19547878 }}</ref> - may be within macrophages that form a [[granuloma]].
** Nice bright red on PAS-D.
*** Have a "central dot".<ref name=pathquiz_1>URL: [http://moon.ouhsc.edu/kfung/jty1/opaq/PathQuiz/A6I001-PQ01-M.htm http://moon.ouhsc.edu/kfung/jty1/opaq/PathQuiz/A6I001-PQ01-M.htm]. Accessed on: 19 October 2010</ref>  
 
====Images====
<gallery>
Image:Histoplasma in granuloma pas-d.jpg | Histoplasmosis - granuloma - [[PASD stain]]. (WC)
Image:Histoplasma_pas-d.jpg | Histoplasmosis - [[PASD stain]]. (WC)
Image:Histoplasma_pas-d_small.jpg | Histoplasmosis - cropped - PASD stain. (WC)
Image:Histoplasma_in_granuloma_gms.jpg | Histoplasmosis - [[GMS stain]]. (WC)
</gallery>
www:
*[http://moon.ouhsc.edu/kfung/jty1/opaq/PathQuiz/PQ-Images/A6I001-3.gif The "central dot" of Histoplasma (ouhsc.edu)].<ref name=pathquiz_1/>
*[http://path.upmc.edu/cases/case693.html Histoplasmosis - several images (upmc.edu)].
 
==Coccidioidomycosis==
===General===
*Organism: ''Coccidioides''.
*Specific organism: ''Coccidioides immitis''.
**Usu. from soil.
*Typical locations: lung, oral cavity.<ref name=Ref_WMSP3>{{Ref WMSP|3}}</ref>
*+/-Immunodeficiency.<ref name=pmid23824371>{{Cite journal  | last1 = Nguyen | first1 = C. | last2 = Barker | first2 = BM. | last3 = Hoover | first3 = S. | last4 = Nix | first4 = DE. | last5 = Ampel | first5 = NM. | last6 = Frelinger | first6 = JA. | last7 = Orbach | first7 = MJ. | last8 = Galgiani | first8 = JN. | title = Recent advances in our understanding of the environmental, epidemiological, immunological, and clinical dimensions of coccidioidomycosis. | journal = Clin Microbiol Rev | volume = 26 | issue = 3 | pages = 505-25 | month = Jul | year = 2013 | doi = 10.1128/CMR.00005-13 | PMID = 23824371 }}</ref>
*Predominantly southwest USA and Mexico.<ref name=pmid23068145>{{Cite journal  | last1 = Welsh | first1 = O. | last2 = Vera-Cabrera | first2 = L. | last3 = Rendon | first3 = A. | last4 = Gonzalez | first4 = G. | last5 = Bonifaz | first5 = A. | title = Coccidioidomycosis. | journal = Clin Dermatol | volume = 30 | issue = 6 | pages = 573-91 | month =  | year =  | doi = 10.1016/j.clindermatol.2012.01.003 | PMID = 23068145 }}</ref>
 
===Microscopic===
Features:
*Forms spherules 60-80 μm in size.<ref name=Ref_WMSP103>{{Ref WMSP|103}}</ref>
**Contain endospores 1-5 μm in diameter.
 
Notes:
*Spherules may be described as a "bag of marbles".
 
====Images====
<gallery>
Image:Coccidioidomycosis - intermed mag.jpg |  Coccidioidomycosis - intermed. mag. (WC)
Image:Coccidioidomycosis - high mag.jpg | Coccidioidomycosis - high mag. (WC)
Image:Coccidioidomycosis_-_very_high_mag.jpg | Coccidioidomycosis - very high mag. (WC)
Image:Coccidioidomycosis_-_2_-_gms_-_very_high_mag.jpg | Coccidioidomycosis - GMS - very high mag. (WC)
Image:Mature_spherule_with_endospores_of_Coccidioides_immitis_PHIL_480_lores.jpg | Coccidioides. (WC)
</gallery>
www:
*[http://library.med.utah.edu/WebPath/jpeg2/AIDS092.jpg Coccidioides (med.utah.edu)].<ref>URL: [http://library.med.utah.edu/WebPath/EXAM/IMGQUIZ/pufrm.html http://library.med.utah.edu/WebPath/EXAM/IMGQUIZ/pufrm.html]. Accessed on: 4 December 2011.</ref>
*[http://path.upmc.edu/cases/case516.html Coccidioidomycosis (upmc.edu)].
 
==Pneumocystis pneumonia==
{{Main|Pneumonia}}
*Abbreviated ''PCP''.
*[[AKA]] ''Pneumocystis jirovecii pneumonia''.
===General===
*Organism: ''pneumocystis'',
*Specific organism: ''Pneumocystis jirovecii''<ref name=pmid16441572>{{Cite journal  | last1 = Redhead | first1 = SA. | last2 = Cushion | first2 = MT. | last3 = Frenkel | first3 = JK. | last4 = Stringer | first4 = JR. | title = Pneumocystis and Trypanosoma cruzi: nomenclature and typifications. | journal = J Eukaryot Microbiol | volume = 53 | issue = 1 | pages = 2-11 | month =  | year =  | doi = 10.1111/j.1550-7408.2005.00072.x | PMID = 16441572 }}</ref> (used to be called ''Pneumocystis carinii'').
**May be spelled ''Pneumocystis jiroveci''.
**Fungus... used to be considered a parasite.
*Typical location: [[lung]].
 
Clinical:
*Opportunistic infection - typically in [[HIV]] +ve individuals.
*May have subtle findings on chest X-ray.
 
===Microscopic===
Features:
*Form frothy aggregates that take the shape of the alveoli they sit within, i.e. they form "alveolar casts".
*"Dented ping-pong ball" appearance.<ref name=Ref_WMSP103>{{Ref WMSP|103}}</ref> **Remember '''P'''C'''P''' = '''p'''ing-'''p'''ong.
**Approximately 7-8 μm in size.
 
DDx:
*[[Pulmonary alveolar proteinosis]].
 
====Images====
<gallery>
Image:Pneumocystosis_carinii_of_lung_in_AIDS_959_lores.jpg | The frothy casts of PCP. (WC)
</gallery>
www:
*[http://commons.wikimedia.org/w/index.php?title=Special%3ASearch&search=Pneumocystis+carinii&go=Go Several images of PCP (WC)].
 
===Stains===
*[[GMS stain]] +ve.
 
==Cryptococcosis==
===General===
*Organism: ''Cryptococcus''.
*Specific organism: ''C. neoformans''.
*Opportunistic infection.
*Typical location: lung.
**Most common fungus seen in CSF specimens.<ref name=Ref_APBR682>{{Ref APBR|682}}</ref>


==Coccidiomycosis==
Trivia:
*''Coccidioides immitis'' - fungus, from soil, typical locations: lung, oral cavity.<ref name=Ref_WMSP3>{{Ref WMSP|3}}</ref>
*Crypto- = hidden/invisible.<ref>URL: [http://en.wiktionary.org/wiki/crypto- http://en.wiktionary.org/wiki/crypto-]. Accessed on: 12 April 2012.</ref>
** Forms spherules 60-80 micrometres in size.<ref name=Ref_WMSP103>{{Ref WMSP|103}}</ref>  
**Why the name? A. The capsule is almost invisible.
** [http://commons.wikimedia.org/wiki/File:Mature_spherule_with_endospores_of_Coccidioides_immitis_PHIL_480_lores.jpg Coccidioides (commons.wikimedia.org)].  


==Pneumocystis pneumonia (PCP) ==
===Gross===
*''Pneumocystis jirovecii'' (used to be called ''Pneumocystis carinii'') - fungus (that used to be considered a parasite), typical location: lung.
Features (brain):
**Clinical: Opportunistic infection. May have subtle finding on chest x-ray.
*Small cystic spaces, often diffuse.
**"Dented ping-pong ball" appearance;<ref name=Ref_WMSP103>{{Ref WMSP|103}}</ref> - remember '''P'''C'''P''' = '''p'''ing-'''p'''ong.
**Known as "soap bubble brain".
**Approximately 7-8 micrometres in size - [http://commons.wikimedia.org/wiki/File:Pneumocystosis_carinii_of_lung_in_AIDS_959_lores.jpg PCP (WP)].  [http://commons.wikimedia.org/w/index.php?title=Special%3ASearch&search=Pneumocystis+carinii&go=Go Several images are here (WC)].


==Cryptococcus==
Image:
*Usually ''C. neoformans'', fungus - opportunistic infection, typical location: lung.
*[http://pathwiki.pbworks.com/w/page/14674145/Mod05Slide38 Soap bubble brain (pathwiki.pbworks.com)].
*Most common fungus seen in CSF specimens.<ref name=Ref_APBR682>{{Ref APBR|682}}</ref>


Appearance:
===Microscopic===
Features:
*Yeast:
*Yeast:
**Round/ovoid 5-15 micrometres (may resemble Histoplasma or Candida -- but often larger).
**Round/ovoid 5-15 micrometres (may resemble Histoplasma or Candida -- but often larger).
**Thick mucopolysacchardie capsule + refractile centre.<ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
**Thick mucopolysacchardie capsule + refractile centre.<ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
**"Tear drop-shapped" budding pattern (useful to differentiate from Blastomyces, Histoplasma).<ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
**"Tear drop-shapped" budding pattern (useful to differentiate from Blastomyces, Histoplasma).<ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
 
*Usually accompanied by very little inflammation.<ref>{{Ref APBR|423 Q29}}</ref>
Images:
*[http://commons.wikimedia.org/wiki/File:Cryptococcosis_of_lung_in_patient_with_AIDS._Mucicarmine_stain_962_lores.jpg Micrograph of crytococcosis - mucicarmine stain (WC)].
*[http://commons.wikimedia.org/wiki/File:Cryptococcosis_of_lung_in_patient_with_AIDS_Methenamine_silver_stain_963_lores.jpg Micrograph of crytococcosis - methenamine silver stain (WC)].


Notes:
Notes:
*May be confused with corpora amylacea in the CNS, esp. as they (like cryptococci) stain for methenamine silver, Alcian blue, and PAS.<ref>URL: [http://flylib.com/books/en/2.953.1.17/1/ http://flylib.com/books/en/2.953.1.17/1/]. Accessed on: 15 December 2010.</ref>
*May be confused with corpora amylacea in the CNS, esp. as they (like cryptococci) stain for methenamine silver, Alcian blue, and PAS.<ref>URL: [http://flylib.com/books/en/2.953.1.17/1/ http://flylib.com/books/en/2.953.1.17/1/]. Accessed on: 15 December 2010.</ref>
====Images====
<gallery>
Image:Cryptococcus.jpg | Cryptococcosis - cytology - [[Field stain]]. (WC)
Image:Cryptococcosis_of_lung_in_patient_with_AIDS._Mucicarmine_stain_962_lores.jpg | Crytococcosis - mucicarmine stain. (WC)
Image:Cryptococcosis_of_lung_in_patient_with_AIDS_Methenamine_silver_stain_963_lores.jpg | Crytococcosis - methenamine silver stain. (WC)
</gallery>
www:
*[http://path.upmc.edu/cases/case89/micro.html Cryptococcosis (upmc.edu)].
*[http://path.upmc.edu/cases/case396.html Cryptococcosis - case 2 (upmc.edu)].


==Cryptosporidiosis==
==Cryptosporidiosis==
===General===
===General===
*Caused by cryptosporidium.
*Caused by ''cryptosporidium''.
*Fecal-oral transmission.  
*Fecal-oral transmission.  
*Usu. in immunoincompetent individuals, e.g. [[HIV|HIV/AIDS]].
*Usu. in immunoincompetent individuals, e.g. [[HIV|HIV/AIDS]].
Line 158: Line 259:
**Bluish staining of brush border '''key feature''' - low power.
**Bluish staining of brush border '''key feature''' - low power.


Images:
====Images====
*[http://www.co.hennepin.mn.us/portal/site/HCInternet/menuitem.3f94db53874f9b6f68ce1e10b1466498/?vgnextoid=bab360a6bb9fc010VgnVCM1000000f094689RCRD Micrograph of cryptosporidium in the gallbladder (hennepin.mn.us)].
<gallery>
Image:Cryptosporidiosis_-_very_high_mag.jpg | Cryptosporidiosis - very high mag. (WC)
Image:Cryptosporidiosis_-_very_high_mag_-_cropped.jpg | Cryptosporidosis - very high mag. - cropped (WC)
</gallery>
www:
*[http://www.tulane.edu/~wiser/protozoology/notes/images/cp_path.gif Schematic picture of cryptosporidium & bowel (tulane.edu)].
*[http://www.tulane.edu/~wiser/protozoology/notes/images/cp_path.gif Schematic picture of cryptosporidium & bowel (tulane.edu)].
*[http://www.brown.edu/Courses/Digital_Path/systemic_path/GI/cryptosporidiosis.html Micrograph of cryptosporidiosis (brown.edu)].
*[http://www.brown.edu/Courses/Digital_Path/systemic_path/GI/cryptosporidiosis.html Micrograph of cryptosporidiosis (brown.edu)].
*[http://www.sciencephoto.com/images/download_lo_res.html?id=670052525 Cryptosporidium - colon (sciencephoto.com)].


Notes:
Notes:
Line 168: Line 272:


==Candidiasis==
==Candidiasis==
*Commonly ''Candida albicans'' - yeast (fungus), locations: oral cavity, vagina.
:''In the context of pap tests see: [[Gynecologic_cytopathology#Candida]]''.
===General===
*Commonly ''Candida albicans''.
*Yeast forms.
*Locations: oral cavity, vagina.
 
===Gross===
Esophageal candidiasis:
*"Sticky": do not wash-off from the mucosa with water irrigation.<ref>URL: [https://www.ncbi.nlm.nih.gov/books/NBK537268/ https://www.ncbi.nlm.nih.gov/books/NBK537268/]. Accessed on: 2022 June 22.</ref>
 
===Microscopic===
Features:
*''Dimorphic'' - seen in two forms:
*''Dimorphic'' - seen in two forms:
**Pseudohyphae<ref name=Ref_WMSP3>{{Ref WMSP|3}}</ref>  - collections of many ''C. albicans'' cells in a branching pattern.
**Pseudohyphae<ref name=Ref_WMSP3>{{Ref WMSP|3}}</ref>  - collections of many ''C. albicans'' cells in a branching pattern.
**Yeast form - single cells, 10 to 12 micrometres in diameter, gram positive.<ref>[http://pathmicro.med.sc.edu/mycology/mycology-3.htm http://pathmicro.med.sc.edu/mycology/mycology-3.htm]</ref>
**Yeast form - single cells, 10 to 12 micrometres in diameter.{{fact}}
*Stains: PAS, methenamine silver.
 
*Images:
Notes:
**[http://pathmicro.med.sc.edu/mycology/candi4.jpg Candida (pseudohyphae) - methenamine silver (med.sc.edu)].
*May be described as "sticks and stones".
**[http://commons.wikimedia.org/wiki/File:Candida_pap_1.jpg Candida on Pap test (WC)].
 
====Images====
www:
*[http://pathmicro.med.sc.edu/mycology/candi4.jpg Candida (pseudohyphae) - methenamine silver (med.sc.edu)].
<gallery>
Image:Candida_pap_1.jpg | Candida on Pap test. (WC)
File:Candidiasis (5494228352).jpg | Candidiasis. (WC/Yale Rosen)
File:Candidiasis - PAS (5493634827).jpg | Candidiasis: PAS stain. (WC/Yale Rosen)
File:Candidiasis - GMS (5493634393).jpg | Candidiasis: Pseudohyphae + Budding yeast. (WC/Yale Rosen)
</gallery>
 
===Stains===
Features:
*PAS +ve.
*Methenamine silver +ve.
*[[Gram stain|Gram]] +ve.<ref name=pmid20711156>{{Cite journal  | last1 = Salerno | first1 = C. | last2 = Pascale | first2 = M. | last3 = Contaldo | first3 = M. | last4 = Esposito | first4 = V. | last5 = Busciolano | first5 = M. | last6 = Milillo | first6 = L. | last7 = Guida | first7 = A. | last8 = Petruzzi | first8 = M. | last9 = Serpico | first9 = R. | title = Candida-associated denture stomatitis. | journal = Med Oral Patol Oral Cir Bucal | volume = 16 | issue = 2 | pages = e139-43 | month = Mar | year = 2011 | doi =  | PMID = 20711156 }}</ref>


==Blastomycosis==
==Blastomycosis==
===General===
*Usually ''Blastomyces dermatitidis'' - fungus.
*Usually ''Blastomyces dermatitidis'' - fungus.
*May be in the oral cavity.<ref name=Ref_WMSP3>{{Ref WMSP|3}}</ref>  
*May be in the oral cavity.<ref name=Ref_WMSP3>{{Ref WMSP|3}}</ref>  
*Histology = '''B'''road-based budding yeast -- is '''B'''lastomyces.<ref name=pmid12375640>PMID 12375640</ref>
 
===Microscopic===
Features:
*'''B'''road-based budding yeast -- is '''B'''lastomyces.<ref name=pmid12375640>{{Cite journal  | last1 = Veligandla | first1 = SR. | last2 = Hinrichs | first2 = SH. | last3 = Rupp | first3 = ME. | last4 = Lien | first4 = EA. | last5 = Neff | first5 = JR. | last6 = Iwen | first6 = PC. | title = Delayed diagnosis of osseous blastomycosis in two patients following environmental exposure in nonendemic areas. | journal = Am J Clin Pathol | volume = 118 | issue = 4 | pages = 536-41 | month = Oct | year = 2002 | doi = 10.1309/JEJ0-3N98-C3G8-21DE | PMID = 12375640 }}</ref>
**The interface between two separating fungi, i.e. fungi in the process of reproducing, is very large.
**The interface between two separating fungi, i.e. fungi in the process of reproducing, is very large.
*Images:
**[http://commons.wikimedia.org/wiki/File:Blastomycosis_cropped.JPG Blastomycosis (wikimedia.org)].
**[http://www.pathguy.com/lectures/blastomycosis.jpg Blastomycosis - budding (pathguy.com)].
**[http://www.lahey.org/Medical/InfectiousDiseases/ID_Blastomycosis.asp Blastomycosis - with broad budding (lahey.org)].


DDx:
*[[Cryptosporidiosis]].
====Images====
<gallery>
Image:Blastomycosis_cropped.JPG | Blastomycosis. (WC)
</gallery>
www:
*[http://www.pathguy.com/lectures/blastomycosis.jpg Blastomycosis - budding (pathguy.com)].
*[http://www.lahey.org/Medical/InfectiousDiseases/ID_Blastomycosis.asp Blastomycosis - with broad budding (lahey.org)].
*[http://pathmicro.med.sc.edu/mycology/blast1.jpg Blastomyces (med.sc.edu)].
==Mucormycosis==
==Mucormycosis==
===General===
===General===
*Causative organism: Mucorales.
*Causative organism: Mucorales.
**Kingdom: Fungi.
**Kingdom: Fungi.
**AKA ''Zygomycota'' (zygomycosis).
**[[AKA]] ''Zygomycota'' (zygomycosis).
*Assoc. with diabetes, immunodeficiency.
*Associated with [[diabetes]], immunodeficiency.


===Microscopic===
===Microscopic===
Features:<ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
Features:<ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
*Branching hyphae variable width.
*Branching hyphae with variable width.
*Granulomata associated.
*[[Granulomata]] associated.
 
Notes:
*Not septated.
*Branching angle typically ~90 degrees.
 
DDx:
*[[Aspergillosis]].
 
====Images====
<gallery>
Image:Zygomycosis.jpg | Zygomycosis - [[cytology]]. (WC)
</gallery>
www:
*[http://granuloma.homestead.com/ZygoHE_02.jpg Mucormycosis (homestead.com)].
*[http://path.upmc.edu/cases/case181.html Mucormycosis - several images (upmc.edu)].
 
==Aspergillosis==
{{Main|Aspergillosis}}
 
==Microsporidiosis==
===General===
*A group of (extremely) small intracellular microorganisms - classified as [[fungi]].<ref name=pmid15777637/>
**Human pathogenic organisms in this group include: ''Enterocytozoon bieneusi'', ''Encephalitozoon hellem'', and ''Encephalitozoon intestinalis''.<ref name=pmid21844802/>
*Important in the context of [[HIV]]/AIDS,<ref name=pmid12775504>{{Cite journal  | last1 = Orenstein | first1 = JM. | title = Diagnostic pathology of microsporidiosis. | journal = Ultrastruct Pathol | volume = 27 | issue = 3 | pages = 141-9 | month =  | year =  | doi =  | PMID = 12775504 }}</ref> and solid organ transplant recipients.
*May be seen in immune competent individuals.<ref name=pmid21844802>{{Cite journal  | last1 = Didier | first1 = ES. | last2 = Weiss | first2 = LM. | title = Microsporidiosis: not just in AIDS patients. | journal = Curr Opin Infect Dis | volume = 24 | issue = 5 | pages = 490-5 | month = Oct | year = 2011 | doi = 10.1097/QCO.0b013e32834aa152 | PMID = 21844802 }}</ref>
 
Clinical:<ref name=pmid21844802/>
*Diarrhea.
*Weight loss.
*Abdominal pain.
 
===Microscopic===
Features:
*Partial villus atrophy (villous blunting) and crypt hyperplasia.<ref name=pmid21844802/>
*Small intracellular microorganisms ~ 1.0-4.0 μm.
 
Images:
*[http://images.wellcome.ac.uk/indexplus/result.html?_IXMAXHITS_=1&_IXACTION_=query&_IXFIRST_=5&_IXemailreal=true&_IXbox=50007&_IXSPFX_=templates%2Ft&_IXFPFX_=templates%2Ft Microsporidiosis (wellcome.ac.uk)].
*[http://wwwnc.cdc.gov/eid/article/18/2/11-1319-f1.htm Microsporidiosis (cdc.gov)].<ref>URL: [http://wwwnc.cdc.gov/eid/article/18/2/11-1319_article.htm http://wwwnc.cdc.gov/eid/article/18/2/11-1319_article.htm]. Accessed on: 2 June 2012.</ref>
 
===EM===
*Small intracellular microorganisms ~ 1.0-4.0 μm.<ref name=pmid15777637>{{Cite journal  | last1 = Didier | first1 = ES. | title = Microsporidiosis: an emerging and opportunistic infection in humans and animals. | journal = Acta Trop | volume = 94 | issue = 1 | pages = 61-76 | month = Apr | year = 2005 | doi = 10.1016/j.actatropica.2005.01.010 | PMID = 15777637 }}</ref>


Image:
Image:
*[http://commons.wikimedia.org/wiki/File:Zygomycosis.jpg Zygomycosis - cytology (WC)].
*[http://commons.wikimedia.org/wiki/File:Fibrillanosema_spore.jpg Microsporidium (WC)].{{fact}}
*[http://granuloma.homestead.com/ZygoHE_02.jpg Mucormycosis (homestead.com)].


=See also=
=See also=

Latest revision as of 15:03, 22 June 2022

Fungi (aspergillus). H&E stain.

Fungi (singular fungus) are microorganisms that are occasionally seen by pathologists.

Overview

  • There are lots of 'em. Below are a few of 'em.

Terminology:[1]

  • Hyphae = microscopic filamentous growth (of fungi) -- single cell.
  • Mycelial = filamentous network of hyphae.
  • Septae/septation = hyphae may be subdivided by septae -- if they aren't they are one mass of protoplasm. (?)
  • Dimorphism = exist in two forms; e.g. single cell (yeast) and mycelial growth.
  • Pseudohyphae = looks like hyphae --but branching pattern is created by separate cells.[2]

Tissue invasive fungi

Typically:[3]

Sign out

  • The gold standard for determining the microorganisms is culture.
  • As anatomical pathologists are approximately 80% accurate (when measured against culture), it is important to state something like correlation with culture is recommended.[4]

Summary table

Name (disease) Kingdom Size Shape Stains Other (microscopic) Clinical References Image
Aspergillus (aspergillosis) Fungi ? Hyphae that branching
with 45 degrees angle 		PAS-D Fruiting heads when aerobic ? Immunosuppression [5]
Aspergillus. (WC)
Zygomycota (zygomycosis);
more specific
Mucorales (mucormycosis) 		Fungi ? Branching hyphae with variable width ? Granulomata assoc. Diabetes, immunodeficient [5]
Zygomycosis. (WC)
Coccidioides, usually C. immitis
(coccidioidomycosis) 		Fungi Large - 20-60 micrometers,
endospores 1-5 micrometers 		Spherules Stains? Other? Immunodeficient [5] Coccidioidomycosis (med.sc.edu)
C. immitis (WC)
Histoplasma (histoplasmosis) Fungi 2-5 micrometers Spherical GMS Intracellular (unlike candida), granulomata Source: soil with bird droppings [5]
Histoplasmosis. (WC)
Blastomyces (blastomycosis) Fungi 5-15 micrometres Spherical (yeast) Stains? Granulomas, broad-based budding yeast Habitat: Northeast America, Africa [5][6]
Blastomyces. (WC)
Paracoccidioides (paracoccidioidomycosis) Fungi 6-60 micrometres Spherical (yeast) Stains? Multiple budding "steering wheel" appearance Clinical??? [5]
P. brasiliensis (WC)
Pneumocystis jirovecii (pneumocystis carinii pneumonia; abbrev. PCP) Fungi (previously thought to be a protozoan) 7-8 micrometres "Dented ping-pong ball" GMS Usually in clusters of alveolar casts with a honeycomb appearance HIV/AIDS associated [7]
PCP. (WC)
Cryptococcus (cryptococcosis) Fungi 5-15 micrometres Yeast GMS Prominent (i.e. thick polysaccharide) capsule HIV/AIDS associated, most common CNS fungus [5]
Crytococcosis - mucicarmine (WC)

Notes:

  • Bold text = key features.

Specific fungi

Histoplasmosis

General

  • Organism: Histoplasma.
  • Specific organism: Histoplasma capulatum.
  • Typical location: lung.
  • Common in immunosuppressed individuals, e.g. HIV/AIDS population.
    • Extrapulmonary or disseminated histoplasmosis is considered to be AIDS-defining.[8]

Microscopic

Features:

  • Often in yeast form - in tissue, spherical, 2-5 micrometres.[9]
  • Intracellular[10] - may be within macrophages that form a granuloma.
    • Nice bright red on PAS-D.
      • Have a "central dot".[11]

Images

  • Histoplasmosis - granuloma - PASD stain. (WC)

  • Histoplasmosis - PASD stain. (WC)

  • Histoplasmosis - cropped - PASD stain. (WC)

  • Histoplasmosis - GMS stain. (WC)

www:

Coccidioidomycosis

General

  • Organism: Coccidioides.
  • Specific organism: Coccidioides immitis.
    • Usu. from soil.
  • Typical locations: lung, oral cavity.[12]
  • +/-Immunodeficiency.[13]
  • Predominantly southwest USA and Mexico.[14]

Microscopic

Features:

  • Forms spherules 60-80 μm in size.[9]
    • Contain endospores 1-5 μm in diameter.

Notes:

  • Spherules may be described as a "bag of marbles".

Images

  • Coccidioidomycosis - intermed. mag. (WC)

  • Coccidioidomycosis - high mag. (WC)

  • Coccidioidomycosis - very high mag. (WC)

  • Coccidioidomycosis - GMS - very high mag. (WC)

  • Coccidioides. (WC)

www:

Pneumocystis pneumonia

Main article: Pneumonia
  • Abbreviated PCP.
  • AKA Pneumocystis jirovecii pneumonia.

General

  • Organism: pneumocystis,
  • Specific organism: Pneumocystis jirovecii[16] (used to be called Pneumocystis carinii).
    • May be spelled Pneumocystis jiroveci.
    • Fungus... used to be considered a parasite.
  • Typical location: lung.

Clinical:

  • Opportunistic infection - typically in HIV +ve individuals.
  • May have subtle findings on chest X-ray.

Microscopic

Features:

  • Form frothy aggregates that take the shape of the alveoli they sit within, i.e. they form "alveolar casts".
  • "Dented ping-pong ball" appearance.[9] **Remember PCP = ping-pong.
    • Approximately 7-8 μm in size.

DDx:

Images

  • The frothy casts of PCP. (WC)

www:

Stains

Cryptococcosis

General

  • Organism: Cryptococcus.
  • Specific organism: C. neoformans.
  • Opportunistic infection.
  • Typical location: lung.
    • Most common fungus seen in CSF specimens.[5]

Trivia:

  • Crypto- = hidden/invisible.[17]
    • Why the name? A. The capsule is almost invisible.

Gross

Features (brain):

  • Small cystic spaces, often diffuse.
    • Known as "soap bubble brain".

Image:

Microscopic

Features:

  • Yeast:
    • Round/ovoid 5-15 micrometres (may resemble Histoplasma or Candida -- but often larger).
    • Thick mucopolysacchardie capsule + refractile centre.[5]
    • "Tear drop-shapped" budding pattern (useful to differentiate from Blastomyces, Histoplasma).[5]
  • Usually accompanied by very little inflammation.[18]

Notes:

  • May be confused with corpora amylacea in the CNS, esp. as they (like cryptococci) stain for methenamine silver, Alcian blue, and PAS.[19]

Images

  • Cryptococcosis - cytology - Field stain. (WC)

  • Crytococcosis - mucicarmine stain. (WC)

  • Crytococcosis - methenamine silver stain. (WC)

www:

Cryptosporidiosis

General

  • Caused by cryptosporidium.
  • Fecal-oral transmission.
  • Usu. in immunoincompetent individuals, e.g. HIV/AIDS.

Microscopic

Features:

  • Uniform spherical nodules 2-4 micrometres in diameter, typical location - GI tract brush border.
    • Bluish staining of brush border key feature - low power.

Images

  • Cryptosporidiosis - very high mag. (WC)

  • Cryptosporidosis - very high mag. - cropped (WC)

www:

Notes:

  • Cryptosporidium parvum?[20]

Candidiasis

In the context of pap tests see: Gynecologic_cytopathology#Candida.

General

  • Commonly Candida albicans.
  • Yeast forms.
  • Locations: oral cavity, vagina.

Gross

Esophageal candidiasis:

  • "Sticky": do not wash-off from the mucosa with water irrigation.[21]

Microscopic

Features:

  • Dimorphic - seen in two forms:
    • Pseudohyphae[12] - collections of many C. albicans cells in a branching pattern.
    • Yeast form - single cells, 10 to 12 micrometres in diameter.[citation needed]

Notes:

  • May be described as "sticks and stones".

Images

www:

  • Candida on Pap test. (WC)

  • Candidiasis. (WC/Yale Rosen)

  • Candidiasis: PAS stain. (WC/Yale Rosen)

  • Candidiasis: Pseudohyphae + Budding yeast. (WC/Yale Rosen)

Stains

Features:

  • PAS +ve.
  • Methenamine silver +ve.
  • Gram +ve.[22]

Blastomycosis

General

  • Usually Blastomyces dermatitidis - fungus.
  • May be in the oral cavity.[12]

Microscopic

Features:

  • Broad-based budding yeast -- is Blastomyces.[23]
    • The interface between two separating fungi, i.e. fungi in the process of reproducing, is very large.

DDx:

Images

  • Blastomycosis. (WC)

www:

Mucormycosis

General

  • Causative organism: Mucorales.
    • Kingdom: Fungi.
    • AKA Zygomycota (zygomycosis).
  • Associated with diabetes, immunodeficiency.

Microscopic

Features:[5]

  • Branching hyphae with variable width.
  • Granulomata associated.

Notes:

  • Not septated.
  • Branching angle typically ~90 degrees.

DDx:

Images

www:

Aspergillosis

Main article: Aspergillosis

Microsporidiosis

General

  • A group of (extremely) small intracellular microorganisms - classified as fungi.[24]
    • Human pathogenic organisms in this group include: Enterocytozoon bieneusi, Encephalitozoon hellem, and Encephalitozoon intestinalis.[25]
  • Important in the context of HIV/AIDS,[26] and solid organ transplant recipients.
  • May be seen in immune competent individuals.[25]

Clinical:[25]

  • Diarrhea.
  • Weight loss.
  • Abdominal pain.

Microscopic

Features:

  • Partial villus atrophy (villous blunting) and crypt hyperplasia.[25]
  • Small intracellular microorganisms ~ 1.0-4.0 μm.

Images:

EM

  • Small intracellular microorganisms ~ 1.0-4.0 μm.[24]

Image:

See also

References

  1. ↑ http://www.fungionline.org.uk/1intro/3growth_forms.html
  2. ↑ http://pathmicro.med.sc.edu/mycology/mycology-3.htm
  3. ↑ CM 17 Apr 2009.
  4. ↑ Sangoi, AR.; Rogers, WM.; Longacre, TA.; Montoya, JG.; Baron, EJ.; Banaei, N. (Mar 2009). "Challenges and pitfalls of morphologic identification of fungal infections in histologic and cytologic specimens: a ten-year retrospective review at a single institution.". Am J Clin Pathol 131 (3): 364-75. doi:10.1309/AJCP99OOOZSNISCZ. PMID 19228642.
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 Lefkowitch, Jay H. (2006). Anatomic Pathology Board Review (1st ed.). Saunders. pp. 682. ISBN 978-1416025887.
  6. ↑ http://pathmicro.med.sc.edu/mycology/mycology-6.htm
  7. ↑ Lefkowitch, Jay H. (2006). Anatomic Pathology Board Review (1st ed.). Saunders. pp. 684. ISBN 978-1416025887.
  8. ↑ Schneider E, Whitmore S, Glynn KM, Dominguez K, Mitsch A, McKenna MT (December 2008). "Revised surveillance case definitions for HIV infection among adults, adolescents, and children aged <18 months and for HIV infection and AIDS among children aged 18 months to <13 years--United States, 2008". MMWR Recomm Rep 57 (RR-10): 1–12. PMID 19052530. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5710a1.htm.
  9. ↑ 9.0 9.1 9.2 Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 103. ISBN 978-0781765275.
  10. ↑ Gorocica, P.; Taylor, ML.; Alvarado-Vásquez, N.; Pérez-Torres, A.; Lascurain, R.; Zenteno, E. (May 2009). "The interaction between Histoplasma capsulatum cell wall carbohydrates and host components: relevance in the immunomodulatory role of histoplasmosis.". Mem Inst Oswaldo Cruz 104 (3): 492-6. PMID 19547878.
  11. ↑ 11.0 11.1 URL: http://moon.ouhsc.edu/kfung/jty1/opaq/PathQuiz/A6I001-PQ01-M.htm. Accessed on: 19 October 2010
  12. ↑ 12.0 12.1 12.2 Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 3. ISBN 978-0781765275.
  13. ↑ Nguyen, C.; Barker, BM.; Hoover, S.; Nix, DE.; Ampel, NM.; Frelinger, JA.; Orbach, MJ.; Galgiani, JN. (Jul 2013). "Recent advances in our understanding of the environmental, epidemiological, immunological, and clinical dimensions of coccidioidomycosis.". Clin Microbiol Rev 26 (3): 505-25. doi:10.1128/CMR.00005-13. PMID 23824371.
  14. ↑ Welsh, O.; Vera-Cabrera, L.; Rendon, A.; Gonzalez, G.; Bonifaz, A.. "Coccidioidomycosis.". Clin Dermatol 30 (6): 573-91. doi:10.1016/j.clindermatol.2012.01.003. PMID 23068145.
  15. ↑ URL: http://library.med.utah.edu/WebPath/EXAM/IMGQUIZ/pufrm.html. Accessed on: 4 December 2011.
  16. ↑ Redhead, SA.; Cushion, MT.; Frenkel, JK.; Stringer, JR.. "Pneumocystis and Trypanosoma cruzi: nomenclature and typifications.". J Eukaryot Microbiol 53 (1): 2-11. doi:10.1111/j.1550-7408.2005.00072.x. PMID 16441572.
  17. ↑ URL: http://en.wiktionary.org/wiki/crypto-. Accessed on: 12 April 2012.
  18. ↑ Lefkowitch, Jay H. (2006). Anatomic Pathology Board Review (1st ed.). Saunders. pp. 423 Q29. ISBN 978-1416025887.
  19. ↑ URL: http://flylib.com/books/en/2.953.1.17/1/. Accessed on: 15 December 2010.
  20. ↑ http://www.dpd.cdc.gov/dpdx/HTML/Cryptosporidiosis.htm
  21. ↑ URL: https://www.ncbi.nlm.nih.gov/books/NBK537268/. Accessed on: 2022 June 22.
  22. ↑ Salerno, C.; Pascale, M.; Contaldo, M.; Esposito, V.; Busciolano, M.; Milillo, L.; Guida, A.; Petruzzi, M. et al. (Mar 2011). "Candida-associated denture stomatitis.". Med Oral Patol Oral Cir Bucal 16 (2): e139-43. PMID 20711156.
  23. ↑ Veligandla, SR.; Hinrichs, SH.; Rupp, ME.; Lien, EA.; Neff, JR.; Iwen, PC. (Oct 2002). "Delayed diagnosis of osseous blastomycosis in two patients following environmental exposure in nonendemic areas.". Am J Clin Pathol 118 (4): 536-41. doi:10.1309/JEJ0-3N98-C3G8-21DE. PMID 12375640.
  24. ↑ 24.0 24.1 Didier, ES. (Apr 2005). "Microsporidiosis: an emerging and opportunistic infection in humans and animals.". Acta Trop 94 (1): 61-76. doi:10.1016/j.actatropica.2005.01.010. PMID 15777637.
  25. ↑ 25.0 25.1 25.2 25.3 Didier, ES.; Weiss, LM. (Oct 2011). "Microsporidiosis: not just in AIDS patients.". Curr Opin Infect Dis 24 (5): 490-5. doi:10.1097/QCO.0b013e32834aa152. PMID 21844802.
  26. ↑ Orenstein, JM.. "Diagnostic pathology of microsporidiosis.". Ultrastruct Pathol 27 (3): 141-9. PMID 12775504.
  27. ↑ URL: http://wwwnc.cdc.gov/eid/article/18/2/11-1319_article.htm. Accessed on: 2 June 2012.
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